Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on March 13, 2025, ASO Home Health Agency 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 home care agency state re-licensure survey conducted on March 13, 2025, ASO Home Health Agency 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:
611.55(e) LICENSURE
Competency Requirements
Name - Component - 00
(e) The home care agency or home care registry also shall include documentation in the direct care worker's file that the agency or registry has reviewed the individual's competency to perform assigned duties through direct observation, testing, training, consumer feedback or other method approved by the Department or through a combination of methods.
Observations:
Based on review of personnel files (PFs) and an interview with the Associate Director, Client Coordinator, and Office Manager, it was determined that the agency failed to maintain documentation of initial competency reviews for direct care workers for six (6) out of seven (7) PF reviewed (PF#1, 2, 3, 5, 6 and 7).
Findings include:
A review of personnel files (PF) was conducted on 3/13/25, starting at 11:20 am. The date of hire (DOH) is indicated below.
PF1 DOH 3/25/23 did not contain documentation of initial competency training.
PF2 DOH 6/5/24 contained certifications of initial training completion with date of 6/8/24 but did not contain actual training records documenting the content, methods, or evaluation of competency.
PF3 DOH 12/19/24 contains a training checklist that was signed by the trainee but lacked trainer signatures and completion dates for all training components.
PF5 DOH 6/5/24 contained certifications of initial training completion with date of 2/25/25 but did not contain actual training records documenting the content, methods, or evaluation of competency.
PF6 DOH 2/23/24 contained certifications of initial training completion with date of 2/28/24 but did not contain actual training records documenting the content, methods, or evaluation of competency.
PF7 DOH 11/4/22 did not contain documentation of initial competency training.
An interview conducted with the agency ' s Associate Director, Client Coordinator and Office Manager on 3/13/25 starting at 2:30 pm confirmed the above findings.
Plan of Correction:Corrective Actions:
Immediate Review and Documentation:
ASO will Conduct a thorough review of all personnel files to identify missing or incomplete documentation of initial competency training.
Create and implement a standardized form for recording initial competency reviews, including:
Training content.
Training methods.
Evaluation of competency.
Update records for PF#1, PF#2, PF#3, PF#5, PF#6, and PF#7 to reflect completed reviews retroactively if permissible.
Enhanced Training Protocols:
Revise the agency's training protocol to include comprehensive documentation requirements. Ensure this protocol mandates:
Detailed records of training content and methods.
Signatures of both trainer and trainee.
Specific completion dates for all training components.
Staff Education:
Conduct an educational session for all trainers and administrative staff on the updated training and documentation protocols.
Provide clear guidance on maintaining accurate records to demonstrate initial competency assessments.
Monitoring and Compliance Checks:
Assign an administrative staff member as the Documentation Compliance Officer to oversee regular audits of personnel files and training records.
Implement monthly file reviews to ensure ongoing compliance with documentation requirements.
Implementation Timeline:
Complete immediate file review and updates by April 15, 2025.
Conduct staff education sessions by April 20, 2025.
Fully implement updated training protocols and monitoring procedures by May 12, 2025.
The Associate Director, Client Coordinator, and Training Specialist will be responsible for implementing and conducting qtr. audits on all personal folders.
611.55(e) LICENSURE
Competency Requirements
Name - Component - 00
The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.
Observations:
Based on a review of personnel files (PFs) and an interview with the Associate Director, Client Coordinator and Office Manager, the agency failed to conduct annual competency review for two (2) of seven (7) PFs (PF# 1 and 4).
Findings include:
A review of personnel files (PF) was conducted on 3/13/25 starting at 11:20 am. The Date of Hire (DOH) is indicated below.
PF#1 DOH 3/25/23 did not contain documentation of annual competency training for 2024.
PF#4 DOH 4/26/22 did not contain documentation of annual competency training for 2023 and 2024.
An interview conducted with the agency ' s Associate Director, Client Coordinator and Office Manager on 3/13/25 starting at 2:30 pm confirmed the above findings.
Plan of Correction:Corrective Actions:
Immediate File Review and Updates:
ASO will Review all personnel files to identify any other staff members with missing or incomplete annual competency reviews.
Document the completion of annual competency reviews for PF#1 (2024) and PF#4 (2023 and 2024) as soon as possible. If retroactive reviews are permissible, conduct them and include signed records.
Implementation of Annual Competency Review Schedule:
Develop a comprehensive tracking system (e.g., digital spreadsheet or HR software) to monitor due dates for annual competency reviews of all staff.
Assign responsibility to an administrative staff member to ensure timely notifications and completion of competency reviews.
Policy Revision and Training:
Update the agency's policies to mandate:
Specific deadlines for the completion of annual competency reviews (e.g., within one month of the due date).
