Initial Comments:
Based on the findings of an onsite State Re-Licensure Survey conducted on June 1, 2026, Deb's Care LLC was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
51.1 (a-c) LICENSURE
CHAPTER 51-LEGAL BASE,SCOPE,DEFINITIONS
Name - Component - 00
51.1. Legal base, scope and
definitions
(a) This subpart implements the
act.
(b) This subpart contains standards
which are applicable to all entities
licensed as health care facilities
under the act. It also identifies
specific health care services which
are restricted to specific health care
facilities.
(c) The following words and terms,
when used in this subpart have the
following meanings, unless the context
clearly indicates otherwise.
Act - The Health Care Facilities
Act (35 P.S. 448.01-448.90b).
Department - The Department of
Health of the Commonwealth.
Observations:
Based on observation and an interview with the administrator, the agency failed to demonstrate that the home care agency's licensure was posted in a conspicuous location on the premises.
Findings include:
A review of The Health Care Facilities Act (35 PS. 448.809b) conducted on May 29, 2026 at 1:00 PM, states, "Posting - The license shall at all times be posted in a conspicuous place on the provider's premises."
Observation of the premises by the surveyor on June 1, 2026 at 9:45 AM found that the home care agency's license was not posted on the wall nor available for review in any manner on the home care agency's premises.
An interview was conducted with the administrator on June 1, 2026 at 11:15 AM. The administrator confirmed that the home care agency's license was not posted in a conspicuous location on the premises and was not readily retrievable.
This is a repeat deficiency although the survey location on June 1, 2026 was different from the survey location/site in 2023.
Plan of Correction:POC is to have license framed and printed hanging prominently on the wall along with all other employee related documents
Initial Comments:
Based on the findings of an onsite State Re-Licensure Survey conducted on June 1, 2026, Deb's Care LLC was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H, Home Care Agencies and Home Care Registries.
Plan of Correction:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of § 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of § 611.53 (relating to child abuse clearance).
Observations:
Based on a review of personnel files (PF) and an interview with the administrator, the home care agency (HCA) did not provide evidence that prior to hiring the individual, a face to face interview was conducted, not less than two satisfactory references were obtained, and a criminal background check was obtained at the time of application or within one year of the date of application for seven (7) of seven (7) PF's reviewed: PF#1, PF#2, PF#3, PF#4, PF#5, PF#6 and PF#7.
Findings include:
An interview held with the administrator on June 1, 2026 at approximately 10:45 AM found that the administrator maintained electronic personnel files on a desktop computer which was at another location. The administrator stated that s/he downloaded files from the desktop computer to a USB drive and subsequently uploaded the files to a laptop computer that was used during the re-licensure survey. The administrator stated that it appeared that some of the files did not upload/download correctly and that information was missing.
A review of PF's was conducted on June 1, 2026 starting at 10:30 AM. The date of hire (DOH) is indicated below.
PF#1 DOH 08/30/2024 did not contain evidence that prior to hiring the individual, a face to face interview was conducted and that two satisfactory non-family member references were obtained. There was only one (1) reference check present in the PF. The Pennsylvania Access to Criminal History (PATCH) report contained in the PF was dated 06/01/2026. The administrator stated that s/he generated another PATCH report on the day of the survey because s/he was unable to locate the original criminal history report.
PF#2 DOH 10/12/2024 did not contain evidence that prior to hiring the individual, a face to face interview was conducted and two satisfactory non-family member references were obtained. There was only one (1) reference check present in the PF and it was dated 08/15/2020. The Pennsylvania Access to Criminal History (PATCH) report contained in the PF was dated 04/21/2021. The administrator stated that PF#2 was a rehire in 2024. Reference checks and a PATCH report were not obtained at the time of rehire in 2024.
PF#3 DOH 07/12/2024 did not contain evidence that prior to hiring the individual, a face to face interview was conducted and two satisfactory non-family member references were obtained. There was only one (1) reference check present in the PF. There was no criminal history report in the PF.
PF#4 DOH 01/01/2023 did not contain evidence that prior to hiring the individual, a face to face interview was conducted and two satisfactory non-family member references were obtained. There was only one (1) reference check present in the PF. The Pennsylvania Access to Criminal History (PATCH) report contained in the PF was dated 06/01/2026. The administrator stated that s/he generated another PATCH report on the day of the survey because s/he was unable to locate the original criminal history report.
