Initial Comments:
Based on the findings of an unannounced onsite state relicensure survey completed May 5, 2025, Adl Senior Care, Llc. was found to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite state relicensure survey completed May 5, 2025, Adl Senior Care, Llc. was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.
Plan of Correction:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
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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 employee files and an interview with the agency Administrator, the agency failed to obtain not less than two satisfactory references, prior to hire, for six (6) out of seven (7) employee files (EF) reviewed (EF#1, EF#2, EF#4-EF#7).
Findings include:
A review of EFs was conducted on May 5, 2025 at approximately 10:15 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 10/02/24: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable). Documentation provided of obtaining two (2) reference on a form that was not dated.
EF#2 DOH 01/28/25: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable). Documentation provided of obtaining two (2) reference on a form that was not dated.
EF#4 DOH 10/07/24: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable). Documentation provided of obtaining two (2) reference on a form that was not dated.
EF#5 DOH 11/30/24: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable).
EF#6 DOH 10/04/24: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable). Documentation provided of obtaining two (2) reference on a form that was not dated.
EF#7 DOH 10/05/24: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable). Documentation provided of obtaining two (2) reference on a form that was not dated.
An interview conducted with the agency Administrator on May 5, 2025 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:Administrator or designated personnel will obtain references for EF#5, and references for EF#1, EF#2, EF#4, EF#6 and EF#7 will be dated.
The administrator or designated employee will conduct an audit of entire employees' files every month for 3 months.
The administrator or designated employee will create a checklist of all required items before employee starts working including references checked. All new employees must have all items in checklist done before they go out to work
The administrator or designated employee will audit entire employee files every month for three months, then audit 10% of employee files every three months to make sure no other employee has the same deficiency
611.56(a) LICENSURE
Health Screening
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(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 employee files and an interview with the agency Administrator, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for three (3) out of seven (7) employee files (EF) reviewed (EF#3. EF#6, EF#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 screening annually. HCWs 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 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).
A review of EFs was conducted on May 5, 2025 at approximately 10:15 a.m. Employee date of hire (DOH) is listed below.
EF#3 DOH 01/22/25: No documentation provided of an individual TB risk assessment upon hire.
EF#6 DOH 10/04/24: No documentation provided of an individual TB risk assessment upon hire.
EF#7 DOH 10/05/24: No documentation provided of an individual TB risk assessment upon hire.
An interview conducted with the agency Administrator on May 5, 2025 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:Administrator or designated personnel will obtain TB risk assessment for employees EF#3, EF#6 and EF#7.
The administrator or designated employee will conduct an audit of entire employees' files every month for 3 months.
The administrator or designated employee will create a checklist of all required items before employee starts working including TB risk assessment upon hire. All new employees must have all items in checklist done before they go out to work
The administrator or designated employee will audit entire employee files every month for three months, then audit 10% of employee files every three months to make sure no other employee has the same deficiency
611.57(a) LICENSURE
Consumer Rights
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(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 request to review of consumer files and an interview with the agency Administrator, agency failed to ensure the consumer was involved in the service planning process, for five (5) of five (5) consumer files (CF) requested (CF#1 - CF#5).
Findings include:
CFs were requested for review on May 5, 2025 at approximately 10:15 a.m. Consumer start of service (SOS) is listed below.
CF#1 SOS 01/22/25: Documentation requested of consumers signed service agreement with the agency. No documentation provided. Per the agency Supervisor, "The client files are not located on the premises."
CF#2 SOS 04/18/25: Documentation requested of consumers signed service agreement with the agency. No documentation provided. Per the agency Supervisor, "The client files are not located on the premises."
CF#3 SOS 04/01/22: Documentation requested of consumers signed service agreement with the agency. No documentation provided. Per the agency Supervisor, "The client files are not located on the premises."
CF#4 SOS 02/05/25: Documentation requested of consumers signed service agreement with the agency. No documentation provided. Per the agency Supervisor, "The client files are not located on the premises."
CF#5 SOS 02/19/25: Documentation requested of consumers signed service agreement with the agency. No documentation provided. Per the agency Supervisor, "The client files are not located on the premises."
An interview conducted with the agency Administrator on May 5, 2025 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:Administrator or designated personnel will keep all client files on the premises at all times. Consumer agreement signed for CF#1, CF#2, CF#3, CF#4 and CF#5 will be in each client's file
The administrator or designated employee will conduct an audit of entire client's files every month for 3 months.
The administrator or designated employee will create a checklist of all required items for every client's file. All new client's file must have all items in checklist done
The administrator or designated employee will audit entire client's files every month for three months, then audit 10% of client's files every three months to make sure no other client has the same deficiency
611.57(c) LICENSURE
Information to be Provided
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(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 request to review consumer files, a review of the consumer admission packet, and an interview with the agency Administrator, the agency failed to provide the consumer, prior to the commencement of services, all or segments of the following: 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, the hours when those services will be provided, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (717-783-1379), the Department of Health complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry, and 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, for five (5) out of five (5) consumer files (CF) reviewed (CF#1-CF#5).
Findings include:
CFs were requested to review on May 5, 2025 at approximately 10:15 a.m. Consumer start of service (SOS) is listed below.
CF#1 SOS 01/22/25: Per the agency Supervisor, "The client files are not located on the premises." No documentation provided of the agency providing the consumer, prior to the start of services, 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, the hours when those services will be provided, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (717-783-1379), the Department of Health complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry, and 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.
