Initial Comments:
Based on the findings of an onsite announced state re-licensure survey conducted on April 23, 2026, Thema Home Care, Ltd. 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 announced state re-licensure survey completed on April 23, 2026, Thema Home Care, Ltd. 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
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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 upon review of direct care worker personnel files (PF) and agency Executive Director, the agency failed to document two (2) satisfactory references prior to employment for three (3) of seven (7) PF reviewed. (PF #1, 2, and 6).
Findings Include:
A review of PF's conducted on April 23, 2026, from approximately 1:00 P.M. to 2:15 P.M. revealed the following:
PF #1, date of hire January 31, 2026, contained no documentation of two (2) satisfactory references.
PF #2, date of hire February 11, 2026, contained no documentation of two (2) satisfactory references.
PF #6, date of hire November 5, 2025, contained no documentation of two (2) satisfactory references.
An interview with the agency Executive Director on April 23, 2026, at approximately 2:30 P.M. confirmed the above findings.
Plan of Correction:Agency will implement a standardized Reference Check process immediately to complete during the onboarding process prior to hire. A standardized form will be completed during employee onboarding and employees will not be able to complete the hiring process until the references are returned. Agency will also audit 100% of all new hires for 90 days to ensure all new hires have completed the reference check process prior to hire. Results will be reviewed by administration, and any variances will result in immediate corrective action.
611.52(c) LICENSURE
Federal Criminal History Record
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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 upon review of direct care worker personnel files (PF) and an interview with the agency Executive Director, the agency failed to obtain a Federal criminal background check for one (1) of seven (7) PF reviewed. (PF #4)
Findings Include:
A review of PF's conducted on April 23, 2026, from approximately 1:00 P.M. to 2:15 P.M. revealed the following:
PF #4, date of hire January 24, 2024, contained a New Jersey driver's license issued January 10, 2023. There was no documentation of residency in Pennsylvania for the two (2) year immediately preceding the date of application. There was no documentation of a Federal criminal background check completed upon hire.
An interview with the agency Executive Director, at approximately 2:30 P.M. confirmed the above findings.
Plan of Correction:The identified individual will complete a Federal Background Check within 30 days. The agency will also conduct a 100% audit for all active employees who were not PA residents for at least 2 years upon hire to ensure all have a federal background check on file. All new hires will be audited for compliance with background check requirements for 90 days, followed by annual audit. Results will be reviewed by administration, and any variances will result in immediate corrective action.
611.56(a) LICENSURE
Health Screening
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(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 upon review of direct care worker personnel files (PF) and an interview with the agency Executive Director, the agency failed to ensure a symptom screen questionnaire and/or an individual tuberculosis (TB) risk assessment were completed upon hire and/or annual TB education was conducted in accordance with CDC (Centers for Disease Control and Prevention) guidelines for seven (7) of seven (7) PF reviewed (PF #1, 2, 3, 4, 5, 6, and 7).
Findings Include:
"The CDC guidelines state baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or tuberculin skin test (TST), shall include a symptom screen questionnaire and an individual tuberculosis (TB) risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended."
Review of PF on April 23, 2026, from approximately 1:00 P.M. to 2:15 P.M. revealed the following:
PF #1, date of hire January 31, 2026, contained no documentation of a TB symptom screening questionnaire and a TB risk assessment completed upon hire.
PF #2, date of hire February 11, 2026, contained no documentation of a symptom screening questionnaire completed upon hire.
PF #3, date of hire July 30, 2025, contained no documentation of a symptom screening questionnaire and a TB risk assessment completed upon hire.
PF #4, date of hire January 24, 2024, contained no documentation of a TB symptom screening questionnaire and a TB risk assessment completed upon hire and no documentation of annual TB education in 2025 and 2026.
PF #5, date of hire February 14, 2024, contained no documentation of a symptom screening questionnaire or a TB risk assessment completed upon hire, and no documentation of annual TB education in 2025 and 2026.
PF #6, date of hire November 5, 2025, contained no documentation of a symptom screening questionnaire and a TB risk assessment completed upon hire.
PF #7, date of hire June 26, 2023, contained no documentation of a symptom screening questionnaire and a TB risk assessment completed upon hire, and no documentation of annual TB education in 2024 and 2025.
An interview with the agency Executive Director on April 23, 2026, at approximately 2:30 P.M. confirmed the above findings.
Plan of Correction:Upon identification that TB symptom screening with Risk Assessments were not completed at hire, all current employees will be required to complete a TB symptom check and risk assessment within 30 days. Annual TB education will also provided to all staff. All new hires will be reviewed for TB screening compliance for 90 days, followed by an annual audit. Annual TB education compliance will be tracked. Results will be reviewed by administration, and any deficiencies will result in immediate corrective action.
Initial Comments:
Based on the findings of an onsite announced home care agency state re-licensure survey conducted on April 23, 2026, Thema Home Care Ltd. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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