Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on March 17, 2025 and offsite on April 4 and 8, 2025, Abundantly Blessed Home Care, LLC 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 state re-licensure survey conducted on March 17, 2025 and offsite on April 4 and 8, 2025, Abundantly Blessed Home 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
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 administrator, the agency failed to conduct a face-to-face interview with the individual prior to hiring or rostering a direct care worker for three (3) of seven (7) PFs (PF# 2, 3 and 4).
Findings include:
A review of personnel files (PF) was conducted on 4/4/25 starting at 12:20 pm. The Date of Hire (DOH) is indicated below.
PF2 DOH 3/15/23, did not have evidence that, prior to hiring or rostering the direct care worker, agency conducted a face-to-face interview with the individual.
PF3 DOH 1/21/25, did not have evidence that, prior to hiring or rostering the direct care worker, agency conducted a face-to-face interview with the individual.
PF4 DOH 7/15/24, did not have evidence that, prior to hiring or rostering the direct care worker, agency conducted a face-to-face interview with the individual.
An interview with the agency ' s administrator on 4/8/25 at approximately 1 pm confirmed the above findings.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and specifically Personnel file #'s (2, 3, and 4), as directed by Citation 0200.
The review showed the Agency policy is to perform face to face interviews and reference checks for all employees, but there was no face-to-face for employees' personnel #'s (2, 3 and 4) as required by 611.51(a). To correct this error on April 28, 2025; the Admin conducted face to face interviews for employees' personnel files # (2, 3 and 4).
To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP").This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers. EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation.
As of May 2, 2025; with the EPIP implementation, all employee Personnel file's including file #'s (2, 3 and 4), have all required documents as directed by 611.51(a). All deficiencies under Citation 0200 have been addressed.
611.52(c) LICENSURE
Federal Criminal History Record
Name - Component - 00
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 the requirements at 6 PA. Code § 15.144(b) (relating to procedure).
Observations:
Based on a review of personnel files (PF) and an interview with the agency ' s administrator, the agency failed to obtain a obtain a federal criminal history record and a letter of determination from the Department of Aging for personnel that has not been a resident of this Commonwealth for the 2 years immediately preceding the date of hire for three (3) of the seven (7) PF reviewed (PF# 1, 2 and 3).
Findings include:
A review of personnel files (PF) was conducted on 4/4/25 starting at 12:20 pm. The Date of Hire (DOH) is indicated below.
PF1 DOH 7/5/23, there was no documentation in the PF to support proof of residency in the State of Pennsylvania for the two (2) years immediately preceding date of hire, nor was there documentation of a Federal criminal background check completed upon hire.
PF2 DOH 3/15/23, contained a Pennsylvania State Driver ' s License that was issued on 8/20/22. There was no documentation in the PF to support proof of residency in the State of Pennsylvania for the two (2) years immediately preceding date of hire, nor was there documentation of a Federal criminal background check completed upon hire.
PF3 DOH 1/21/25, contained a Pennsylvania State Driver ' s License that was issued on 7/11/24. There was no documentation in the PF to support proof of residency in the State of Pennsylvania for the two (2) years immediately preceding date of hire, nor was there documentation of a Federal criminal background check completed upon hire.
An interview with the agency ' s administrator on 4/8/25 at approximately 1 pm confirmed the above findings.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and specifically Personnel file #'s ( 1, 2, and 3), as directed by Citation 0320. The review showed the Agency did and does perform the required background checks for employees, but did not conduct the required background checks for employees' Personnel #'s ( 1, 2, and 3) as required by 611.52(c).
To correct this error as of April 17, 2025; the Admin has begun obtaining federal criminal history records and Letter(s) of Determination from the Department of Aging, to ensure the employees are cleared to work as require by as required by 611.52(c), for employees' personnel #'s ( 1, 2, and 3).
To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 611.52(c) including ensuring all federal criminal history records and Letter(s) of Determination from the Department of Aging, have been met before a new employee can provide service consumers. EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation.
As of May 19, 2025; with the EPIP implementation, all employee Personnel file's including file #'s ( 1, 2, and 3), have all required documents as directed by 611.52(c). All deficiencies under Citation 0320 will have been addressed.
611.52(d) LICENSURE
Proof of Residency
Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation
Observations:
Based on a review of personnel files (PF) and an interview with the agency ' s administrator, the agency failed to provide evidence of Pennsylvania (PA) residency for the two (2) consecutive years immediately preceding the date of hire (DOH) through submission of any one of the following documents: (1) Motor vehicle records, such as a valid driver's license or a State-issued identification. (2) Housing records, such as mortgage records or rent receipts. (3) Public utility records and receipts, such as electric bills. (4) Local tax records. (5) A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it. (6) Employment records, including records of unemployment compensation for three (3) of seven (7) PFs reviewed (PF#1, 2 and 3).
Findings include:
A review of personnel files (PF) was conducted on 4/4/25 starting at 12:20 pm. The Date of Hire (DOH) is indicated below.