CF#2 SOS 04/18/25: Per the agency Supervisor, "The client files are not located on the premises." No documentation provided of the agency providing the consumer, prior to the start of services, 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, the hours when those services will be provided, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (717-783-1379), the Department of Health complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry, and 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.
CF#3 SOS 04/01/22: Per the agency Supervisor, "The client files are not located on the premises." No documentation provided of the agency providing the consumer, prior to the start of services, 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, the hours when those services will be provided, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (717-783-1379), the Department of Health complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry, and 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.
CF#4 SOS 02/05/25: Per the agency Supervisor, "The client files are not located on the premises." No documentation provided of the agency providing the consumer, prior to the start of services, 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, the hours when those services will be provided, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (717-783-1379), the Department of Health complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry, and 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.
CF#5 SOS 02/19/25: Per the agency Supervisor, "The client files are not located on the premises." No documentation provided of the agency providing the consumer, prior to the start of services, 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, the hours when those services will be provided, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (717-783-1379), the Department of Health complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry, and 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.
An interview conducted with the agency Administrator on May 5, 2025 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:Administrator or designated personnel will keep all client files on the premises at all times. Consumer agreement signed for CF#1, CF#2, CF#3, CF#4 and CF#5 will be in each client's file. Consumer agreement signed by each client to include: 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, the hours when those services will be provided, who to contact at the Department for information about licensure requirements for a home care agency (717-783-1379), the Department of Health complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman for Lehigh County 484-619-3337, Ombudsman program for Northampton county, contact Agency on aging 610-829-4540. the hiring and competency requirements applicable to direct care workers employed by the home care agency, and a disclosure addressing the employee status of the direct care worker providing services to the consumer
The administrator or designated employee will conduct an audit of entire client's files every month for 3 months to make sure all client's file have the consumer agreement signed that include all above items
The administrator or designated employee will create a checklist of all required items for every client's file. All new client's file must have all items in checklist done
The administrator or designated employee will audit entire client's files every month for three months, then audit 10% of client's files every three months to make sure no other client has the same deficiency
611.57(d) LICENSURE
Documentation
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(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 request to review consumer files and an interview with the agency Administrator, agency failed to maintain consumer documentation on file at the agency for five (5) of five (5) consumer files (CF) requested (CF#1 - CF#5).
Findings include:
CFs were requested to review on May 5, 2025 at approximately 10:15 a.m. Consumer start of service (SOS) is listed below.
CF#1 SOS 01/22/25: Documentation requested of consumers signed service agreement with the agency. No documentation provided. Per the agency Supervisor, "The client files are not located on the premises."
CF#2 SOS 04/18/25: Documentation requested of consumers signed service agreement with the agency. No documentation provided. Per the agency Supervisor, "The client files are not located on the premises."
CF#3 SOS 04/01/22: Documentation requested of consumers signed service agreement with the agency. No documentation provided. Per the agency Supervisor, "The client files are not located on the premises."
CF#4 SOS 02/05/25: Documentation requested of consumers signed service agreement with the agency. No documentation provided. Per the agency Supervisor, "The client files are not located on the premises."
CF#5 SOS 02/19/25: Documentation requested of consumers signed service agreement with the agency. No documentation provided. Per the agency Supervisor, "The client files are not located on the premises."
An interview conducted with the agency Administrator on May 5, 2025 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:Administrator or designated personnel will keep all client files on the premises at all times. CF#1-CF#5
The administrator or designated employee will conduct an audit of entire client's files every month for 3 months to make sure all client's file are at the office at all times
The administrator or designated employee will create an in-service of all office employees about the requirement of all client's files must be kept at the office at all times.
The administrator or designated employee will audit entire client's files every month for three months, then audit 10% of client's files every three months to make sure no other client has the same deficiency
Initial Comments:
Based on the findings of an unannounced onsite state relicensure survey completed May 5, 2025, Adl Senior Care, Llc. was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
35 P. S. § 448.809b LICENSURE
Photo Id Reg
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Law amended July 11, 2022 Act 79 2022 HB 2604
(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.
(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.
(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.
(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.
Observations:
Based on observation of Identification badges (ID) and an interview with the agency Administrator, agency failed to format/issue ID badges per regulatory requirements for one (1) of one (1) observation (Observation #1).
Findings include:
Chapter 611 'Home Care Agencies and Home Care Registries' 611.5 'Definitions' "Direct Care Worker- The individual employed by a home care agency or referred by a home care registry to provide home care services to a consumer."
Observation #1: Observation of employee Identification Badge (ID) on May 5, 2025 at approximately 11:30 a.m. revealed the current ID badge employee title (employee #2, #3, #5, #8) is listed as 'Home Health Aide'. The employees actual title is 'Direct Care Worker'.
An interview conducted with the agency Administrator on May 5, 2025 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:Administrator or designated personnel to send out a mass communication message to all staff asking them to return their ID to the main office if the title says, "Home Health Aide" and they are a Direct Care Worker.
Administrator or designated personnel to create new ID's for those who present to the office including employees #2, #3, #5 and #8 found in this audit.
Administrator or designated personnel to update all previous ID templates to reflect the correct definition of Direct Care Worker to ensure accuracy during the onboarding process and to comply with Chapter 611.
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