PF#5 DOH 12/08/2022 did not contain evidence that prior to hiring the individual, a face to face interview was conducted and two satisfactory non-family member references were obtained. There was only one (1) reference check present in the PF. The Pennsylvania Access to Criminal History (PATCH) report contained in the PF was dated 06/01/2026. The administrator stated that s/he generated another PATCH on the day of the survey because s/he was unable to locate the original criminal history report.
PF#6 DOH 01/31/2023 did not contain evidence that prior to hiring the individual, a face to face interview was conducted and two satisfactory non-family member references were obtained. There was only one (1) reference check present in the PF dated 09/01/2021. The administrator stated that PF#6 was a rehire in 2023. Reference checks were not obtained at the time of rehire in 2023. There was no criminal history report present in the PF.
PF#7 DOH 03/07/2026 did not contain evidence that prior to hiring the individual, a face to face interview was conducted and two satisfactory non-family member references were obtained. There was only one (1) reference check present in the PF. There was no criminal history report present in the PF.
An interview conducted with the administrator on June 1, 2026 starting at 11:15 AM confirmed the above findings.
Plan of Correction:The POC is to have all initial applications and interview documents including references will be scanned in and digitally available on the cloud moving forward this included reference checks taken at the time of hire. We plan to monitor this quarterly. Administrator office manager Shall be responsible for conducting quarterly review. POC date is 7/16/2026
611.52(c) LICENSURE
Federal Criminal History Record
Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code § 15.144(b) (relating to procedure).
Observations:
Based on a review of personnel files (PF) and an interview with the administrator, the home care agency (HCA) failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for an individual who provided no evidence of residency in the Commonwealth for the 2 years immediately preceding the date of request for a criminal history report. One (1) of seven (7) PF's did not meet the requirement: PF#3.
Findings include:
A review of PF's was conducted on June 1, 2026 starting at 10:30 AM. The date of hire (DOH) is indicated below.
PF#3 DOH 07/12/2024 contained a Delaware Driver's License. There was no evidence in the PF that the individual resided in the Commonwealth for the two (2) years immediately preceding the date of the request for a criminal history report and no evidence of a federal criminal history report and a letter of determination from the Department of Aging.
An interview conducted with the administrator on June 1, 2026 starting at 11:15 AM confirmed the above findings.
Plan of Correction:The POC is All applicants without 2 year instate residency will submit to federal back ground check along with child line clearance prior to hire. All new hires going forward will be have background checks completed prior start of work. We plan to monitor this quarterly. Administrator office manager Shall be responsible for conducting quarterly review. POC date is 7/16/2026
611.52(d) LICENSURE
Proof of Residency
Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation
Observations:
Based on a review of personnel files (PF) and an interview with the administrator, the home care agency (HCA) did not obtain Pennsylvania (PA) proof of residency for the direct care worker (DCW) for the two (2) consecutive years immediately preceding the date of hire through the submission of any one of the following documents: (1) Motor vehicle records, such as a valid driver's license or a State-issued identification. (2) Housing records, such as mortgage records or rent receipts. (3) Public utility records and receipts, such as electric bills. (4) Local tax records. (5) A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it. (6) Employment records, including records of unemployment compensation. Three (3) of seven (7) PF's reviewed did not meet the requirement: PF#1, PF#2, and PF#3.
Findings include:
A review of PF's was conducted on June 1, 2026 starting at 10:15 AM. The date of hire (DOH) is indicated below.
PF#1 DOH 08/30/2025 contained a copy of a PA Identification (ID) Card issued 02/28/2025. There was no verifiable documentation of PA residency for the two (2) consecutive years immediately preceding the DOH from 08/30/2023 to 02/28/2025.
PF#2 DOH 10/12/2024 contained a PA Driver's License (DL) issued 09/24/2019. The individual was hired in 2021, then rehired again in 2024. There was no verifiable documentation of PA residency for the two (2) consecutive years immediately preceding the DOH from 10/12/2022 to 10/12/2024.