Detailed documentation requirements for each review.
Provide training for all supervisors and administrative staff on the revised policies and the importance of compliance.
Ongoing Monitoring and Auditing:
Conduct quarterly audits of personnel files to verify that annual competency reviews are completed and properly documented.
Assign the role of Compliance Officer to oversee audits and address any deficiencies promptly.
Implementation Timeline:
Complete file review and documentation updates for PF#1, PF#4, and any other identified deficiencies by April 15, 2025.
Fully implement the tracking system and revised policy by April 30, 2025.
Conduct staff training sessions on the new procedures System wide by May 12, 2025.
The associate Director, Client Coordinator, and Training coordinator will be responsible for the implementation and conducting a qtr. audit on a annual basis.
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), the Centers for Disease Control (CDC) guidelines and an interview with the Associate Director, Client Coordinator, and Office Manager, the agency did not provide documentation that a direct care worker (DCW) was screened and free from active mycobacterium tuberculosis for two (2) of seven (7) PF's (PF# 3 and 6) and did not provide documentation that a direct care worker completed a baseline tuberculosis symptom screen questionnaire and individual tuberculosis risk assessment upon hire for six (6) of seven (7) PF's (PF# 2, 3, 4, 5, 6 and 7).
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. After baseline testing for infection with tuberculosis, HCWs should receive TB screen 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;(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).
Findings include:
A review of personnel files (PF) was conducted on 3/13/25 starting at 11:20 am. The Date of Hire (DOH) is indicated below.
PF2 DOH 6/5/24 did not contain evidence that a TB symptom screen questionnaire, nor a TB risk assessment was completed upon hire.
PF3 DOH 12/19/24 contained documentation of QuantiFERON Gold TB test completed on 7/14/23 which is over 1 year prior to hire date.
PF4 DOH 4/26/22 did not contain evidence that a TB symptom screen questionnaire, nor a TB risk assessment was completed upon hire.
PF5 DOH 6/5/24 did not contain evidence that a TB symptom screen questionnaire, nor a TB risk assessment was completed upon hire.
PF6 DOH 2/23/24 contains a positive QuantiFERON Gold TB test result dated 2/29/24 but did not contain documentation of chest x-ray to rule out active tuberculosis as required. File also did not contain evidence that a TB symptom screen questionnaire, nor a TB risk assessment was completed upon hire.
PF7 DOH 11/4/22 did not contain evidence that a TB symptom screen questionnaire, nor a TB risk assessment was completed upon hire.
An interview conducted with the agency ' s Associate Director, Client Coordinator and Office Manager on 3/13/25 starting at 2:30 pm confirmed the above findings.
Plan of Correction:Corrective Actions:
Immediate Screening and Documentation:
ASO will Conduct tuberculosis symptom screening and risk assessments for all DCWs whose files lack these documents, including PF#2, PF#3, PF#4, PF#5, PF#6, and PF#7.
Arrange chest x-rays for DCWs with positive tuberculosis test results, including PF#6, to rule out active tuberculosis.
Policy Update:
Revise the agency's tuberculosis screening policy to align with CDC guidelines, ensuring baseline screenings include:
A two-step tuberculin skin test (TST) or interferon-gamma release assay (IGRA).
A tuberculosis symptom screen questionnaire.
An individual tuberculosis risk assessment.
Include procedures for annual tuberculosis education for DCWs.
Training for Staff:
Conduct training for administrative staff and health care workers on revised tuberculosis screening and documentation protocols.
Emphasize the importance of maintaining compliance with CDC guidelines for preventing tuberculosis transmission.
Monitoring and Compliance Checks:
Implement a tracking system (digital or manual) to monitor TB screening completion and documentation for all personnel.
Schedule quarterly audits of personnel files to ensure ongoing compliance with screening and documentation requirements.
Implementation Timeline:
Complete initial screenings, risk assessments, and chest x-rays for affected personnel by April 15, 2025.
Revise agency policies and conduct staff training by April 30, 2025.
Implement the tracking system and begin file audits by May 12, 2025.
Associate Director, Staffing Coordinator, and training specialist will be responsible for the implementation of this.
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) and the Centers for Disease Control (CDC) Guideline and an interview with the Associate Director, Client Coordinator, and Office Manager, the agency failed to ensure each direct care worker were provided with annual mycobacterium tuberculosis education for two (2) of seven (7) PF's reviewed (PF# 4 and 7).
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. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease (CDC Guidelines for Preventing 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 PF's was conducted on 3/13/25 starting at 11:20 am. The date of hire (DOH) is indicated below.
PF#4 DOH 4/26/22 did not contain any documentation of annual tuberculosis education provided in 2023.
