Initial Comments:
Based on an onsite state re-licensure survey completed 5/16/25, Agewell Caregiver Service was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite state re-licensure survey completed 5/16/25, Agewell Caregiver Service was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.
Plan of Correction:
611.55(c) LICENSURE
Competency Requirements
Name - Component - 00
A competency examination or training program developed by an agency or registry for a direct care worker who will provide personal care must address the following additional subject areas: 1. Bathing, shaving, grooming and dressing; 2. Hair, skin and mouth care; 3. Assistance with ambulation and transferring; 4. Meal preparation and feeding; 5. Toileting; 6. Assistance with self-administered medications.
Observations:
Based on a review of personnel files (PF), policy, and interviews with the owners, the agency failed to ensure direct care worker initial competency and training included personal care subject areas for five (5) of seven (7) PFs reviewed. (PFs 1, 2, 4, 5, and 6)
Findings include:
A 5/16/25 review of Hiring, Competency Testing and Training for Home Health Aide/Direct Care Workers policy revealed: " ...A competency examination or training program developed by an agency or registry for a direct care worker who will provide personal care must address the following additional subject areas: 1. Bathing, shaving, grooming and dressing 2. Hair, skin and mouth care 3. Assistance with ambulation and transferring 4. Meal prep and feeding 5. Toileting 6. Assistance with self-administered medications ... the [agency] shall include documentation of the direct care worker ' s satisfactory completion of competency requirements in the direct care worker ' s file ... "
A PF review conducted on 5/16/25 between approximately 11:30 am to 1:00 pm revealed:
PF1: Start of Service (SOS): 3/20/24.
PF2: SOS: 3/18/25.
PF4: SOS: 10/5/23.
PF5: SOS: 1/15/24.
PF6: SOS: 9/26/23.
PFs 1,2,4,5, and 6 contained documentation titled Staff Training Policy (section 52.21 Staff Training): Sign off sheet. The document failed to include personal care subject areas.
A 5/16/25 interview with EMP1 (Secretary) revealed that the agency had failed to replace an online Learning Management System (LMS) that became inaccessible as of 2023. The LMS had been utilized by the agency to provide direct care workers with training and competency testing in the areas of personal care. After the LMS became unavailable employee training and competency review documentation was solely based on Chapter 52.21 topics.
The agency failed to follow policy and document PF1, 2, 4, 5, and 6 ' s initial training and competency in the areas of 1. Bathing, shaving, grooming and dressing 2. Hair, skin and mouth care 3. Assistance with ambulation and transferring 4. Meal prep and feeding 5. Toileting 6. Assistance with self-administered medications.
The finding was reviewed with EMP1 (secretary) and EMP2 (owner) during an exit interview conducted on 5/16/25 at approximately 1:30 pm.
Plan of Correction:1. The Agency will prepare materials that will adequately address the additional subject areas of ADLs and IADLs.
2. The Agency will provide orientation and training to DCWs on ADLs and IADLs along with the training materials.
3. The Agency will prepare a questionnaire and conduct a competency test with a passing grade of 80.00% on the subject to ensure that the DCW demonstrate the competency requirements to perform the duties.
4. The Agency will highlight the Individual Care/Support Plan (if available) or develop a care plan with the consumer or with the consumer's representative to ensure that the consumer has control in the decision-making process while honoring privacy, dignity and respect.
5. The Agency will provide training and orientation annually. Agency will also provide additional training to DCW depending on their needs.
6. The agency will update the Staff Training Policy to address the competency requirements before hiring or rostering DCW.
7. All the documents produced will be kept in accordance with HIPAA in the PF
.
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), policy, and interviews with the owners, the agency failed to ensure direct care worker annual competency reviews included personal care subject areas for four (4) of seven (7) PFs reviewed. (PFs 3, 4, 6, and 7)
Findings include:
A 5/16/25 review of Hiring, Competency Testing and Training for Home Health Aide/Direct Care Workers policy revealed: " ...A competency examination or training program developed by an agency or registry for a direct care worker who will provide personal care must address the following additional subject areas: 1. Bathing, shaving, grooming and dressing 2. Hair, skin and mouth care 3. Assistance with ambulation and transferring 4. Meal prep and feeding 5. Toileting 6. Assistance with self-administered medications ... the [agency] shall include documentation in the direct care worker ' s file ...the competency review must occur at least once per year after initial competency ... "
A PF review conducted on 5/16/25 between approximately 11:30 am to 1:00 pm revealed:
PF3: Start of Service (SOS): 3/15/21.
PF4: SOS: 10/5/23.
PF6: SOS: 9/26/23.
PF7: SOS: 7/18/21. PF7 failed to contain annual training for 2023.
PFs 3, 4, 6, and 7 ' s 2024 training and PF3 ' s 2023 training documents were titled Staff Training Policy (section 52.21 Staff Training): Sign off sheet. The annual training documentation failed to include personal care subject areas. A 5/16/25 interview with EMP1 (Secretary) revealed that the agency had failed to replace an online Learning Management System (LMS) that became inaccessible as of 2023. The LMS had been utilized by the agency to provide direct care workers with training and competency testing in the areas of personal care. After the LMS became unavailable employee training and competency review documentation was solely based on Chapter 52.21 topics.
The agency failed to follow policy and document PF3, 4, 6, and 7 ' s annual training and competency review in the areas of 1. Bathing, shaving, grooming and dressing 2. Hair, skin and mouth care 3. Assistance with ambulation and transferring 4. Meal prep and feeding 5. Toileting 6. Assistance with self-administered medications.
The finding was reviewed with EMP1 (secretary) and EMP2 (owner) during an exit interview conducted on 5/16/25 at approximately 1:30 pm.
Plan of Correction:1. The Agency will prepare a comprehensive questionnaire that will cover all the topics from §611.55(b) and §611.55 (c) and other topics from Chapter 52. Long-Term Living HCBS included and conduct a competency test with a passing grade of 80.00% on the subject to ensure that the DCW demonstrate the competency requirements to perform the duties.
2. The Agency will also seek access to online training (LMS) resources available, encourage and assist DCWs with online training, complete training online and obtain completion certificates at the end of each course and provide a copy to the Agency.
3. The Agency will focus on ADLs and IADLs highlighting the Individual Care/Support Plan (if available) or developing a care plan with the consumer's representative to ensure that the consumer has control in the decision-making process while honoring independent living philosophy, privacy, dignity and respect.
4. Agency will provide initial and annual training and orientation to all active DCWs and identified back-up DCWs (not currently employed) irrespective of their employment status.
5. The agency will update the Staff Training Policy to address the competency requirements before hiring or rostering DCW.
6. All the documents produced will be kept in accordance with HIPAA in the PF.
Initial Comments:
Based on an onsite state re-licensure survey completed 5/16/25, Agewell Caregiver Services was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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