PF#3 DOH 07/12/2024 contained a Delaware DL. There was no verifiable documentation of PA residency for the two (2) consecutive years immediately preceding the DOH from 07/12/2022 to 07/12/2024.
An interview conducted with the administrator on June 1, 2025 starting at 11:15 AM confirmed the above findings.
Plan of Correction:prior to hire proper documentation will be obtained making sure potential employee has been in state for 2 consecutive years prior to employment using Motor vehicle records, such as a valid driver's license or a State-issued identification. Housing records, such as mortgage records or rent receipts. Public utility records and receipts, such as electric bills. Local tax records. A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it. Employment records, including records of unemployment compensation. The Agency Believes all deficiencies will be corrected by 7/16/2026. Going forward the monitoring will take place quarterly
611.55(a) LICENSURE
Competency Requirements
Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.
Observations:
Based on a review of personnel files (PF) and an interview with the administrator, the home care agency (HCA) failed to assure that prior to providing services to a consumer, the direct care worker (DCW) completed intial competency training or testing for four (4) of seven (7) PF's reviewed: PF#2, PF#5, PF#6, and PF#7.
Findings include:
An interview held with the administrator on June 1, 2026 at approximately 10:45 AM found that the administrator maintained electronic personnel files on a desktop computer which was at another location. The administrator stated that s/he downloaded files from the desktop computer to a USB drive and subsequently uploaded the files to a laptop computer that was used during the re-licensure survey. The administrator stated that it appeared that some of the files did not upload/download correctly and that information was missing.
A review of PF's was conducted on June 1, 2026 starting at 10:30 AM. The date of hire (DOH) is indicated below.
PF#2 DOH 10/12/2024 contained an initial competency examination that was dated 08/12/2019. The individual was a rehire in 2024. There was no evidence of initial competency testing or training upon rehire in 2024.
PF#5 DOH 12/08/22 did not contain any evidence of initial competency training or testing at the time of hire.
PF#6 DOH 01/31/2023 contained an initial competency examination that was dated 09/01/2021. The individual was a rehire in 2023. There was no evidence of initial competency testing or training upon rehire in 2023.
PF#7 DOH 03/07/2026 contained no evidence of initial competency testing or training at the time of hire.
An interview with the administrator on June 1, 2026 starting at 11:15 AM confirmed the above findings.
Plan of Correction:Prior to employment Employees will under go initial competency training or testing. This testing and training will be acknowledge and saved in employees digital file upon completed along with annual assessments. The Agency Believes all deficiencies will be corrected by 7/15/2026. Going forward the monitoring will take place quarterly
611.55(e) LICENSURE
Competency Requirements
Name - Component - 00
The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.
Observations:
Based on a review of personnel files (PF) and an interview with the administrator, the home care agency (HCA) failed to assure that a competency review occurred at least once per year after initial competency was established for five (5) of seven (7) PF's reviewed: PF#2, PF#3, PF#4, PF#5, and PF#6.
Findings include:
An interview held with the administrator on June 1, 2026 at approximately 10:45 AM found that the administrator maintained electronic personnel files on a desktop computer which was at another location. The administrator stated that s/he downloaded files from the desktop computer to a USB drive and subsequently uploaded the files to a laptop computer that was used during the re-licensure survey. The administrator stated that it appeared that some of the files did not upload/download correctly and that information was missing.
A review of PF's was conducted on June 1, 2026 starting at 10:30 AM. The date of hire (DOH) is indicated below.
PF#2 DOH 10/12/2024 did not contain evidence of an annual competency review in 2025.
PF#3 DOH 07/12/2024 did not contain evidence of an annual competency review in 2025.
PF#4 DOH 01/01/2023 did not contain evidence of an annual competency review in 2024 or 2025.
PF#5 DOH 12/08/2022 did not contain evidence of an annual competency review in 2023, 2024, or 2025.
PF#6 DOH 01/31/2023 did not contain evidence of an annual competency review in 2024 or 2025.
An interview held with the administrator on June 1, 2026 starting at 11:15 AM confirmed the above findings.
Plan of Correction:employees will undergo initial and annual competency training or testing this will be saved to the employees cloud file. The Agency Believes all deficiencies will be corrected by 7/16/2026. Going forward the monitoring will take place quarterly to ensure compliance
611.56(a) LICENSURE
Health Screening
Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.
