Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on May 22, 2025, with the off-site portion of the survey being conducted on May 23, 2025, Above the Rest Home Care, LLC was found to be in compliance with the requirements of 28 Pa. Code, Health and Safety, Part IV, Health Facilities, Subpart A. Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on May 22, 2025, with the off-site portion of the survey being conducted on May 23, 2025, Above the Rest Home Care, LLC was found not to be in compliance with the following requirements of Title 28 Health and Safety Part IV, Health Facilities, Subpart H. Chapter 611 Home Care Agencies and Home Care Registries.
Plan of Correction:
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 review of agency policy, agency (consumer) and personnel files and based on interview with the Branch Manager (Employee #6), the agency failed to obtain proof-of-residency documentation which verified Pennsylvania (PA) residency for the previous two (2) year period prior to the date of hire or first date of assignment for three (3) of five (5) staff members with direct consumer contact. (Employees #1, #2 and #5)
Findings Include:
On May 22, 2025 at approximately 12:18 PM, review of agency "Core Policies" revealed the following under "1.1 Welcome Policy":
The company complies with all...state employment laws...
Consumer #1: On May 22, 2025 at approximately 10:09 AM, review of the agency file revealed the direct care worker (DCW-Employee #1) provided home care services in April and May 2025.
Consumer #2: On May 22, 2025 at approximately 10:44 AM, review of the agency file revealed the DCW (Employee #2) provided home care services in April and May 2025.
Consumer #3: On May 22, 2025 at approximately 11:17 AM, review of the agency file revealed the DCW (Employee #1) provided home care services in April and May 2025.
Consumer #5: On May 22, 2025 at approximately 11:56 AM, review of the agency file revealed the registered nurse (RN-Employee #5) completed the nursing assessment on 05/17/2025.
Review of personnel file documentation on May 22, 2025 at approximately 12:38 PM and May 23, 2025 at approximately 11:05 AM revealed the following:
Employee #1: The date of hire of the DCW was 10/22/2024. Review of proof-of-residency documentation revealed the PA driver's license was issued on 08/04/2023 which was less than 2 years (24 months) prior to the date of hire.
Employee #2: The first date of assignment of the DCW to provide home care services was 10/29/2024. Review of proof-of-residency documentation revealed the PA driver's license was issued on 09/14/2023 which was less than 2 years (24 months) prior to the first date of assignment.
Employee #5: The date of hire of the RN was 02/19/2025. Review of proof-of-residency documentation revealed the PA driver's license was issued on 10/25/2024 which was less than 2 years (24 months) prior to the date of hire.
There was no documentation in the personnel file which provided evidence the agency had obtained documentation which verified PA residency for the two (2) year period prior to the date of hire or first date of assignment for Employees #1, #2 and #5.
During interview conducted on May 22, 2025 at approximately 2:20 PM, the Branch Manager confirmed there was no documentation in the personnel file which provided evidence the agency had obtained documentation which verified PA residency for the two (2) year period prior to the date of hire or first date of assignment for Employees #1, #2 and #5.
Plan of Correction:1. Corrective Method:
The agency has begun reviewing and updating consumer files to ensure that proof of residency documentation is on file for all assigned employees. Acceptable documents such as PA driver's licenses, utility bills, signed leases, Tax 1040 form,W-2's, real estate sale or purchase agreements, property deeds, and proof or prior residency in another state.
2. Prevention Process:
The intake checklist has been updated to include verification of Pennsylvania residency for two full years. If documentation does not meet the requirement, the employee will be required to complete FBI fingerprinting. Clerical staff are being trained to identify and collect this documentation prior to any assignments.
3. Monitoring Responsibility:
The Regional Director will ensure files are audited to confirm compliance before any employee is scheduled for services.
611.52(f) LICENSURE
Records Maintained
Name - Component - 00
The home care agency or home care registry shall maintain files for direct care workers and members of the office staff which include copies of State Police criminal history records or Department of Aging letters of determination regarding Federal criminal history records. The files shall be available for Department inspection. The agency or registry shall maintain copies of the criminal history report for the agency or registry owners, which shall be available for department inspection.
Observations:
Based on review of agency procedures, agency (consumer) and personnel files and based on interview with the Branch Manager (Employee #6), the agency failed to ensure personnel file documentation included evidence a federal criminal history record report (letter of determination) had been requested through the Pennsylvania Department of Aging nor that a Pennsylvania State Police (PSP) criminal history report had been requested for three (3) of six (6) agency employees. (Employees #4, #5 and #6)
Findings Include:
On May 22, 2025 at approximately 9:48 AM, review of agency "Hiring Process" procedure revealed the following:
Caregivers are background checked...
