Initial Comments:
Based on the findings of an onsite state re-licensure and licensure complaint survey conducted on March 3 and 20, 2025 and offsite on March 6, 9, 27 and 28, 2025, AG Home Care Services LLC was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
51.3 (f) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Observations:
Based on a review of Department of Health (DOH) Event Reporting System (ERS) and an interview with agency's manager, the agency failed to notify Department of Health for service disruption that could seriously compromise quality assurance or patient safety.
Findings include:
A review of Department of Health (DOH) Event Reporting System (ERS) was conducted on 3/3/35 9 am. ERS report review range was set from 1/1/25 to 3/3/25. There was no ERS report from the agency regarding disruption of service.
An interview with manager at 3/20/25 at 1:20 pm revealed the following:Agency's manager was notified of fraudulent clock in and out activity of agency's direct care worker (DCW) for a client. Manager conducted own investigation and found that it was true that the agency's DCW has fraudulenetly clocked in and out without providing service including 1/18/25 or 1/17/25 when the client was hosptialized.
Plan of Correction:After the surveyor from DOH, the CEO of AG home Care Services, initiated and held a mandatory meeting with management. The goal of the meeting was to in service management on the findings from the DOH and educate on DOH Event Reporting Process system.
As a result of this meeting effective immediately 4/6/2025, management was educated on the department of Health
Event Reporting System.
The administrator educated management on the Regulations Regarding ERS Reporting Requirements and the reporting process.
It will be the responsibility of the Administrator/Management to review all Regulations Regarding ERS Reporting requirements monthly and report any event that falls withing the guidelines.
The administrator entered the reported event in DOH ERS on 4/6 and 4/8/2025 as per DOH guidelines for review.
Initial Comments:
Based on the findings of an onsite home care agency state re-licensure and license complaint survey conducted on March 3 and 20, 2025 and offsite on March 6, 9, 27 and 28, 2025, AG Home Care Services 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:
611.4(c) LICENSURE
Requirements for HCA and HCR
Name - Component - 00
Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.
Observations:
Based on two (2) onsite attempts to conduct a licensure and complaint survey, a review of Client Files (CR), Personnel Files (PF) and interview with agency ' s administrator, manager and secretary, the agency failed to allow a proper conduction to inspect and review records of consumers and staff.
A review of Chapter 611.5 Definitions for home care agencies and home care registries was conducted on March 3, 2025 at 12 pm. The requirements reads, " ...Inspection-A scheduled or unscheduled examination or assessment of a home care agency or home care registry during regular business hours, to determine compliance with requirements for licensure using one or more of the following means: inspection of records, interviews with office staff, consumers and direct care workers, and observation of the provision of services to consumers who have consented in advance to observation... "
An announced onsite visit was made on 3/3/25 at 10:30 am. Agency's administrator's girlfriend greeted the surveyor and stated that the administrator is unavailable currently. Surveyor left a business card and requested contact back from administrator.
A phone interview with administrator on 3/6/25 1 pm revealed that agency ' s administrator has limited availability and will email surveyor a good date for a scheduled onsite survey.
On 3/9/25, administrator emailed surveyor that administrator will be available on 3/20/25.
On 3/12/25, surveyor emailed and confirmed that survey will be conducted on 3/20/25.
On 3/20/25 at 10:40 am, surveyor arrived at the agency ' s office and found that agency ' s administrator was unavailable, and agency's manager and secretary stated the survey will be conducted with two staff members instead.
A review of Client Record (CR) was conducted on 3/20/25 at 10:45 am. The Start of Care (SOC) date is indicated below.
CR1 SOC 2/23/23, file was not available onsite.
CR2 SOC 2/1/25, file was not available onsite.
CR3 SOC 1/3/22, file was not available onsite.
CR4 SOC 1/15/24, file was not available onsite.
CR5 SOC 10/20/23, file was not available onsite.
CR6 SOC 8/15/24, file was not available onsite.
CR7 SOC 4/24/23, file was not available onsite.