Observations:
Based on a review of personnel files (PF), the Centers for Disease Control and Prevention (CDC) Guidelines, and an interview with the administrator, the home care agency (HCA) did not provide evidence that a direct care worker (DCW), upon hire, completed a TB test (e.g., a TB single blood assay test or a two-step tuberculin skin test (TST) for five (5) of seven (7) PF's reviewed: PF#2, PF#3, PF#4, PF#5, and PF#6, a baseline individual TB risk assessment and a TB symptom evaluation upon hire for seven (7) of seven (7) PF's reviewed: PF#1, PF#2, PF#3, PF#4, PF#5, PF#6, and PF#7, and annual TB education for five (5) of seven (7) PF's reviewed: PF#2, PF#3, PF#4, PF#5, and PF#6.
Findings include:
The Centers for Disease Control and Prevention (CDC) and the National TB Controllers Association released updated recommendations for Tuberculosis (TB) screening, testing, and treatment of health care personnel on May 17, 2019. These recommendations update the health care personnel screening and testing section of the 2005 CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings. All health care personnel should be screened for TB upon hire (i.e., preplacement). TB screening is a process that includes: a baseline individual TB risk assessment, a TB symptom evaluation, and a TB test (e.g., a TB single blood assay test or a two-step tuberculin skin test (TST), and additional evaluation for TB disease as needed. Health care personnel with a positive TB test result should receive a symptom evaluation and a chest x-ray to rule out TB disease. Additional workup may be needed based on those results. All health care personnel should receive TB education annually. TB education should include information on TB risk factors, the signs and symptoms of TB disease, and TB infection control policies and procedures. (CDC/MMWR/May 17, 2019/Vol.68/No.19).
An interview held with the administrator on June 1, 2026 at approximately 10:45 AM found that the administrator maintained electronic personnel files on a desktop computer which was at another location. The administrator stated that s/he downloaded files from the desktop computer to a USB drive and subsequently uploaded the files to a laptop computer that was used during the re-licensure survey. The administrator stated that it appeared that some of the files did not upload/download correctly and that information was missing.
A review of PF's was conducted on June 1, 2026 starting at 10:30 AM. The date of hire (DOH) is indicated below.
PF#1 DOH 08/30/2025 did not contain evidence that a baseline individual TB risk assessment or TB symptom evaluation was completed upon hire.
PF#2 DOH 10/12/2024 did not contain evidence that a TST or a single blood assay test was completed upon hire. The TST documentation contained in the PF was dated 07/09/2025 (TST#1) and 07/24/2025 (TST#2). The administrator stated that "TB tests are repeated every year." There was no evidence that a baseline individual TB risk assessment or TB symptom evaluation was completed upon hire nor was there evidence of annual TB education in 2025.
PF#3 DOH 07/12/2024 contained no evidence that a TST or a single blood assay test was completed upon hire or anytime thereafter. There was no evidence that a baseline individual TB risk assessment or TB symptom evaluation was completed upon hire nor was there evidence of annual TB education in 2025.
PF#4 DOH 01/01/2023 contained no evidence that a TST or a single blood assay test was completed upon hire or anytime thereafter. There was no evidence that a baseline individual TB risk assessment or TB symptom evaluation was completed upon hire nor was there evidence of annual TB education in 2025.
PF#5 DOH 12/08/2022 did not contain evidence that a TST or a single blood assay test was completed upon hire. The TST documentation contained in the PF was dated 07/09/2025 (TST#1) and 07/24/2025 (TST#2). The administrator stated that "TB tests are repeated every year." There was no evidence that a baseline individual TB risk assessment or TB symptom evaluation was completed upon hire nor was there evidence of annual TB education in 2023, 2024 or 2025.
PF#6 DOH 01/31/2023 did not contain evidence that a TST or a single blood assay test was completed upon hire. The TST documentation contained in the PF was dated 07/09/2025 (TST#1) and 07/23/2025 (TST#2). The administrator stated that "TB tests are repeated every year." There was no evidence that a baseline individual TB risk assessment or TB symptom evaluation was completed upon hire nor was there evidence of annual TB education in 2024 or 2025.
