Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on April 30, 2025, Compassionate Kinfolk Home Healthcare 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 unannounced re-licensuse survey conducted on April 30, 2025, Compassionate Kinfolk Home Healthcare 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:
611.51(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 Personal files (PF) and an interview with the Owner, the agency failed to ensure that 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 for four (4) of the seven (7) PF's, (PF#1, 2, 4 and 6).
Findings include:
A review of PF conducted on April 30, 2025 at approximately 10:45 am revealed the following:
PF#1 - Date of Hire: 8/29/2022. PF contained a Face-to Face interview sheet that was not completed.
PF#2 - Date of Hire: 1/6/2022. PF contained two (2) references that were obtained from family members.
PF#4 - Date of Hire: 8/15/2019. PF did not contain documentation a face-to-face interview was conducted upon hire.
PF#6 - Date of Hire: 4/26/2022. PF did not contain documentation a face-to-face interview was conducted upon hire.
An interview with the Owner conducted on April 30, 2025 at approximately 12:30 pm confirmed the above findings.
Plan of Correction:Compliance director will conduct face to face, receive 2 reference forms for each individual prior to hiring along with criminal background check. Office manager will create and implement a spreadsheet to monitor interview sheets, criminal background checks and references on monthly basis.
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 Owner, 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 four (4) of seven (7) files reviewed. (PF# 2, 3, 4 and 7.)
Findings include:
A review of PF conducted on April 30, 2025 at approximately 10:45 am revealed the following:
PF#2 - Date of Hire: 1/6/2022. PF did not contain evidence that a Pennsylvania State Police Criminal Background was obtained upon hire. A criminal background on file was dated for 2/25/2020.
PF#3 - Date of Hire: 12/20/2018. PF did not contain evidence that a Pennsylvania State Police Criminal Background was obtained upon hire. A criminal background on file was dated for 1/3/2019.
PF#4 - Date of Hire: 8/15/2019. PF did not contain evidence that a Pennsylvania State Police Criminal Background was obtained upon hire. A criminal background on file was dated for 12/18/2019.
PF#7 - Date of Hire: 11/9/2020. PF did not contain evidence that a Pennsylvania State Police Criminal Background was obtained upon hire. A criminal background on file was dated for 1/20/2021.
An interview with the Owner conducted on April 30, 2025 at approximately 12:30 pm confirmed the above findings.
Plan of Correction:Compliance director 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. Compliance director will create a spreadsheet to monitor and audit criminal background checks on weekly basis. Compliance director and manager will audit all files to prevent future deficiencies.
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 (PF) and an interview with the Owner, the agency failed to ensure that an annual competency was performed for six (6) of seven (7) PF's reviewed: (PF#1, 2, 3, 4, 6 and 7).
Findings include:
A review of PF conducted on April 30, 2025 at approximately 10:45 am revealed the following:
PF#1 - Date of Hire: 8/29/2022. PF did not contain documentation that annual competencies were completed for 2023 and 2024.
PF#2 - Date of Hire: 1/6/2022.PF did not contain documentation that annual competencies were completed for 2023 and 2024.
PF#3 - Date of Hire: 12/20/2018.PF did not contain documentation that annual competencies were completed for 2023 and 2024.
PF#4 - Date of Hire: 8/15/2019.PF did not contain documentation that annual competencies were completed for 2023 and 2024.
PF#6 - Date of Hire: 4/26/2022.PF did not contain documentation that annual competencies were completed for 2023 and 2024.
PF#7 - Date of Hire: 11/9/2020.PF did not contain documentation that annual competencies were completed for 2023 and 2024.
An interview with the Owner conducted on April 30, 2025 at approximately 12:30 pm confirmed the above findings.
Plan of Correction: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. Compliance director will create a spreadsheet to track it monthly to make sure there are no deficiencies.
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 Owner, 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)
Findings include:
A review of PF conducted on April 30, 2025 at approximately 10:45 am revealed the following:
PF#1 - Date of Hire: 8/29/2022. PF contained documentation that a two (2) step Tuberculin Skin Test (TST) was obtained late on 10/20/22 and 10/27/2022. No documentation that a symptom screening/ risk assessment was obtain upon hire.
PF#2 - Date of Hire: 1/6/2022. PF contained documentation that a symptom screening/ risk assessment was obtain upon hire.
PF#3 - Date of Hire: 12/20/2018. PF contained documentation that a symptom screening/ risk assessment was obtain upon hire.
PF#4 - Date of Hire: 8/15/2019. PF contained documentation that a two (2) step Tuberculin Skin Test (TST) was obtained late on 12/9/2019 and 12/19/2019. No documentation that a symptom screening/ risk assessment was obtain upon hire.
PF#5 - Date of Hire: 7/19/2024. PF contained documentation that a two (2) step Tuberculin Skin Test (TST) was obtained late on 10/7/24 and 10/17/2024. No documentation that a symptom screening/ risk assessment was obtain upon hire.
