Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on March 14, 2025, Able Mind & Body Home Care, 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 unannounced home care agency state re-licensure survey conducted on March 14, 2025, Able Mind & Body Home Care, LLC., 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:
611.52(a) LICENSURE
Criminal Background Checks
Name - Component - 00
The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.
Observations:
Based on a review of personnel files (PF) and an interview with the Office Director, the agency failed to obtain a Pennsylvania State Police Criminal Background report at the time of application or within one year immediately preceding the date of application for seven (7) of seven (7) files reviewed. (PF#1, 2, 3, 4, 5, 6 and 7.)
Findings include:
A review of PF's was conducted on March 14, 2025 at approximately 10:25 am.
PF#1 Date of Hire 11/10/2021. PF contained a Pennsylvania State Police Criminal Background dated for 5/11/2022.
PF#2 Date of Hire 11/08/2021. PF contained a Pennsylvania State Police Criminal Background dated for 5/19/2022.
PF#3 Date of Hire 9/20/2023. PF contained a Pennsylvania State Police Criminal Background dated for 7/16/2024.
PF#4 Date of Hire 11/9/2021. PF contained a Pennsylvania State Police Criminal Background dated for 5/19/2022.
PF#5 Date of Hire3/16/2015. PF contained a Pennsylvania State Police Criminal Background dated for 2/22/2021.
PF # 7 Date of Hire: 11/2/2020. PF contained a Pennsylvania State Police Criminal Background dated for 2/10/2021.
An interview with the Office Director on March 14, 2025 at approximately 1:00 pm confirmed the above findings.
Plan of Correction:During the onboarding process, the agency office will run the criminal background checks. Cleared background checks must be received in office prior to orientation being scheduled. If they do not obtain a background check, the Caregiver Manager will be responsible to get this documentation before caregiver begins orientation and before caregiver commences work. Every year the Caregiver Manager will follow up with new criminal background checks to ensure the problem does not recur.
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 personnel files (PF), Centers for Disease Control Guidelines, and an interview with the Office Administrator, the agency failed to 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 and provide documentation of an initial Symptom Screening questionnaire and Tuberculosis Risk Assessment upon hire for seven (7) of seven (7) PF's, (PF#1, 2, 3, 4, 5, 6, and 7).
Findings include:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: 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. 2. Completion of a tuberculosis symptom questionnaire. 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education annually. HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(5-16-19)
A review of PF's was conducted on March 14, 2025 at approximately 10:25 am.
PF#1 Date of Hire 11/10/2021. PF contained a one (1) step tuberculin skin test (TST) dated for 10/26/2021. No evidence that a two (2) step PPD was obtained upon hire.
PF#2 Date of Hire 11/08/2021. PF contained a one (1) step tuberculin skin test (TST) dated for 12/01/2021. No evidence that a two (2) step PPD was obtained upon hire. File did not contain a symptom screening / risk assessment upon hire.
PF#3 Date of Hire 9/20/2023. PF did not contained evidence that a two (2) step tuberculin skin test (TST) was obtained upon hire. File did not contain a symptom screening / risk assessment upon hire.
PF#4 Date of Hire: 11/9/2021. PF contained a one (1) step tuberculin skin test (TST) dated for 6/7/2022. No evidence that a two (2) step PPD was obtained upon hire. File did not contain a symptom screening / risk assessment upon hire.
PF#5 Date of Hire: 3/16/2015. PF did not contained evidence that a two (2) step tuberculin skin test (TST) was obtained upon hire.
PF # 6 Date of Hire: 11/10/2021. PF contained a one (1) step tuberculin skin test (TST) dated for 10/15/2024. No evidence that a two (2) step PPD was obtained upon hire. File did not contain a symptom screening / risk assessment upon hire.
PF # 7 Date of Hire: 11/2/2020. PF contained a Chest X-Ray dated for 6/16/2023. No evidence that a tuberculin test was obtained upon hire. File did not contain a symptom screening / risk assessment upon hire.
An interview with the Office Director on March 14, 2025 at approximately 1:00 pm confirmed the above findings.
Plan of Correction:The agency will send test forms to all workers and direct workers to be filled out by their physicians upon completing TB testing procedures. These forms will be returned to the agency immediately before the specified deadline. Phone calls have started to be made and will continue to be made to all caregivers/workers to explain the need to fulfill this requirement by May 14, 2025. Failure to comply to this request will result in suspension until the forms are received by the office. The Caregiver Manager is responsible for making sure that the staff are efficient in completing this task. Moving forward the Caregiver Manager will make sure that these forms are provided to each new hire and completed before case assignment.
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 personnel files (PFs), the Centers for Disease Control guidelines, and interview with the Office Administrator, the agency failed to ensure each direct care worker were provided with annual mycobacterium tuberculosis education for seven (7) of seven (7) PF's reviewed, (PF#1, 2, 3, 4, 5, 6 and 7).
Findings include:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. And 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education annually. HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(5-16-19)
A review of PF's was conducted on March 14, 2025 at approximately 10:25 am.
PF#1 Date of Hire 11/10/2021. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2022, 2023 and 2024.
PF#2 Date of Hire 11/08/2021. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2022, 2023 and 2024.
PF#4 Date of Hire 11/9/2021. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2022 and 2023.
PF#5 Date of Hire3/16/2015. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2022, 2023 and 2024.