PF#7 DOH 03/07/2026 did not contain evidence that a baseline individual TB risk assessment or TB symptom evaluation was completed upon hire.
An interview with the administrator on June 1, 2026 starting at 11:15 AM confirmed the above findings.
Plan of Correction:Direct care worker upon hire will furnish a negative tb test taken within one year of hire or have one taken prior to hire with negative result in accordance with the Centers for Disease Control and Prevention Guidelines. The Agency Believes all deficiencies will be corrected by 7/15/2026. Going forward the monitoring will take place quarterly
611.57(a) LICENSURE
Consumer Rights
Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.
Observations:
Based on a review of consumer files (CF), HHA eXchange (platform used for communication between the managed care organization (MCO) and home care agency (HCA), and an interview with the administrator, the HCA failed to ensure that the consumer was receiving services with reasonable accommodation of individual needs and preferences for three (3) of five (5) CF's reviewed: CF#2, CF#3, and CF#4.
Findings include:
A review of CF's was conducted on June 1, 2026 starting at 9:15 AM. The start of care (SOC) is indicated below.
CF#2 SOC 10/12/2024 was authorized by the MCO to receive 10 hours of service per day or 70 hours of service per week. The MCO created a plan of care (POC) in HHA eXchange for the direct care worker (DCW) which listed the duties to be performed by the DCW. A review of randomly selected dates from the visit calendar in HHA eXchange for 05/06/26, 05/08/2026, 05/11/2026, 05/13/2026, and 05/18/2026 found that there were no duties documented by the DCW per the POC in HHA eXchange.
CF#3 SOC 05/12/2025 was authorized by the MCO to receive 12 hours of service per day or 84 hours of service per week. There was no POC established by either the MCO nor the HCA. A review of randomly selected dates from the visit calendar in HHA eXchange for 05/04/26, 05/15/26, 05/16/26, 5/22/26, and 5/24/26 found that there were no duties documented by the DCW per the POC in HHA eXchange.
CF#4 SOC 08/30/2025 was authorized by the MCO to receive 8 to 9 hours of service per day or 61 hours of service per week. A review of the visit calendar in HHA eXchange found that there were numerous days throughout April and May whereby the number of hours of service per day was either unable to be determined or not provided in accordance with the authorized hours. The following dates contained a clock in time, but no clock out time and therefore, the daily service hours were unable to be determined: 4/4/26, 4/6/26, 4/8/26, 4/14/26, 4/16/26, 4/20/26, 4/23/26, 5/8/26, 5/9/26, 5/15/26, and 5/24/26. The following dates contained no evidence of a visit by the DCW: 4/9/26, 4/14/26, to 4/15/26, 4/17/26 to 4/19/26, 04/21/26 to 04/22/26, 4/24/26 to 4/30/26, 5/2/26, 5/3/26, 5/5/26, 5/7/26, 5/10/26, 5/12/26, 5/13/26, 5/15/26 to 5/19/26, and 5/21/26 to 5/22/26.
An interview conducted with the administrator on June 1, 2026 starting at 11:15 AM confirmed the above findings.
Plan of Correction:Hha exchange is reviewed daily to ensure consumers are receiving services with reasonable accommodation of individual needs and preferences. The Agency Believes all deficiencies will be corrected by 7/16/2026. Going forward the monitoring will take place quarterly
611.57(b) LICENSURE
Prohibitions
Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.
Observations:
Based on a review of consumer files (CF) and an interview with the administrator, the home care agency (HCA) failed to assure that the consumer received information concerning the prohibitions that no individual as a result of the individual's affiliation with a HCA may assume power of attorney or guardianship over a consumer utilizing the services of that HCA, and that the HCA may not require a consumer to endorse checks over to the HCA. Five (5) of five (5) CF's did not meet the requirement: CF#1, CF#2, CF#3, CF#4, and CF#5.
Findings include:
A review of CF's was conducted on June 1, 2026 starting at 9:15 AM. The start of care (SOC) is indicated below.
CF#1 SOC 01/01/2023 did not contain evidence that the consumer received information concerning the prohibitions that no individual as a result of the individual's affiliation with a HCA may assume power of attorney or guardianship over a consumer utilizing the services of that HCA, and that the HCA may not require a consumer to endorse checks over to the HCA.