An interview with agency ' s manger and secretary on 3/20/25 at 11 am revealed the following:
Due to administrator only has access to CRs including inactive client files, agency's staff members are unable to provide files to surveyor for inspection.
A review of Personnel File (PF) was conducted on 3/20/25 at 11:30 am.
PF5, with a hire date of approximately as May 2024, file was not available onsite.
PF6, with a hire date of approximately as April 2025, file was not available onsite.
An interview with agency's manager and secretary on 3/20/25 at 11:30 am revealed the following:
The agency's staff members were unable to provide above files to surveyor for inspection.
An interview with agency ' s manager on 3/20/25 at 11 am and 11:30 am confirmed that personnel files and consumer files were not available onsite.
Plan of Correction:After the surveyor from DOH, the CEO of AG home Care Services, initiated and held a mandatory meeting with all management. The goal of the meet was to in service management on the findings of the missing documentation regarding the employee files.
As a result of this meeting effective immediately 4/6/2025,
AGHCS has implemented the following (employment check list and Patient/Client Checklist) to bring current files and remain in compliance with state code 611.5.
1. Administrator/Management will perform Quarterly Audits using the personnel file checklist and Patient/Client Check list.
2. Employees will be notified regarding expired or missing documentation with expected date needed to be completed.
3. Patient/Clients will be notified of required documentation for file and explanation will be provided and signature obtained. Documents will be kept in locked a locked file cabinet.
4. Any employee file outdated or incomplete, will be provided two weeks to update or complete required documentation before being removed from their work schedule.
5. Any Patient/client file that are not in compliance, Management will review all required documentation and obtain signatures and place signed in patient/client files by May 20th, 2025.
6. All employee Files that are not in compliance will be required to submit missing documentation noted via employment or Personnel checklist by May 20th, 2025. If not received employee will be removed from their work schedule until documentation is completed.
7. All Employee and Patient/client files will remain on site in a locked file cabinet for updating and review upon request for inspection.
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
Name - Component - 00
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 on a review of personnel files (PF) and an interview with agency ' s manager, the agency did not obtain at least two satisfactory references or conduct a face-to-face interview with the individual for the individuals prior to hiring or rostering a direct care worker for seven (7) of seven (7) PFs (PF 1, 2, 3, 4, 5, 6 and 7).
Findings include:
A review of personnel files (PF) was conducted on 3/20/25 starting at 11:30 am and 3/27/25 starting at 10 am. The Date of Hire (DOH) is indicated below.
PF1 DOH 2/2/23 did not have evidence that, prior to hiring or rostering the direct care worker, agency obtained two (2) satisfactory references from non-family members or conducted a face to face interview.
PF2 DOH 2/13/23 did not have evidence that, prior to hiring or rostering the direct care worker, agency obtained two (2) satisfactory references from non-family members or conducted a face to face interview.
PF3 DOH January 2022 did not have evidence that, prior to hiring or rostering the direct care worker, agency obtained two (2) satisfactory references from non-family members or conducted a face to face interview.
PF4 DOH 1/25/25 did not have evidence that, prior to hiring or rostering the direct care worker, agency obtained two (2) satisfactory references from non-family members or conducted a face to face interview.
PF5, with a hire date approximately as May 2024, did not have evidence that, prior to hiring or rostering the direct care worker, agency obtained two (2) satisfactory references from non-family members or conducted a face to face interview.
PF6, with a hire date approximately April 2023, did not have evidence that, prior to hiring or rostering the direct care worker, agency obtained two (2) satisfactory references from non-family members or conducted a face to face interview.
PF7 DOH 3/2/23 did not have evidence that, prior to hiring or rostering the direct care worker, agency obtained two (2) satisfactory references from non-family members or conducted a face to face interview.
An interview with the agency ' s manager on 3/20/25 at approximately 11:30 am confirmed these findings.
Plan of Correction:After the surveyor from DOH, the CEO of AG Home Care Services initiated and held a mandatory meeting with all management. The goal of the meeting was to provide in-service to management on the findings of the missing documentation regarding the employee files.