PF#6 - Date of Hire: 4/26/2022. PF contained documentation that a one (1) step Tuberculin Skin Test (TST) was obtained late on 8/22/22. No evidence that a two (2) step was obtained. No documentation that a symptom screening/ risk assessment was obtain upon hire.
PF#7 - Date of Hire: 11/9/2020. PF contained documentation that a QuantiFERON Gold was obtained late on 2/4/2022. No documentation that a symptom screening/ risk assessment was obtain upon hire.
An interview with the Owner conducted on April 30, 2025 at approximately 12:30 pm confirmed the above findings.
Plan of Correction:Office Manager and Compliance director will 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 . Office manager will create a spreadsheet to monitor tb screenings on monthly basis to prevent future deficiencies.
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 Owner, the agency failed to ensure each direct care worker were provided with annual mycobacterium tuberculosis education for six (6) of seven (7) PF's reviewed, (PF#1, 2, 3, 4, 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)
Findings include:
A review of PF conducted on April 30, 2025 at approximately 10:45 am revealed the following:
PF#1 - Date of Hire: 8/29/2022. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2023 and 2024.
PF#2 - Date of Hire: 1/6/2022. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2023, 2024 and 2025
PF#3 - Date of Hire: 12/20/2018. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2019, 2020, 2021, 2022, 2023 and 2024.
PF#4 - Date of Hire: 8/15/2019. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2020, 2021, 2022, 2023 and 2024.
PF#6 - Date of Hire: 4/26/2022 .PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2023 and 2024.
PF#7 - Date of Hire: 11/9/2020. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2021, 2022, 2023 and 2024.
An interview with the Owner conducted on April 30, 2025 at approximately 12:30 pm confirmed the above findings.
Plan of Correction:Compliance Director will 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. 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. Compliance director will create a spreadsheet to ensure each direct care worker will be provided with annual mycobacterium tuberculosis education.
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 facility admission packet and interview with the Owner, it was determined that the agency failed to provide consumers with the following information upon admission a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (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 one (1) of the five (5) consumer files reviewed. (CF#2).
Findings include:
A review of CF conducted on April 30, 2025 at approximately 11:45 am revealed the following:
CF#2 - Start of Care: 11/28/2022. CF did not contain documentation that the consumer received the following information: 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 the Owner conducted on April 30, 2025 at approximately 12:30 pm confirmed the above findings.
Plan of Correction: Patient coordinator will ensure to provide consumers with the following information upon admission a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (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. Patient Coordinator will create spreadsheet to ensure that patients will receive proper information & literature for services that will be reviewed on monthly basis to prevent future deficiencies.
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 consumer files (CF) and an interview with the Owner there was no evidence that the agency provided the consumer with information regarding the prohibitions that 1) no individual as a result of the individual's affiliation with the home care agency may assume power of attorney or guardianship of a consumer using the services of the agency, and 2) the home care agency may not require a consumer to endorse checks over to the home care agency for one (1) of five (5) CF's reviewed: (CF# 2 ).
Findings include:
A review of CF conducted on April 30, 2025 at approximately 11:45 am revealed the following:
CF#2 - Start of Care: 11/28/2022. CF did not contain documentation that the consumer received the following information: 1) no individual as a result of the individual's affiliation with the home care agency may assume power of attorney or guardianship of a consumer using the services of the agency, and 2) the home care agency may not require a consumer to endorse checks over to the home care agency.
An interview with the Owner conducted on April 30, 2025 at approximately 12:30 pm confirmed the above findings.
Plan of Correction: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. Moving forward compliance director will create a spreadsheet to monitor and audit all files to prevent future deficiencies.
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 Owner, prior to the commencement of services, the home care agency did not provide to the consumer, the consumer's legal representative or a responsible family member (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 (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 five (5) of the five (5) CF's reviewed. (CF#1, 2, 3, 4 and 5.)
Findings include:
A review of CF conducted on April 30, 2025 at approximately 11:45 am revealed the following:
CF#1 - Start of Care: 4/28/2024. CF did not contain documentation that the consumer received information regarding (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.
CF#2 - Start of Care: 11/28/2022. CF was did not contain documentation that the consumer received the following information upon admission: (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 (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.
CF#3 - Start of Care: 12/01/2023. CF did not contain documentation that the consumer received information regarding (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.
CF#4 - Start of Care: 9/01/2023. CF was did not contain documentation that the consumer received the following information upon admission: (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 (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.
CF#5 - Start of Care: 2/5/2025. PF did not contain documentation that the following informatio was provided to the consumer: (2) The hours when those services will be provided, (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 the Owner conducted on April 30, 2025 at approximately 12:30 pm confirmed the above findings.
Plan of Correction:Patient coordinator will ensure that prior to commencing any service with a consumer, consumers will be provided (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 (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. Moving forward Patient Coordinator and Office Manager will create a spreadsheet to monitor and audit consumer files on a weekly basis to prevent future deficiencies. Patient coordinator will contact consumers to make sure they receive & understand all of their documents.
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey, Compassionate Kinfolk Home Healthcare Agency on April 30, 2025, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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