PF # 6 Date of Hire 11/10/2021. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2022 and 2023.
PF # 7 Date of Hire: 11/2/2020. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2022 and 2023.
An interview with the Office Director on March 14, 2025 at approximately 1:00 pm confirmed the above findings.
Plan of Correction:The agency will implement an annual training requirement on Mycobacterium tuberculosis for all direct care workers. The Caregiver Manager will ensure compliance by maintaining updated TB documentation in personnel files. Staff will receive training by May 1, 2025, and the process will be integrated into onboarding and annual reviews. The Caregiver Manager is responsible for full implementation by May 14, 2025.
In the meantime to correct the identified PFs, The agency will send test forms to all workers and direct workers to be filled out by their physicians upon completing TB testing procedures. These forms will be returned to the agency immediately before the specified deadline.
611.57(a) LICENSURE
Consumer Rights
Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.
Observations:
Based on review of Consumer Files (CF), HHA eXchange and interview with the Office Director, it was determined that the agency failed to ensure that the consumer The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk for three (3) of the five (5) consumer files reviewed. (CR#3, 4 and 5).
Findings include:
A review of PF's was conducted on March 14, 2025 at approximately 11:35 am.
CF#3 - Start of Care: 11/7/2022. A review of HHA eXchange determined the following:
2/8/2025 - 5:04 hours out of 6:00 hours provided
2/11/2025 - 5:15 hours out of 6:00 hours provided
2/14/2025 - 5:05 hours out of 6:00 hours provided
2/15/2025 - 5:02 hours out of 6:00 hours provided
2/16/2025 - 5:12 hours out of 6:00 hours provided
3/4/2025 - 5:00 hours out of 6:00 hours provided
3/7/2025 - 5:11 hours out of 6:00 hours provided
CF#4 - Start of Care: 5/17/2024.A review of HHA eXchange determined the following:
1/6/2025 - 4:29 hours out of 5 hours provided
1/14/2025 - 4:06 hours out of 5 hours provided
1/20/2025 - 4:38 hours out of 5 hours provided
1/21/2025 - 4:22 hours out of 5 hours provided
1/22/2025 - 4:08 hours out of 5 hours provided
1/27/2025 - 4:39 hours out of 5 hours provided
1/29/2025 - 4:12 hours out of 5 hours provided
2/4/2025 - 4:37 hours out of 5 hours provided
CF#5 - Start of Care: 2/1/2022. A review of HHA eXchange determined the following:
2/4/2025 - 1:46 hours out of 2 hours provided
2/8/2025 - 1:28 hours out of 2 hours provided
2/9/2025 - 1:41 hours out of 2 hours provided
2/11/2025 - 1:41 hours out of 2 hours provided
2/18/2025 - 1:46 hours out of 2 hours provided
2/22/2025 - 1:50 hours out of 2 hours provided
An interview with the Office Director on March 14, 2025 at approximately 1:00 pm confirmed the above findings.
Plan of Correction:The Scheduling manager will arrange for the identified clients to have their missed times made up as per their intended schedule by May 14, 2025. The scheduling manager be in better contact with caregiver and client during and after each shift to understand what happened to the service times, should there be a late or early clock ins. Then arrangements will be made to make up any missed time. The scheduler will arrange for weekly check ins with the client to assess if the client has a need to adjust their schedule. With the client's permission, necessary adjustments will be made to ensure that the client is receiving all of their scheduled services.
611.57(c) LICENSURE
Information to be Provided
Name - Component - 00
(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 a review of consumer files (CF) and an interview with the Director, 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: (2) The hours when those services will be provided. (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). (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 for five (5) of the five (5) CF's reviewed. (CF#1,2,3, 4 and 5)
Findings include:
A review of PF's was conducted on March 14, 2025 at approximately 10:25 am.
CF#1 Start of Care: 11/1/2024. File did not contain documentation that the consumer received the following information: 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).
CF#2 Start of Care: 4/1/2023. File did not contain documentation that the consumer received the following information: 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).
CF#3 Start of Care: 11/17/2022. File did not contain documentation that the consumer received the following information: 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).
CF#4 Start of Care: 5/17/2024. File did not contain documentation that the consumer received the following information: (2) The hours when those services will be provided. 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).
CF#5 Start of Care: 2/1/2022. File did not contain documentation that the consumer received the following information: 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). (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.
An interview with the Office Director on March 14, 2025 at approximately 1:00 pm confirmed the above findings.
Plan of Correction:The agency will prepare and provide to all of its consumers/consumer's representative with an updated disclosure forms that addresses the direct caregivers' status and tax/insurance obligations, along with responsibilities of both the consumers and the agency. The updated form will also include the hours of service, the names of the services that will be provided. In addition to this updated form, a leaflet which will include The Department's complaint hot line and Ombudsman Program of all 5 of the agency's service counties and the local AAA, will be included in this packet to the consumer. This information will be prepared and mailed out to the respective consumers by 4/5/2025. Forms will be required to be signed and mailed back upon receipt. Phone calls will follow within one week of mailing it out by the Client Success Associate to ensure receipt and to encourage them to mail it back to the office expeditiously to be received by 5/14/25. Moving forward the Client Success Associate will make sure that this and all other required forms are enclosed in the intake packet.
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey, Able Mind & Body Home Care, LLC., on March 13, 2025, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|