As a result of this meeting, effective immediately, 4/06/2025, AGHCS will not employ prospective employees until all required documentation, according to 611.51(a), is completed.
AGHCS has implemented the following (employment checklist and Personnel file Checklist) to bring current files in compliance with state code 611.51(a).
1. All employees who were cited will have their face-to-face interview documented on the employment checklist by the administrator/manager who performed the interview by May 20th, 2025.
2. All employee files cited during DOH inspection will be updated with required satisfactory references by May 20th, 2025. The administrator/Manager will contact and document reference checks on their employment checklist.
AGHCS has implemented the following(employment checklist and Personnel file Checklist) to maintain compliance with state code 611.51(a).
1.AG Home Care administrator will conduct a face-to-face meeting in person, via Teams, Facetime, or any video conference modality with all potential employees prior to employment and document the meeting on the Employment checklist.
2. AG Home Care administrator will obtain two satisfactory references before employment and document on employment checklist.
3. Administrator/Manager/secretary will perform Quarterly Audits utilizing the personnel file checklist.
4. Any employee files that are outdated or incomplete, Employees will be provided two weeks to update or complete required documentation before being removed from their work schedule.
611.52(b) LICENSURE
State Police Criminal History Record
Name - Component - 00
If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.
Observations:
Based on a review of personnel files (PF) and an interview with agency ' s manager, the agency failed to provide documentation of a Pennsylvania State Police Criminal Background Check at the time of application or within 1 year immediately preceding the date of application for three (3) of seven (7) PF's reviewed (PF# 1, 3 and 7).
Findings include:
A review of personnel files (PF) was conducted on 3/20/25 starting at 11:30 am and 3/27/25 starting at 10 am. The Date of Hire (DOH) is indicated below.
PF1 DOH 2/2/23, contained documentation of a Pennsylvania State Police Criminal Background Check completed on 3/19/25 which is late.
PF3 DOH January 2022, contained documentation of a Pennsylvania State Police Criminal Background Check completed on 3/4/25 which is late.
PF7 DOH 3/2/23, contained no documentation of a Pennsylvania State Police Criminal Background Check completed.
An interview conducted with the agency ' s manager on 3/20/25 at approximately 11:30 am confirmed the above findings.
Plan of Correction:After the surveyor from DOH visited on 3/28/25, the CEO of AG Home Care Services initiated and held a mandatory meeting with management. The goal of the meeting was to provide in-service management on the findings of the missing documentation regarding the employee files.
As a result of this meeting, effective immediately, 4/06/2025, AGHCS will continue to require criminal background checks as per Pa Code 611.52.
611.52. Criminal background checks.
(a) General rule. 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. An applicant for employment as a member of the office staff for the home care agency or home care registry and the owner or owners of the home care agency or home care registry are also required to obtain a criminal history report in accordance with requirements contained in this section.
(b) State Police criminal history record. If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.
(c) Federal criminal history record. 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 6 Pa. Code 15.144(b) (relating to procedure)
All files cited will be reviewed and brought into compliance by 4/30/25 with the required documentation. If Documentation is not received by the expected date, the employee will be removed from their schedule until the document is received.
The administrator/Manager/secretary will perform Quarterly Audits of employee files with the employee file checklist to maintain compliance.
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 agency ' s manager, agency failed to maintain documentation of initial competency reviews for direct care workers for two (2) out of seven (7) PF reviewed (PF# 2 and 3).
Findings include:
A review of personnel files (PF) was conducted on 3/20/25 starting at 11:30 am and 3/27/25 starting at 10 am. The Date of Hire (DOH) is indicated below.
PF2 DOH 2/13/23 did not contain documentation of initial competency training.
PF3 DOH January 2022 did not contain documentation of initial competency training.
An interview with the agency's manager on 3/20/25 at approximately 11:30 am confirmed these findings.
Plan of Correction:After the surveyor from DOH, the CEO of AG home Care Services, initiated and held a mandatory meeting with management. The goal of the meeting was to provide in-service to management on the findings of the missing documentation regarding the employee files.