CF#2 SOC 10/12/2024 did not contain evidence that the consumer received information concerning the prohibitions that no individual as a result of the individual's affiliation with a HCA may assume power of attorney or guardianship over a consumer utilizing the services of that HCA, and that the HCA may not require a consumer to endorse checks over to the HCA.
CF#3 SOC 05/12/2025 did not contain evidence that the consumer received information concerning the prohibitions that no individual as a result of the individual's affiliation with a HCA may assume power of attorney or guardianship over a consumer utilizing the services of that HCA, and that the HCA may not require a consumer to endorse checks over to the HCA.
CF#4 SOC 08/30/2025 did not contain evidence that the consumer received information concerning the prohibitions that no individual as a result of the individual's affiliation with a HCA may assume power of attorney or guardianship over a consumer utilizing the services of that HCA, and that the HCA may not require a consumer to endorse checks over to the HCA.
CF#5 SOC 07/12/2024 did not contain evidence that the consumer received information concerning the prohibitions that no individual as a result of the individual's affiliation with a HCA may assume power of attorney or guardianship over a consumer utilizing the services of that HCA, and that the HCA may not require a consumer to endorse checks over to the HCA.
An interview held with the administrator on June 1, 2026 starting at 11:15 AM confirmed the above findings.
Plan of Correction:All consumer will receive information concerning the prohibitions that no individual as a result of the individual's affiliation with a HCA may assume power of attorney or guardianship over a consumer utilizing the services of that HCA, and that the HCA may not require a consumer to endorse checks over to the HCA. This will be signed and acknowledged and scanned into the cloud. The Agency Believes all deficiencies will be corrected by 7/16/2026. Going forward the monitoring will take place quarterly
611.57(c) LICENSURE
Information to be Provided
Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.
Observations:
Based on a review of consumer files (CF) and an interview with the administrator, the home care agency (HCA) failed to assure that prior to the start of services, the consumer, consumer's legal representative or a responsible family member received information pertaining to the list of services to be provided to the consumer, the identity of the direct care worker (DCW) who was to provide the services, the hours when the services were to be provided, the phone number for the Department regarding information about the HCA's licensure and compliance, the complaint hotline phone number, the hiring and competency requirements of the DCW and a disclosure form intended to document if the DCW was or was not an employee of the agency and if the HCA maintained general and professional liability insurance. Five (5) of five (5) CF's reviewed did not meet the requirement: CF#1, CF#2, CF#3, CF#4, and CF#5.
Findings include:
A review of CF's was conducted on June 1, 2026 starting at 9:15 AM. The start of care (SOC) is indicated below.
CF#1 SOC 01/01/2023 did not contain evidence that, prior to the start of services, the consumer, consumer's legal representative or a responsible family member received information pertaining to the listing of services to be provided to the consumer, the identity of the DCW who was to provide the services, and the hours when the services were to be provided. The service agreement included a section intended to document that the consumer received the admission packet which contained the phone number at the Department for information about the HCA's licensure and compliance, the complaint hotline phone number, and the hiring and competency requirements of the DCW. The above-noted section of the service agreement was not completed (left blank) and therefore, it was unable to be determined if the consumer received the information contained in the admission packet. There was no evidence of a disclosure form in the consumer file, intended to indicate if the direct care worker (DCW) was or was not an employee of the agency, nor if the HCA maintained professional and general liability insurance.
CF#2 SOC 10/12/2024 did not contain evidence that, prior to the start of services, the consumer, consumer's legal representative or a responsible family member received information pertaining to the listing of services to be provided to the consumer, the identity of the DCW who was to provide the services, and the hours when the services were to be provided. The service agreement included a section intended to document that the consumer received the admission packet which contained the phone number at the Department for information about the HCA's licensure and compliance, the complaint hotline phone number, and the hiring and competency requirements of the DCW. The above-noted section of the service agreement was not completed (left blank) and therefore, it was unable to be determined if the consumer received the information contained in the admission packet. There was no evidence of a disclosure form in the consumer file, intended to indicate if the direct care worker (DCW) was or was not an employee of the agency, nor if the HCA maintained professional and general liability insurance.
