Initial Comments:
Based on the findings of an onsite unannounced state license survey completed March 31, 2026, Visiting Angels of Pittsburgh was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced state license survey completed March 31, 2026, Visiting Angels of Pittsburgh was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.
Plan of Correction:
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 CDC (Center for Disease Control and Prevention) guidelines, direct care worker personnel files (PF), and staff (EMP) interview, the agency failed to ensure each direct care worker was screened for mycobacterium tuberculosis (TB) in accordance with CDC (Center for Disease and Control) guidelines prior to consumer contact for six (6) of seven (7) personnel files (PF1-PF6).
Findings included:
According to "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," "Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST [tuberculin skin testing], shall include a symptom screen questionnaire and an individual TB risk assessment." Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6819-H.pdf
Review of personnel files was conducted on March 31, 2026, at 10 a.m.
PF1 was hired on 3/3/2026 and in contact with consumers beginning 3/4/2026. PF1 contained no TB symptom screen questionnaire completed prior to consumer contact.
PF2 was hired on 2/18/2026 and in contact with consumers beginning 2/28/2026. PF2 contained no TB symptom screen questionnaire completed prior to consumer contact.
PF3 was hired on 2/5/2026 and in contact with consumers beginning 2/9/2026. PF3 contained no TB symptom screen questionnaire completed prior to consumer contact.
PF4 was hired on 11/25/2025 and in contact with consumers beginning 11/29/2025. PF4 contained no TB symptom screen questionnaire completed prior to consumer contact.
PF5 was hired on 11/12/2025 and in contact with consumers beginning 11/24/2025. PF5 contained no TB symptom screen questionnaire completed prior to consumer contact.
PF6 was hired on 1/28/2026 and in contact with consumers beginning 2/7/2026. PF6 contained no TB symptom screen questionnaire completed prior to consumer contact.
Interview with EMP1 (director) and EMP2 (owner/admin) on March 31, 2026, at 12:15 p.m. confirmed above findings.
Plan of Correction:S 0701
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual.
We were using the wrong TB screening questionnaire upon hire for our caregivers. We have updated our onboarding process to include the correct TB screening form which met the surveyor's approval during the exit interview. The surveyor stated we did not have to go back and have the caregivers complete a new screening form. Just adopt the correct form moving forward.
2. Indicate how the facility will act to protect patients in similar situations.
We have implemented this document in our onboarding process as of 4/1/2026
3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur.
The document has been hard coded in our offer packets. All individuals offered a position will complete the screening form prior to orientation.
4. Indicate how it plans to monitor its performance to make sure that solutions are sustained; and
We will audit 10 new hires quarterly for compliance.
5. Provide dates when corrective action will be completed. 4/23/2026
611.56(b) LICENSURE
Health Screening
Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.
Observations:
Based on review of Centers for Disease Control and Prevention (CDC) guidelines, direct care worker personnel files (PF) and staff (EMP) interview, the agency failed to ensure one (1) of one (1) eligible employee (PF7) received annual mycobacterium tuberculosis (TB) education in accordance with CDC guidelines.
Findings included:
According to CDC guidelines "Serial screening and testing not routinely recommended. Annual TB education is recommended." Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6819-H.pdf
Review of personnel files was conducted on March 31, 2026, at 10 a.m.
PF7 was hired on 2/12/2025 and in contact with consumers beginning 2/20/2025. PF7 had no annual TB education completed.
Interview with EMP1 (director) and EMP2 (owner/admin) on March 31, 2026, at 12:15 p.m. confirmed above findings.
Plan of Correction:1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual.
All PFs listed in the survey will receive TB training during the month of April, 2026. All other Caregivers on our Roster will also receive the training in April of 2026.
2. Indicate how the facility will act to protect patients in similar situations.
We will send out Annual TB training to all caregivers annually in April.
3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur.
The TB training Plan has been added to the entire PA leadership team calendar to send out TB training on March 25th annually.
4. Indicate how it plans to monitor its performance to make sure that solutions are sustained;
Annually in May we will audit 50% of the caregivers to assure they have completed their annual TB Training
5. Provide dates when corrective action will be completed. 4/23/2026
Initial Comments:
Based on the findings of an onsite unannounced state license survey completed March 31, 2026, Visiting Angels of Pittsburgh was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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