PF1 DOH 7/5/23, there was no documentation in the PF to support proof of residency in the State of Pennsylvania for the two (2) years immediately preceding date of hire.
PF2 DOH 3/15/23, contained a Pennsylvania Driver's license issued on 8/20/22. There was no evidence to support proof of PA residency for the two consecutive years immediately preceding the DOH.
PF3 DOH 1/21/25, contained a Pennsylvania Driver's license issued 7/11/24. There was no evidence to support proof of PA residency for the two consecutive years immediately preceding the DOH.
An interview with the agency ' s administrator on 4/8/25 at approximately 1 pm confirmed the above findings.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and specifically Personnel file #'s (1, 2 and 3), as directed by Citation 0330.
The review showed the Agency does obtain proof of Pennsylvania (PA) residency for employees, but did not provide documentation for employees' personnel #'s (1, 2 and 3) as required by 611.51(a).
To correct this error as of April 28, 2025; the Admin has obtained the required documentation for employees' personnel #'s (1, 2 and 3). To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers. EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation. As of May 2, 2025; with the EPIP implementation, all employee Personnel file's including file #'s (1, 2 and 3), have all required documents as directed by 611.51(a). All deficiencies under Citation 0330 have been addressed.
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) and an interview with the administrator, the home care agency (HCA) failed to provide evidence of a competency examination or training program that addressed the following subject matter areas: bathing, shaving, grooming, dressing, hair, skin, mouth care, assistance with ambulations and transfers, toileting, assistance with self-administered medications for four (4) of seven (7) PFs (PF# 1, 2, 5 and 6).
Findings include:
A review of personnel files (PF) was conducted on 4/4/25 starting at 12:20 pm. The Date of Hire (DOH) is indicated below.
PF1 DOH 7/5/23, contained a competency test completed on 7/12/24. However, there was no evidence of training or testing in the following subjects: bathing, shaving, grooming, dressing, hair, skin, mouth care, assistance with ambulation and transfers, toileting, and assistance with self-administered medications.
PF2 DOH 3/15/23, contained a competency test completed on 9/17/24. However, there was no evidence of training or testing in the following subjects: bathing, shaving, grooming, dressing, hair, skin, mouth care, assistance with ambulation and transfers, toileting, and assistance with self-administered medications.
PF5 DOH 10/20/21, contained a competency test completed on 10/7/24. However, there was no evidence of training or testing in the following subjects: bathing, shaving, grooming, dressing, hair, skin, mouth care, assistance with ambulation and transfers, toileting, and assistance with self-administered medications.
PF6 DOH 11/11/21, contained a competency test completed on 11/13/24. However, there was no evidence of training or testing in the following subjects: bathing, shaving, grooming, dressing, hair, skin, mouth care, assistance with ambulation and transfers, toileting, and assistance with self-administered medications.
An interview with the agency ' s administrator on 4/8/25 at approximately 1 pm confirmed the above findings.
Plan of Correction:Competency Training
- Effective immediately -All DCWs are required to take and pass a competency test covering bathing, shaving, grooming, dressing hair and skin, mouth care, assistance with ambulations and transfers skills, including bathing and transfers, toileting, assistance with self-administered medications, and reminders. This is a strict policy- candidates may need to retake the test multiple times if necessary. Management will audit files upon hiring and monthly to prevent recurrence. Yearly assessments will be given to all employees employed for 1 year or more. This plan will be completed by 4/30/25.
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 administrator, the agency failed to conduct annual competency review for three (3) of seven (7) PFs (PF# 5, 6 and 7).
Findings include:
A review of personnel files (PF) was conducted on 4/4/25 starting at 12:20 pm. The Date of Hire (DOH) is indicated below.
PF5 DOH 10/20/21, did not contain documentation of annual competency training for 2022 and 2023.
PF6 DOH 11/11/21, did not contain documentation of annual competency training for 2022 and 2023.
PF7 DOH 5/15/19, did not contain documentation of annual competency training for 2022 and 2023.
An interview with the agency ' s administrator on 4/8/25 at approximately 1 pm confirmed the above findings.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and specifically Personnel file # (5, 6 and 7) as directed by Citation 0621.
The review showed the Agency does provide employees with annual competency training and testing, but did not provide documentation that the annual competency training and testing for employees' personnel # (5, 6 and 7) was taken and or completed as required by 611.51(a).
To correct this error as of April 17, 2025; the Admin, contacted the specified employees and requiring them to complete and pass the annual competency training and testing. Documentation of the test and training is now in the employment files for employees' personnel # (5, 6 and 7). To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers along with Annual Training Requirements being added to the Agency's operations calendars. The EPIP Review and Annual Training requirements will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation and or training. As of May 19, 2025; with the EPIP implementation, all employee Personnel file's including file # (5, 6 and 7), will have all required documents as directed by 611.51(a). All deficiencies under Citation 0621 have been addressed.
