Initial Comments:
Based on the findings of an onsite state relicensure survey completed March 16, 2026, Empathy of All Hearts Home Care Services LLC was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite state relicensure survey completed March 16, 2026, Empathy of All Hearts Home Care Services LLC was found not to be in compliance with the 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
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.
Observations:
Based on a review of employee files (EF) of direct care workers and staff (EMP) interview, the agency failed to ensure that each employee with direct consumer contact was screened for mycobacterium tuberculosis (TB) in accordance with CDC guidelines for seven (7) of seven (7) employee files reviewed (EF1, EF2, EF3, EF4, EF5, EF6 and EF7).
Findings include:
The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis...HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease....A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST within the previous 12 months, a single TST can be administered in the new setting. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(RR-17) http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
A review of employee files (EF) of direct care workers on 3/16/26 at 10:08 a.m. revealed the following:
EF1 Date of Hire 5/21/25, did not contain documentation of a symptom screen questionnaire and an individual TB risk assessment.
EF2 Date of Hire 1/24/25, did not contain documentation of a symptom screen questionnaire and an individual TB risk assessment.
EF3 Date of Hire 12/8/25, did not contain documentation of a symptom screen questionnaire and an individual TB risk assessment.
EF4 Date of Hire 11/11/24, There was a documented negative result TST completed 11/4/24. There was no evidence documented of a second TST completed in accordance with CDC guidelines. Did not contain documentation of a symptom screen questionnaire and an individual TB risk assessment.
EF5 Date of Hire 9/26/25, There was a documented negative result TST completed 7/23/25. There was no evidence documented of a second TST completed in accordance with CDC guidelines Did not contain documentation of a symptom screen questionnaire and an individual TB risk assessment.
EF6 Date of Hire 2/24/26, There was a documented negative result TST completed 3/30/25. There was no evidence documented of a second TST completed in accordance with CDC guidelines. Did not contain documentation of a symptom screen questionnaire and an individual TB risk assessment.
EF7 Date of Hire 2/19/25, did not contain documentation of a symptom screen questionnaire and an individual TB risk assessment.
During an interview on 3/16/26, at 11:48 a.m. EMP1 the Administrator confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for those individuals and/or practices identified in the deficiency statement(s).
2 step tb or documentation of 2nd TB or TB Gold or Chest Xray are required within the next 5/15/26.
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
We will audit all files
2. What measures (actions/forms/system changes, etc.) will be put in place to ensure that the deficient practice does not recur?
We will audit all files The File checklist will require for the employee to write the date for when the tb was conducted whether it is a 2 step, TB gold, or chest Xray to ensure all required dates for documentation was received.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance programs will be established/followed?
- The agency administrator, Executive Assistant, and Staffing Coordinator upon hire will audit the file after completed for initial hire. Every Quarter all files will be audited to ensure no decencies will occur.
5. Date of when the corrective action will be completed.
May 15, 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 employee files (EF), Centers for Disease Control (CDC) Guidelines, and staff (EMP) interview, it was determined the agency failed to ensure all workers with direct consumer contact received annual mycobacterium tuberculosis (TB) education for three (3) of seven (7) direct care worker employee files reviewed (EF2, EF4 and EF7)
Findings include:
The CDC guidelines state...."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
A review of employee files (EF) of direct care workers on 3/16/26 at 10:08 a.m. revealed the following:
EF2 Date of Hire 1/24/25, no documentation was available to verify annual TB education was provided.
EF4 Date of Hire 11/11/24, no documentation was available to verify annual TB education was provided.
EF7 Date of Hire 2/19/25, no documentation was available to verify annual TB education was provided.
During an interview on 3/16/26, at 11:48 a.m. EMP1 the Administrator confirmed the above findings.
Plan of Correction:1. What corrective action will be accomplished for those individuals and/or practices identified in the deficiency statement(s).
TB questionnaires will be required for all employees upon hire and annually
2. How will you identify other individuals having the potential to be affected by the same deficient practice?
We will audit all files
3. What measures (actions/forms/system changes, etc.) will be put in place to ensure that the deficient practice does not recur?
We will add the Tb questionnaire to our onboarding documents to ensure they are completed upon hiring, and we will add the tb questionnaire to the annual training packet to ensure the tb questionnaire is completed annually.
4. How will the corrective action be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance programs will be established/followed?
- The agency administrator, Executive Assistant, and Staffing Coordinator upon hire will audit the file after completed for initial hire. Every Quarter all files will be audited to ensure no decencies will occur.
5. Date of when the corrective action will be completed.
May 15, 2026
Initial Comments:
Based on the findings of an onsite state relicensure survey completed March 16, 2026, Empathy of All Hearts Home Care Services LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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