Consumer #5: On May 22, 2025 at approximately 11:56 AM, review of the agency file revealed the DCW (Employee #4) provided home care services in May 2025 and that the registered nurse (RN-Employee #5) completed the nursing assessment on 05/17/2025.
Review of personnel file documentation on May 22, 2025 at approximately 12:38 PM and May 23, 2025 at approximately 11:05 AM revealed the following:
Employee #4: The first date of assignment of the DCW to provide home care services was 05/17/2025. Review of residency documentation revealed the driver's license was issued by the state of New York. A Federal criminal history record report was requested through the Federal Bureau of Investigation office in West Virginia. There was no documentation in the personnel file which provided evidence a federal criminal history record report had been requested through the Pennsylvania Department of Aging.
Employee #5: The date of hire of the RN was 02/19/2025. There was no documentation in the personnel file which provided evidence a criminal history record report had been requested through the PSP.
Employee #6: During interview conducted on May 22, 2025, the Branch Manager reported the date of hire for same was 06/03/2024. Review of residency documentation revealed the driver's license was issued by the state of New Jersey. There was no documentation in the personnel file which provided evidence a federal criminal history record report had been requested through the Pennsylvania Department of Aging nor was documentation present which provided evidence a criminal history record report had been requested through the PSP.
During interview conducted on May 22, 2025 at approximately 2:20 PM, the Branch Manager confirmed there was no documentation in the personnel file which provided evidence a federal criminal history record report (letter of determination) had been requested through the Pennsylvania Department of Aging nor that a Pennsylvania State Police (PSP) criminal history report had been requested for the above referenced agency employees.
Plan of Correction:1. Corrective Method:
Employee #4 is being re-fingerprinted using the PA Department of Aging's service code. Employee #5, a long-term PA resident, has a completed PATCH clearance on file. Employee #6 is fully compliant and has all documentation filed.
2. Prevention Process:
The agency has always required fingerprinting for out-of-state employees but was unaware that a specific service code tied to the Department of Aging was required. Since taking over ownership, this process has been new to our team. We are now updating our onboarding instructions and checklists to include the proper code. Clerical staff have been trained accordingly and are applying the new process going forward.
3. Monitoring Responsibility:
The Clerical Administrative Staff is responsible for ensuring clearances are completed using the correct codes before employee assignment.
611.55(b) LICENSURE
Competency Requirements
Name - Component - 00
A competency examination or training program developed by an agency or registry for a direct care worker shall address, at a minimum, the following subject areas: 1. Confidentiality; 2. Consumer control and the independent living philosophy; 3. Instrumental activities of daily living; 4. Recoginizing changes in the consumer that need to be addressed; 5. Basic infection control; 6. Universal precautions; 7. Handling of emergencies; 8. Documentation; 9. Recognizing and reporting abuse or neglect; and 10. Dealing with difficult behaviors.
Observations:
Based on review of agency procedures, agency (consumer) and personnel files and based on interview with the Branch Manager (Employee #6), the agency failed to ensure the initial competency evaluation program completed by four (4) of four (4) direct care workers (DCW) included the subject matter of documentation. (Employees #1, #2, #3 and #4)
Findings Include:
On May 22, 2025 at approximately 9:48 AM, review of agency "Hiring Process" procedure revealed the following:
Caregivers...are oriented on staff policy & procedures and home care best practices before they begin working.
Consumer #1: On May 22, 2025 at approximately 10:09 AM, review of the agency file revealed the direct care worker (DCW-Employee #1) provided home care services in April and May 2025.
Consumer #2: On May 22, 2025 at approximately 10:44 AM, review of the agency file revealed the DCW (Employee #2) provided home care services in April and May 2025.
Consumer #3: On May 22, 2025 at approximately 11:17 AM, review of the agency file revealed the DCW (Employee #1) provided home care services in April and May 2025.
Consumer #4: On May 22, 2025 at approximately 11:36 AM, review of the agency file revealed the DCW (Employee #3) provided home care services in April and May 2025.
Consumer #5: On May 22, 2025 at approximately 11:56 AM, review of the agency file revealed the DCW (Employee #4) provided home care services in May 2025.
