Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on May 1, 2025, Acts Senior Home Services, 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 unannounced state re-licensure survey conducted on May 1, 2025, Acts Senior Home Services, 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 personnel files (PFs) and interview with administrator of the agency, the agency failed to provide documentation of two positive references for three (3) of seven (7) PFs. (PF# 5, 6, & 7 ).
Findings include:
Review of PFs conducted on 5/1/25 at approximately 11:30 AM revealed the following:
PF# 5, Date of Hire: 8/7/23. Contained documentation of only one (1) positive reference obtained.
PF# 6, Date of Hire: 3/18/24. Contained no documentation of two positive reference obtained.
PF# 4, Date of Hire: 4/10/23. Contained documentation of only one (1) positive reference obtained.
An interview with the agency's administrator conducted on 5/1/25 at approximately 2:00 PM confirmed the above findings.
Plan of Correction:Effective 5/2/25 the hiring manager of our direct care workers will use our designated reference check form to ensure code compliance by obtaining not less than two satisfactory references for the individual and ensuring the two satisfactory references are present in the direct care worker's personnel file, thus confirming understanding of and adherence to code 611.51(a) LICENSURE #2 Hiring or Rostering Prerequisites. An internal audit/PIP of personnel files upon hire quarterly will occur until 100% adherence is achieved. Our corporate compliance team will receive a report from the PIP.
611.57(b) LICENSURE
Prohibitions
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(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 review of the agency's consumer information packet, consumer records (CR) and interview with the agency's administrator, the agency failed to provide documentation that 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 and that 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 for nine (9) of nine (9) CR reviewed. (CR#'s 1, 2, 3, 4, 5, 6, 7, 8 & 9)
Findings include:
Review of CRs conducted on 5/1/25, at approximately 10:30 A.M revealed the following:
CR# 1, start of care: 4/16/24, did not contain documentation that the consumer was informed that 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 and that 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.
CR# 2, start of care: 11/11/24, did not contain documentation that the consumer was informed that 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 and that 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.
CR# 3, start of care: 4/9/25, did not contain documentation that the consumer was informed that 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 and that 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.
CR# 4, start of care: 8/8/23, did not contain documentation that the consumer was informed that 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 and that 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.
CR# 5, start of care: 3/9/23, did not contain documentation that the consumer was informed that 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 and that 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.
CR# 6, start of care: 4/12/24, did not contain documentation that the consumer was informed that 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 and that 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.
CR# 7, start of care: 3/28/24, did not contain documentation that the consumer was informed that 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 and that 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.
CR# 8, start of care: 6/20/23, did not contain documentation that the consumer was informed that 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 and that 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.
CR# 9, start of care: 6/16/23, did not contain documentation that the consumer was informed that 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 and that 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.
Interview with the administrator on 5/1/25, at approximately 2:00 P.M. confirmed the above findings.
Plan of Correction:Currently, until our Home Services resident handbook is updated with the required verbiage, every new service admission will include a licensure disclosure document that will be signed by the consumer/POA and agency representative confirming understanding of and adherence to 611.57(b) LICENSURE
Prohibitions:
(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. An internal audit/PIP of all new admissions paperwork will occur monthly until 100% adherence is achieved.
611.57(c) LICENSURE
Information to be Provided
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(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 review of the consumer records (CRs) and interview with administrator, the agency failed to 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 prior to the commencement of services: 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 for nine (9) of nine (9) CRs reviewed (CR #'s 1, 2, 3, 4, 5, 6, 7, 8 & 9).
Findings include:
Review of CRs conducted on 5/1/25, at approximately 10:30 A.M and revealed the following:
CR# 1, Start of Care: 4/16/24, did not contain 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, 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.
CR# 2, Start of Care: 11/11/24, did not contain 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, 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.
CR# 3, Start of Care: 4/9/25, did not contain 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, 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.
CR# 4, Start of Care: 8/8/23, did not contain 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, 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.
CR# 5, Start of Care: 3/9/23, did not contain 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, 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.
CR# 6, Start of Care: 4/12/24, did not contain 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, 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.
CR# 7, Start of Care: 3/28/24, did not contain 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, 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.
CR# 8, Start of Care: 6/20/23, did not contain 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, 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.
CR# 9, Start of Care: 6/16/23, did not contain 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, 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.
Interview with the agency administrator on 5/1/25, at approximately 2:00 P.M. confirmed the above findings.
Plan of Correction:Currently, until our Home Services resident handbook is updated with the required verbiage and contact information, every new service admission will include a consumer notice disclosure document, which includes contact information for the PA Dept of Health License Information number (717-783-1379) as well as 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 will be signed and disclosed at every consumer admission. which will be signed by the consumer/POA and agency representative confirming understanding of and adherence to Code 611.57(c) LICENSURE Information to be Provided: An internal audit/PIP of all new admissions paperwork will occur monthly until 100% adherence is achieved.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on May, 1, 2025, Acts Senior Home Services, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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