As a result of this meeting, effective immediately 4/06/2025 to bring employee files cited in compliance.
The administrator/manager will assign time/days to meet with employees to complete competencies before May 20th 2025. Once completed employee certificate of completion will be placed in the employee's file.
The administrator/manager will remove Employees from their work schedule if Competency is not received by May 20th 2025.
These competencies exam will encompass all the required elements listed in chapter 611.55. To maintain compliance AGHCS has implemented an Employee Personnel file Checklist.
1. The administrator/Manager will provide an initial and annual employee competency test before employment and to maintain employment. Direct Care Staff Training:
2. Administrator/Manager/secretary will perform Quarterly Audits of employee files with a personnel file checklist to maintain compliance with employee education.
3. The Administrator/Manager/Secretary will notify employees of required Training. Employees will be provided two weeks to complete the required training before being removed from their work schedule.
4. Employees will provide a copy of completed training to the Administrator/Manager/Secretary, who will place the certificate of completion in the employee personnel file.
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 agency ' s manager, the agency failed to conduct annual competency review for three (3) of seven (7) PFs (PF# 1, 3 and 6).
A review of personnel files (PF) was conducted on 3/20/25 starting at 11:30 am and 3/27/25 starting at 10 am. The Date of Hire (DOH) is indicated below.
PF1 DOH 2/2/23, did not contain documentation of annual competency training for 2024 and 2025.
PF3 DOH January 2022, did not contain documentation of annual competency training for 2023.
PF6, with a hire date approximately as April 2023, did not contain documentation of annual competency training for 2024.
An interview with the agency's manager on 3/20/25 at approximately 11:30 am confirmed these findings.
Plan of Correction:After the surveyor from DOH, the CEO of AG home Care Services, initiated and held a mandatory meeting with management. The goal of the meeting was to provide in-service to management on the findings of the missing documentation regarding the employee files.
As a result of this meeting, effective immediately 4/06/2025 to bring employee files cited in compliance.
The administrator/manager will assign time/days to meet with employees to complete competencies before May 20th 2025. Once completed employee certificate of completion will be placed in the employee's file.
The administrator/manager will remove Employees from their work schedule if Competency is not received by May 20th 2025.
These competencies exam will encompass all the required elements listed in chapter 611.55. To maintain compliance AGHCS has implemented an Employee Personnel file Checklist.
1. The administrator/Manager will provide an initial and annual employee competency test before employment and to maintain employment. Direct Care Staff Training:
2. Administrator/Manager/secretary will perform Quarterly Audits of employee files with a personnel file checklist to maintain compliance with employee education.
3. The Administrator/Manager/Secretary will notify employees of required Training. Employees will be provided two weeks to complete the required training before being removed from their work schedule.
4. Employees will provide a copy of completed training to the Administrator/Manager/Secretary, who will place the certificate of completion in the employee personnel file.
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 agency ' s manager, the agency did not provide documentation that a direct care worker (DCW) was screened and free from active mycobacterium tuberculosis for five (5) of seven (7) PF's (PF# 1, 2, 3, 4 and 5) 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 seven (7) of seven (7) PF's (PF# 1, 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 3/20/25 starting at 11:30 am and 3/27/25 starting at 10 am. The Date of Hire (DOH) is indicated below.
PF1 DOH 2/2/23, did not contain evidence of a completed two step TST or TB single blood assay, TB symptom screening questionnaire, or TB risk assessment upon hire.
PF2 DOH 2/13/23, did not contain evidence of a completed two step TST or TB single blood assay, TB symptom screening questionnaire, or TB risk assessment upon hire.
PF3 DOH January 2022, did not contain evidence of a completed two step TST or TB single blood assay, TB symptom screening questionnaire, or TB risk assessment upon hire.
PF4 DOH 1/25/25, did not contain evidence of a completed two step TST or TB single blood assay, TB symptom screening questionnaire, or TB risk assessment upon hire.