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 administrator, the agency did not provide documentation that a direct care worker (DCW) was screened and free from active mycobacterium tuberculosis for three (3) of seven (7) PFs (PF# 1, 3 and 4) and failed to ensure that a direct care worker completed a baseline tuberculosis symptom screen questionnaire and individual tuberculosis risk assessment upon hire for three (3) of seven (7) PF's (PF#2, 3 and 4).
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).
A review of personnel files (PF) was conducted on 4/4/25 starting at 12:20 pm. The Date of Hire (DOH) is indicated below.
PF1 DOH 7/5/23, did not contain evidence that a two-step TST or TB single blood assay was completed upon hire.
PF2 DOH 3/15/23, did not contain evidence that a TB symptom screen questionnaire, nor a TB risk assessment was completed upon hire.
PF3 DOH 1/21/25, contained documentation of tuberculin skin test (TST) completed on 1/7/25. There was no evidence that a 2nd step TST was completed. File did not contain evidence that a TB symptom screen questionnaire, nor a TB risk assessment was completed upon hire.
PF4 DOH 7/15/24, contained documentation of tuberculin skin test (TST) completed on 2/28/24. There was no evidence that a 2nd step TST was completed. File did not contain evidence that a TB symptom screen questionnaire, nor a TB risk assessment was completed upon hire.
An interview with the agency ' s administrator on 4/8/25 at approximately 1 pm confirmed the above findings.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and specifically Personnel Files # (2, 3 and 4) as directed by Citation 0700. The review showed the Agency does require employees to provide negative test results for mycobacterium tuberculosis along with an annual TB risk symptom assessment according to the Center for Disease Control (CDC) guidelines upon hire and continued employment; but the Agency did not receive the negative test results and or provide the TB risk and symptom assessment documentation for employees' personnel #'s (2,3 and 4) as required by 611.51(a). To correct this error as of April 17, 2025; the Admin has contacted ALL Agency employees' specifically employee's # (2,3 and 4) and requested mycobacterium tuberculosis testing and a TB risk and symptom assessment be completed immediately along with informing the employees they were no longer allowed to assist or serve patients until Agency receive the required negative TB testing along with immediately performing a TB risk and symptom assessment was completed and documentation for its personnel files. Agency is prepared to initiate its Back-up Policy to ensure all Patients' care was/is not interrupted if the specified employees TB risk and symptom assessment or results are positive. To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 11.51(a), have been met before a new employee can provide service consumers. EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation. As of May 19, 2025; with the EPIP implementation, all employee Personnel file's including file # (2,3 and 4), have all required documents as directed by 611.51(a). All deficiencies under Citation 0700 have been addressed.
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 a review of personnel files (PFs) and the Centers for Disease Control (CDC) Guideline and an interview with agency ' s administrator, the agency failed to ensure each direct care worker were provided with annual mycobacterium tuberculosis education for two (2) of seven (7) PF's reviewed (PF# 5 and 6).
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 4/4/25 starting at 12:20 pm. The Date of Hire (DOH) is indicated below.
PF5 DOH 10/20/21, did not contain any documentation of annual tuberculosis education provided in 2022 and 2024.
PF6 DOH 11/11/21, did not contain any documentation of annual tuberculosis education provided in 2023 and 2024.
An interview with the agency ' s administrator on 4/8/25 at approximately 1 pm confirmed the above findings.
Plan of Correction:To ensure this Agency is in future compliance, the Admin has reviewed the entire Agency's employee personnel files including and specifically Personnel file #'s (PF# 5 and 6) as directed by Citation 0710. The review showed the Agency does require employees to provide test results for mycobacterium tuberculosis according to the Center for Disease Control (CDC) guidelines, but did not provide the required annual symptom screen questionnaire and an individual TB risk assessment for employees. To correct this error as of May 2, 2024; the Admin has contacted the identified employees' and (PF# 5 and 6) and requested all employees to complete the required documentation for the annual mycobacterium tuberculosis symptom screen questionnaire and an individual TB risk assessment.
To prevent this from reoccurring the Agency created a new Employee Personnel In-Take Policy ("EPIP"). This Policy will ensure all new hiring requirements of 611.51(a), have been met before a new employee can provide service consumers along with adding the annual symptom screen questionnaire and an individual TB risk assessment for employees to the Agency's operations calendars. The EPIP Review will be overseen and conducted by the Admin quarterly and annually to identify if any employee files have missing documentation including ensuring the annual symptom screen questionnaire and an individual TB risk assessment for employees are on the Agency's operations calendars. As of May 2, 2025; with the EPIP implementation, all employee Personnel file's including file employees' and (PF# 5 and 6) have all required documents as directed by 611.51(a). All deficiencies under Citation 0710 have been addressed.
Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on March 17, 2025 and offsite on April 4 and 8, 2025, Abundantly Blessed Home Care, LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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