Review of personnel file documentation on May 22, 2025 at approximately 12:38 PM and May 23, 2025 at approximately 11:05 AM revealed the following:
Employee #1: The date of hire of the DCW was 10/22/2024. The initial "Companion Competency" evaluation checklist was completed on 10/24/2024.
Employee #2: The first date of assignment of the DCW to provide home care services was 10/29/2024. The initial "Companion Competency" evaluation checklist was completed on 10/24/2024.
Employee #3: The first date of assignment of the DCW to provide home care services was 10/28/2024. The initial "Companion Competency" evaluation checklist was completed on 10/24/2024.
Employee #4: The first date of assignment of the DCW to provide home care services was 05/17/2025. The initial "Companion Competency" evaluation checklist was completed on 05/14/2025.
There was no documentation on the "Companion Competency" checklist which provided evidence the competency evaluation program completed by the above referenced DCW's included the subject matter of documentation.
During interview conducted on May 22, 2025 at approximately 2:20 PM, the Branch Manager confirmed there was no documentation on the "Companion Competency" checklist which provided evidence the competency evaluation program completed by the above referenced DCW's included the subject matter of documentation.
Plan of Correction:1. Corrective Method:
The Companion Competency checklist has been updated to include required subjects. All cited employees (#1–4) have either completed or are in the process of completing the updated form.
2. Prevention Process:
Only the updated competency checklist is now in use. All new and existing direct care workers will be required to complete it prior to working and annually thereafter. We have a competency file log to track both initial and annual completions, and reminders are sent in advance of expiration dates.
3. Monitoring Responsibility:
The Regional Director is responsible for confirming the form is completed and filed before an employee begins services.
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 review of agency procedures, agency (consumer) and personnel files and guidance from the Centers for Disease Control (CDC), and based on interview with the Branch Manager (Employee #6), the agency failed to ensure initial screening for mycobacterium tuberculosis (TB) had been completed in accordance with CDC guidance for three (3) of five (5) employees with direct consumer contact. (Employees #1, #2, #3 and #5)
Findings Include:
On May 22, 2025 at approximately 9:48 AM, review of agency "Hiring Process" procedure revealed the following:
Health screenings...required by State and Federal regulations are kept up to date.
On May 22, 2025 at approximately 3:45 PM, review of CDC recommendations for initial TB screening for health care personnel revealed the following as documented on the CDC website: https://www.cdc.gov/tb-healthcare-settings/hcp/screening-testing/index.html
All health care personnel should be screened for TB upon hire (preplacement).
The TB screening process for health care personnel includes:
-A baseline individual TB risk assessment;
-TB symptom evaluation; and
-A TB test (TB blood test or a TB skin test (2-Step))...
Consumer #1: On May 22, 2025 at approximately 10:09 AM, review of the agency file revealed the direct care worker (DCW-Employee #1) provided home care services in April and May 2025.
Consumer #2: On May 22, 2025 at approximately 10:44 AM, review of the agency file revealed the DCW (Employee #2) provided home care services in April and May 2025.
Consumer #3: On May 22, 2025 at approximately 11:17 AM, review of the agency file revealed the DCW (Employee #1) provided home care services in April and May 2025.
Consumer #4: On May 22, 2025 at approximately 11:36 AM, review of the agency file revealed the DCW (Employee #3) provided home care services in April and May 2025.
Consumer #5: On May 22, 2025 at approximately 11:56 AM, review of the agency file revealed the registered nurse (RN-Employee #5) completed the nursing assessment on 05/17/2025.
Review of personnel file documentation on May 22, 2025 at approximately 12:38 PM and May 23, 2025 at approximately 11:05 AM revealed the following:
Employee #1: The date of hire of the DCW was 10/22/2024.
Employee #2: The first date of assignment of the DCW to provide home care services was 10/29/2024.
Employee #3: The first date of assignment of the DCW to provide home care services was 10/28/2024.
Employee #5: The date of hire of the RN was 02/19/2025.
There was no documentation in the personnel file which provided evidence the above referenced staff members had completed the second TST test.
During interview conducted on May 22, 2025 at approximately 2:20 PM, the Branch Manager confirmed there was no documentation in the personnel file which provided evidence TB screening had been completed in accordance with CDC guidance for the above referenced employees.
Plan of Correction:1. Corrective Method:
The agency is currently finalizing the Second Step PPD tests for the staff identified in the citation. While some have already completed the process, others are pending or no longer with the agency. Documentation is actively being collected and filed for all applicable personnel.