PF5, with a hire date approximately as May 2024, did not contain evidence of a completed two step TST or TB single blood assay, TB symptom screening questionnaire, or TB risk assessment upon hire.
PF6, with a hire date approximately as April 2023, did not contain evidence that a TB symptom screen questionnaire, nor a TB risk assessment was completed upon hire.
PF7 DOH 3/2/23, 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 manager on 3/20/25 at approximately 11:30 am confirmed the above findings.
Plan of Correction:After the surveyor from DOH on 3/28/25, the CEO of AG Home Care Services initiated and held a mandatory meeting with management. The goal of the meeting was to provide in-service management on the CDC guidelines regarding Required TB Screening for all health care workers and the importance of following the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.
effective immediately Management will review the CDC Guidelines and implement them on 4/6/25.
As per the CDC guidelines, all health Care workers are required to have a baseline Tuberculosis (TB) screening, including an individual risk assessment. Health care workers are considered at increased risk for TB if they marked yes to any of the baseline questions. Centers of Disease Control and Prevention (CDC) updated the recommendation for TB testing of health care personnel on May 17, 2019.
According to the CDC Guidelines via Website.
1. All AGHCS health care personnel are to be screened for TB upon hire with an individual risk assessment, symptom evaluation, and a TB Test (either the interferon gamma release assay, or IGRA, blood test or the tuberculin skin test). Thereafter, annual TB testing is not recommended unless there is a known exposure to someone with a TB infection or known transmission in the work setting.
2. TB education will be conducted annually for health care Personnel by management via CDC website. Signed documentation will be required and placed in the employee files as proof of education.
3. Employees unable to obtain TB testing by 4/30/25, will be removed from active duty until TB testing is completed.
4. All Documents will remain in the employee file, which will be kept at the office for updating and review for inspection.
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 agency ' s manager, the agency failed to ensure each direct care worker were provided with annual mycobacterium tuberculosis education for five (5) of seven (7) PF's reviewed (PF# 1, 2, 3, 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, 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).
Findings include:
A review of personnel files (PF) was conducted on 3/20/25 starting at 11:30 am and 3/27/25 starting at 10 am. The Date of Hire (DOH) is indicated below.
PF1 DOH 2/2/23, did not contain any documentation of annual tuberculosis education provided in 2024 and 2025.
PF2 DOH 2/13/23, did not contain any documentation of annual tuberculosis education provided in 2024 and 2025.
PF3 DOH January 2022, did not contain any documentation of annual tuberculosis education provided in 2023, 2024 and 2025.
PF6, with a hire date approximately as April 2023, did not contain any documentation of annual tuberculosis education provided in 2024.
PF7 DOH 3/2/23, did not contain any documentation of annual tuberculosis education provided in 2024 and 2025.
An interview conducted with the agency's manager on 3/20/25 at approximately 11:30 am confirmed the above findings.
Plan of Correction:After the surveyor from DOH on 3/28/25, the CEO of AG Home Care Services initiated and held a mandatory meeting with management. The goal of the meeting was to provide in-service management on the CDC guidelines regarding Required TB Screening for all health care workers and the importance of following the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.
effective immediately Management will review the CDC Guidelines and implement them on 4/6/25.
As per the CDC guidelines, all health Care workers are required to have a baseline Tuberculosis (TB) screening, including an individual risk assessment. Health care workers are considered at increased risk for TB if they marked yes to any of the baseline questions. Centers of Disease Control and Prevention (CDC) updated the recommendation for TB testing of health care personnel on May 17, 2019.
According to the CDC Guidelines via Website.
1. All AGHCS health care personnel are to be screened for TB upon hire with an individual risk assessment, symptom evaluation, and a TB Test (either the interferon gamma release assay, or IGRA, blood test or the tuberculin skin test). Thereafter, annual TB testing is not recommended unless there is a known exposure to someone with a TB infection or known transmission in the work setting.
2. TB education will be conducted annually for health care Personnel by management via CDC website. Signed documentation will be required and placed in the employee files as proof of education.