PF#7 DOH 11/4/22 did not contain any documentation of annual tuberculosis education provided in 2023 and 2024.
An interview conducted with agency ' s Associate Director, Client Coordinator and Office Manager on 3/13/25 starting at 2:30 pm confirmed the above findings.
Plan of Correction:Corrective Actions:
Immediate Review and Training:
ASO will Provide tuberculosis education to PF#4 (for 2023) and PF#7 (for 2023 and 2024) immediately, and document completion in their personnel files.
Review the records of all other direct care workers to ensure compliance with annual tuberculosis education requirements.
Policy Revision:
Revise agency policies to ensure annual tuberculosis education is provided to all direct care workers in alignment with CDC guidelines.
Include a requirement for proper documentation of completed education, specifying the date, content, and attendance.
Training Materials and Sessions:
Develop or procure tuberculosis education materials that align with CDC guidelines, ensuring comprehensive coverage of required topics.
Schedule annual training sessions and maintain a record of attendance.
Tracking and Monitoring:
Implement a tracking system to monitor and manage annual tuberculosis education for all staff. This may include a digital log or HR software to track due dates and completion status.
Assign an administrative staff member to oversee the tracking system and ensure timely completion.
Auditing and Compliance Checks:
Conduct quarterly audits of personnel files to verify compliance with annual tuberculosis education requirements.
Immediately address any identified deficiencies.
Implementation Timeline:
Complete the education and documentation for PF#4 and PF#7 by April 15, 2025.
Update policies and implement the tracking system by April 30, 2025.
Begin conducting quarterly audits by May May 12, 2025.
The Associate Director, Staffing Coordinator and training Specialist will be responsible for this implementation.
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 the consumer records (CR) and an interview with the Associate Director, Client Coordinator, and Office Manager, the agency failed to provide documentation prior to the commencement of services, the home care agency or home care registry provided 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 the following: (5) 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 for seven (7) of seven (7) CRs reviewed (CR 1, 2, 3, 4, 5, 6 and 7).
Findings include:
A review of Consumer Records (CR) was conducted on 3/13/25 starting 12:30 pm. The Start of Care (SOC) date is indicated below.
CR1 SOC 1/25/25 did not contain documentation that the consumer received the following information prior to the start of services: (5) 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.
CR2 SOC 12/25/22 did not contain documentation that the consumer received the following information prior to the start of services: (5) 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.
CR3 SOC 5/9/22 did not contain documentation that the consumer received the following information prior to the start of services: (5) 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.
CR4 SOC 2/10/24 did not contain documentation that the consumer received the following information prior to the start of services: (5) 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.
CR5 SOC 11/10/23 did not contain documentation that the consumer received the following information prior to the start of services: (5) 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.
C R6 SOC 9/28/23 did not contain documentation that the consumer received the following information prior to the start of services: (5) 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.
CR7 SOC 4/8/23 did not contain documentation that the consumer received the following information prior to the start of services: (5) 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.
An interview with agency ' s Associate Director, Client Coordinator and Office Manager on 3/13/25 starting at 2:30 pm confirmed the above findings.
Plan of Correction:Corrective Actions:
Immediate Documentation and Notification:
Provide the required information packets, including the telephone number of the Ombudsman Program and hiring/competency requirements for direct care workers, to the consumers associated with CR#1-7 and document receipt in their records.
Review all current consumer records to ensure the information packets were provided, and address any deficiencies immediately.
Update Consumer Intake Process:
Revise the intake process to ensure that the required information packet is provided to each consumer, their legal representative, or responsible family member prior to the start of services.
Include a checklist as part of the intake documentation that confirms receipt of the information packet. This checklist will include a signature line for the consumer or their representative and date of receipt.
Staff Training and Awareness:
Train all intake staff on the updated process and the importance of providing and documenting the required information.
Develop a reference guide for staff detailing all required components of the information packet.
Policy Revision and Implementation:
Update the agency's policies to mandate the provision of the information packet during the intake process and the documentation of its receipt in the consumer's record.
Establish a policy that requires periodic audits of consumer records to verify compliance.
Monitoring and Auditing:
Assign an administrative staff member to conduct monthly audits of consumer records to ensure that the required information packets are consistently provided and documented.
Implement a tracking system (e.g., a digital log) to ensure timely completion of this process for new consumers.
Implementation Timeline:
Distribute and document the missing information packets for CR#1-7 by April 10, 2025.
Revise intake policies and train staff by April 20, 2025.
Begin monthly audits and implement the tracking system by May 12, 2025.
The Associate Director, will be responsible for the implementation of this COP.
Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on March 13, 2025, ASO Home Health Agency was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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