CF#3 SOC 05/12/2025 did not contain evidence that, prior to the start of services, the consumer, consumer's legal representative or a responsible family member received information pertaining to the listing of services to be provided to the consumer, the identity of the DCW who was to provide the services, and the hours when the services were to be provided. The service agreement included a section intended to document that the consumer received the admission packet which contained the phone number at the Department for information about the HCA's licensure and compliance, the complaint hotline phone number, and the hiring and competency requirements of the DCW. The above-noted section of the service agreement was not completed (left blank) and therefore, it was unable to be determined if the consumer received the information contained in the admission packet. There was no evidence of a disclosure form in the consumer file, intended to indicate if the direct care worker (DCW) was or was not an employee of the agency, nor if the HCA maintained professional and general liability insurance.
CF#4 SOC 08/30/2025 did not contain evidence that, prior to the start of services, the consumer, consumer's legal representative or a responsible family member received information pertaining to the listing of services to be provided to the consumer, the identity of the DCW who was to provide the services, and the hours when the services were to be provided. The service agreement included a section intended to document that the consumer received the admission packet which contained the phone number at the Department for information about the HCA's licensure and compliance, the complaint hotline phone number, and the hiring and competency requirements of the DCW. The above-noted section of the service agreement was not completed (left blank) and therefore, it was unable to be determined if the consumer received the information contained in the admission packet. There was no evidence of a disclosure form in the consumer file, intended to indicate if the direct care worker (DCW) was or was not an employee of the agency, nor if the HCA maintained professional and general liability insurance.
CF#5 SOC 07/12/2024 did not contain evidence that, prior to the start of services, the consumer, consumer's legal representative or a responsible family member received information pertaining to the listing of services to be provided to the consumer, the identity of the DCW who was to provide the services, and the hours when the services were to be provided. The service agreement included a section intended to document that the consumer received the admission packet which contained the phone number at the Department for information about the HCA's licensure and compliance, the complaint hotline phone number, and the hiring and competency requirements of the DCW. The above-noted section of the service agreement was not completed (left blank) and therefore, it was unable to be determined if the consumer received the information contained in the admission packet. There was no evidence of a disclosure form in the consumer file, intended to indicate if the direct care worker (DCW) was or was not an employee of the agency, nor if the HCA maintained professional and general liability insurance.
An interview held with the administrator on June 1, 2026 starting at 11:15 AM confirmed the above findings.
Plan of Correction:information will be provided new consumer/patient handbook
prior to the start of services, the consumer, consumer's legal representative or a responsible family member receive information pertaining to the list of services to be provided to the consumer, the identity of the direct care worker who was to provide the services, the hours when the services were to be provided, the phone number for the Department regarding information about the HCA's licensure and compliance, the complaint hotline phone number, the hiring and competency requirements of the DCW and a disclosure form intended to document if the DCW was or was not an employee of the agency and if the HCA maintained general and professional liability insurance this information will be uploaded tom the cloud labeled with caregiver and consumer name. The Agency Believes all deficiencies will be corrected by 7/16/2026. Going forward the monitoring will take place quarterly
Initial Comments:
Based on the findings of an onsite State Re-Licensure Survey conducted on June 1, 2026, Deb's Care LLC was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
35 P. S. § 448.809b LICENSURE
Photo Id Reg
Name - Component - 00
Law amended July 11, 2022 Act 79 2022 HB 2604
(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.
(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.
(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.
(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.
Observations:
Based on an interview with the administrator, it was determined that the Agency failed to provide evidence of photo identification tags that included the employee's name, title, picture, and the name of the Agency.
Findings include:
During discussion with the administrator on June 1, 2026 at approximately 11:00 AM, the surveyor asked the administrator for the identification badge that is provided to agency personnel. The administrator retrieved a file from the laptop computer that contained a photographs of ID badges created for several employees, but none of the badges contained a picture of the employees. The administrator did not know why the photos were not appearing on the badges.
An interview conducted with the administrator on June 1, 2026 at 11:15 AM confirmed the above findings.
Plan of Correction:All employees photo identification tags that included the employee's name, title, picture, and the name of the Agency. will be scanned and uploaded to cloud attached to employee file. The Agency Believes all deficiencies will be corrected by 7/16/2026. Going forward the monitoring will take place quarterly
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