3. Employees unable to obtain TB testing by 4/30/25, will be removed from active duty until TB testing is completed.
4. All Documents will remain in the employee file, which will be kept at the office for updating and review for inspection.
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 a review of the consumer records (CR), Electronic Visit Verification (EVV) and an interview with the agency's manager and secretary, the agency failed to ensure following consumer 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 and (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 for seven (7) of seven (7) CRs reviewed (CR# 1, 2, 3, 4, 5, 6 and 7).
Findings include:
A review of Client Record (CR) was conducted on 3/20/25 at 10:45 am. The Start of Care (SOC) date is indicated below.
CR1 SOC 2/23/23, file was not available onsite. There was no documentation that the consumer received 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 and (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
CR2 SOC 2/1/25, file was not available onsite. There was no documentation that the consumer received 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 and (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
CR3 SOC 1/3/22, file was not available onsite. There was no documentation that the consumer received 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 and (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
CR4 SOC 1/15/24, file was not available onsite. There was no documentation that the consumer received 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 and (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
CR5 SOC 10/20/23, file was not available onsite. There was no documentation that the consumer received 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 and (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
CR6 SOC 8/15/24, file was not available onsite. There was no documentation that the consumer received 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 and (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
CR7 SOC 4/24/23, file was not available onsite. There was no documentation that the consumer received 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 and (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
An interview with agency's manager on 3/20/25 at 11 am confirmed the above findings.
Plan of Correction:After the surveyor from DOH visited on 3/28/2025, the CEO of AG Home Care Services initiated and held a mandatory meeting with management. The goal of the meeting was to provide in-service to management on the findings of the consumer records.
Effective immediately Management will review all required documents as per PA code 611.57 with the Patient/Client upon admission.
1. Management will provide All new Patient/Clients an AGHCS patient handbook.
2. Management will review Patient/Client handbook with consumer and obtain a signature on all required documents.
3. Managment will place all signed documents in Patient/Client files in the office.
5. Management will Review Patient/client files quarterly for any updates and to maintain compliance according to PA code 611.57.
6. Files will be kept secure in the office for review by management and for inspection.
611.57(b) LICENSURE
Prohibitions
Name - Component - 00
(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 a review of the consumer records (CR), Electronic Visit Verification (EVV), and an interview with the agency ' s manager and secretary, the agency failed to provide following information in a form that is easily read and understood prior to the commencement of services: 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 for seven (7) of seven (7) CRs reviewed (CR# 1, 2, 3, 4, 5, 6 and 7).
Findings include:
A review of Client Record (CR) was conducted on 3/20/25 at 10:45 am. The Start of Care (SOC) date is indicated below.
CR1 SOC 2/23/23, file was not available onsite. There was no documentation that the consumer received the following information: 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.
CR2 SOC 2/1/25, file was not available onsite. There was no documentation that the consumer received the following information: 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.
CR3 SOC 1/3/22, file was not available onsite. There was no documentation that the consumer received the following information: 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.
CR4 SOC 1/15/24, file was not available onsite. There was no documentation that the consumer received the following information: 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.
CR5 SOC 10/20/23, file was not available onsite. There was no documentation that the consumer received the following information: 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.
CR6 SOC 8/15/24, file was not available onsite. There was no documentation that the consumer received the following information: 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.
CR7 SOC 4/24/23, file was not available onsite. There was no documentation that the consumer received the following information: 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 interview with agency's manager on 3/20/25 at 11 am confirmed the above findings.
Plan of Correction:After the surveyor from DOH visited on 3/28/2025, the CEO of AG Home Care Services initiated and held a mandatory meeting with management. The goal of the meeting was to provide in-service to management on the findings of the consumer records.
Effective immediately Management will review all required documents as per PA code 611.57 with the Patient/Client upon admission.
1. Management will provide All new Patient/Clients an AGHCS patient handbook.
2. Management will review Patient/Client handbook with consumer and obtain a signature on all required documents.
3. Managment will place all signed documents in Patient/Client files in the office.
5. Management will Review Patient/client files quarterly for any updates and to maintain compliance according to PA code 611.57.