2. Prevention Process:
At onboarding, we were under the impression that one-step TB testing was sufficient. This has been clarified and all staff are now required to complete a two-step TB test before beginning services.
3. Monitoring Responsibility:
The Clerical Administrative Staff is responsible for ensuring two-step TB screenings are completed and documented before client assignments.
611.57(d) LICENSURE
Documentation
Name - Component - 00
(d) The home care agency or home care registry shall maintain documentation on file at the agency or registry of compliance with the requirements of this section which shall be available for Department inspection.
Observations:
Based on review of agency documentation and agency (consumer) files and based on interview with the consumers' responsible party and the Branch Manager (Employee #6), the agency failed to ensure documentation was maintained in the agency file which provided evidence three (3) of five (5) consumers were provided notice of the identity of the direct care worker and the hours services would be provided prior to the initiation of home care services. (Consumers #1, #3 and #4)
Findings Include:
On May 22, 2025 at approximately 9:48 AM, review of agency "Signature Pages" consumer packet revealed the following:
Consent for Treatment...I hereby give my permission for authorized personnel of your agency to implement the...Plan of Care.
Consumer #1: On May 22, 2025 at approximately 10:09 AM, review of the agency file revealed the following:
-Home care services were initiated on 01/07/2025;
-The direct care worker (DCW-Employee #1) provided home care services in April and May 2025;
-The payor source authorized 832 hours of home care services per year effective 12/26/2024; and
-The master schedule established in HHAeXchange (software) was 4 hours per day for two (2) days per week.
During telephone interview conducted on May 22, 2025 at approximately 1:36 PM, the consumer's responsible party reported the agency provided notification of the identity of the DCW and the hours services would be provided prior to the initiation of home care services.
There was no documentation in the agency file which provided evidence the agency maintained documentation that notice of the identity of the DCW and the hours services would be provided had been provided to the consumer/responsible party prior to the initiation of home care services.
Consumer #3: On May 22, 2025 at approximately 11:17 AM, review of the agency file revealed the following:
-Home care services were initiated on 01/06/2025;
-The direct care worker (DCW-Employee #1) provided home care services in April and May 2025;
-The payor source authorized up to 20 hours of home care services per week effective 12/18/2024; and
-The master schedule established in HHAeXchange was 3 hours per day for one (1) day per week.
During telephone interview conducted on May 22, 2025 at approximately 1:41 PM, the consumer's responsible party reported the agency provided notification of the identity of the DCW but could not recall if the agency provided notification of the hours services would be provided prior to the initiation of home care services.
There was no documentation in the agency file which provided evidence the agency maintained documentation that notice of the identity of the DCW and the hours services would be provided had been provided to the consumer/responsible party prior to the initiation of home care services.
Consumer #4: On May 22, 2025 at approximately 11:36 AM, review of the agency file revealed the following:
-Home care services were initiated on 01/03/2025; and
-The direct care worker (DCW-Employee #3) provided home care services in April and May 2025.
During telephone interview conducted on May 22, 2025 at approximately 1:49 PM, the consumer's responsible party reported the agency provided notification of the identity of the DCW prior to the initiation of home care services.
There was no documentation in the agency file which provided evidence the agency maintained documentation that notice of the identity of the DCW had been provided to the consumer/responsible party prior to the initiation of home care services.
During interview conducted on May 22, 2025 at approximately 2:20 PM, the Branch Manager confirmed the agency failed to maintain documentation in the agency file which provided evidence the above referenced consumers/responsible parties were provided notice of the identity of the direct care worker and the hours services would be provided prior to the initiation of home care services.
Plan of Correction:1. Corrective Method:
The agency is actively working on updating consumer files to reflect that responsible parties were informed of caregiver assignments and schedules. Where applicable, supporting documentation is being added or noted based on prior communication.
2. Prevention Process:
The agency is in the process of adding a new confirmation form to the admission packet that will document the name of the assigned caregiver, their schedule of hours, and confirmation that the responsible party was informed. While the form has not yet been formally implemented, it is currently being finalized and will be used going forward at intake and when a new caregiver is assigned.
3. Monitoring Responsibility:
The Nurse Case Manager will be responsible for completing the new documentation with the responsible party and ensuring the form is filed in the consumer's record before services begin.
Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on May 22, 2025, with the off-site portion of the survey being conducted on May 23, 2025, Above the Rest Home Care, LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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