6. Files will be kept secure in the office for review by management and for inspection.
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 agency ' s manager and secretary, 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: (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 for seven (7) of seven (7) CRs reviewed (CR 1, 2, 3, 4, 5, 6 and 7).
Findings include:
A review of Client Record (CR) was conducted on 3/20/25 at 10:45 am. The Start of Care (SOC) date is indicated below.
CR1 SOC 2/23/23, file was not available onsite. There was no documentation that the consumer received the following information: (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.
CR2 SOC 2/1/25, file was not available onsite. There was no documentation that the consumer received the following information: (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.
CR3 SOC 1/3/22, file was not available onsite. There was no documentation that the consumer received the following information: (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.
CR4 SOC 1/15/24, file was not available onsite. There was no documentation that the consumer received the following information: (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.
CR5 SOC 10/20/23, file was not available onsite. There was no documentation that the consumer received the following information: (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.
CR6 SOC 8/15/24, file was not available onsite. There was no documentation that the consumer received the following information: (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.
CR7 SOC 4/24/23, file was not available onsite. There was no documentation that the consumer received the following information: (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.
An interview with agency's manager on 3/20/25 at 11 am confirmed the above findings.
Plan of Correction:After the surveyor from DOH visited on 3/28/2025, the CEO of AG Home Care Services initiated and held a mandatory meeting with management. The goal of the meeting was to provide in-service to management on the findings of the consumer records.
1. Effective immediately Management will review all required documents as per PA code 611.57 with the Patient/Client upon admission.
2. Management will provide All new Patient/Clients an AGHCS patient handbook which includes a list of home care services and who will be providing the services, Hours of service will be provided, Type of Waivers utilized for services, DOH number for complaints, local ombudsman agency and number, job description, and patient/client responsibilities.
2. Management will review Patient/Client handbook with consumer and obtain a signature on all required documents.
3. Managment will acquire signatures of all documents required on patient/clients' files cited and place all signed documents in Patient/Client files in the office by May 20th, 2025.
4. Management will Review Patient/client files quarterly for any updates and to maintain compliance according to PA code 611.57.
5. Files will be kept secure in the office for review by management and for inspection.
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 a review of Client Record (CR), and an interview with agency's manager, the agency failed to maintain documentation on file at the agency or registry of compliance with the requirements of this section which shall be available for Department inspection.
A review of Client Record (CR) was conducted on 3/20/25 at 10:45 am.
The agency's manager stated the following: the agency receives clients via insurance service coordinators (SC) and do not have client files at the office. Manager wasn't aware of any files that exist other than HHAexchange program which shows authorized hours, care plans that are set by SCs, and calendars for clock in and out activity for visit verification. The administrator was not at the office. Per manager and secretary of agency, the administrator only has access to CRs including inactive client files. The clinical records do not contain any of the required documentation as listed in Chapter 611.57(a), Chapter 611.57(b) and Chapter 611.57(c). There is no documentation that the client received the above information.
An interview with manager on 3/20/25 at 11 am confirmed the above findings.
Plan of Correction:After the surveyor from DOH, the CEO of AG home Care Services, initiated and held a mandatory meeting with all management. The goal of the meet was to in service management on the findings of the missing documentation regarding the employee files.
As a result of this meeting effective immediately 4/6/2025,
AGHCS has implemented the following (client/Patient file check list) to bring current files and remain in compliance with state code 611.57(a), 611.57(b), and 611.57(c).
1.Administrator/Management will perform Quarterly Audits using the client/Patient file check list on all Clients/Patients.
Copies of files will remain in a secured location for review when requested by DOH.
Management will update files within two weeks (4/14/25).
Initial Comments:
Based on the findings of an onsite home care agency state re-licensure and license complaint survey conducted on March 3 and 20, 2025 and offsite on March 6, 9, 27 and 28, 2025, AG Home Care Services LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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