Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on May 15, 2025, Lightspring 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 home care agency state re-licensure survey conducted on May 15, 2025, Lightspring 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 the administrator, the agency failed to provide documentation that at least two satisfactory and verifiable references were obtained for one (1) of ten (10) PFs reviewed, (PF #7).
Findings include:
A review of PF's conducted on May 15, 2025 from approximately 11:20 AM to 12:15 PM revealed the following:
PF #7, Date of Hire: 8/28/2024. File did not contain any documentation of at least two (2) verifiable and satisfactory reference checks.
An interview with the administrator on May 15, 2025, at approximately 12:40 PM confirmed the above findings.
Plan of Correction:The Agency will carry out reference checks for the audited employees. Reference checks will be completed for all employees upon hire. Completed reference forms will be added to the employee files.
The administrator is in charge of monitoring and ensuring that plan of correction is implemented.
The office will audit the employee files upon hire and also every month to ensure that these remedies are sustained.
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 the administrator, 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 one (1) of ten (10) PFs reviewed, (PF #2).
Findings include:
A review of PFs was conducted on May 15, 2025 from approximately 11:15 AM to 12:15 PM.
PF #2, Date of Hire: 10/25/2023, did not contain any documentation of a PA State Police Criminal Background Check.
An interview with the administrator on May 15, 2025, at approximately 12:40 PM confirmed the above findings.
Plan of Correction:All employees will have their PA State Police Criminal Background Check upon hire .
Employee (PF #2) will have their PA State Police Criminal Background Check immediately and the results documented in their file.
The administrator is in charge of monitoring and ensuring that plan of correction is implemented.
The HR team will audit the employee files up on hire and also every month to ensure that these remedies are sustained.
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 administrator, the agency failed to provide documentation of a Federal Bureau of Investigation criminal history report for one (1) of ten (10) PFs reviewed, (PF #2).
Findings include:
Pennsylvania Act 169 of 1996 as amended by Act 13 of 1997 requires an applicant/ employee who has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out-of-state, in addition to the Pennsylvania State Police Criminal History Check, the applicant/employee will also need to obtain an FBI Criminal History Check and letter of determination from the Department of Aging within ninety (90) days of employment. An employee is defined as any applicant or new employee hired after July 1, 1998. The definition of employee includes contract employees who have direct contact with residents or unsupervised access to their personal living quarters.
A review of PFs was conducted on May 15, 2025, from approximately 11:15 AM to 12:15 PM.
PF #2, Date of Hire: 10/25/2023, did not contain any documentation of a Federal Bureau of Investigation criminal history report. File contained a copy of a New York driver's license issued 11/4/2021.
An interview with the administrator May 15, 2025, at approximately 12:40 PM confirmed the above findings.
Plan of Correction:The HR team will audit all employee files to identify people who need and are missing the FBI fingerprint and request it from employees.
Employee identified will be asked to submitted their FBI Finger print report immediately.
All new hires who require the FBI fingerprint will be required to submit one with in 90 days of hire before they are put on the roaster.
The FBI finger print reports for all identified employees will be put in their files.
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 review of personnel files (PF) and an interview with the administrator, the agency failed to document proof of Pennsylvania (PA) residency preceding date of hire 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 two (2) of ten (10) PFs reviewed, (PF# 3 and 4.)
Findings include:
A review of PFs was conducted on May 15, 2025, from approximately 11:15 AM to 12:15 PM.
PF# 3, Date of Hire: 4/8/2024, contained a Pennsylvania Identification card issued on 3/15/2024. There was no proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire.
PF# 4, Date of Hire: 11/2/2023, contained a Pennsylvania Identification card issued on 10/3/2023. There was no proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire.
An interview conducted with the administrator on May 15, 2025, at approximately 12:40 PM confirmed the above findings.
Plan of Correction:LightSpring home care uses the a section in the application form to collect data about employees length of stay in PA as well as a valid PA license or ID.
The HR team will review each application form during onboarding and ensure that the section is completed and reviewed.
If an employee is flagged for not completing the section on the application form, HR will review the submitted ID cards or ask them for any of the listed documents to prove they have lived in PA for more 2 years or more.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.
Observations:
Based on a review of personnel files (PF), the Centers for Disease Control (CDC) guidelines, PA REVISED Guidance for Home Care Agencies, Home Health Care Agencies and Hospices During COVID-19 Pandemic dated May 20, 2020, and an interview with the office manager, the agency did not provide documentation that a direct care worker was screened for and free from active mycobacterium tuberculosis, in accordance with CDC guidelines, for three (3) of ten (10) PF's reviewed, (PF#1, 6, and 10.)
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)
PA REVISED Guidance for Home Care Agencies, Home Health Care Agencies and Hospices During COVID-19 Pandemic dated May 20, 2020 states, "9. Pre-employment Health Screening: The requirement for an initial baseline 2 step Mantoux skin test for tuberculin skin testing is temporarily suspended. All applicants must complete an individual risk assessment and symptom evaluation prior to hire. Any new employee who does not provide evidence of a Mantoux skin test within the previous 12 months must, as a condition of employment, receive the tuberculin skin test as soon as possible following termination of the Governor ' s COVID-19 Disaster Declaration."
A review of PFs was conducted on 5/15/25 from approximately 11:15 AM to 12:15 PM.
PF#1, Date of Hire: 7/15/2024, did not contain any documentation of a completed tuberculosis symptom evaluation or risk assessment at the time of hire.
PF#6, Date of Hire: 2/15/2024, contained documentation that a QuantiFERON test was completed on 6/4/2024 with no results recorded.
PF#10, Date of Hire: 11/27/2023, did not contain any documentation of a completed tuberculosis symptom evaluation or risk assessment at the time of hire.
An interview with the administrator conducted on 5/15/25 at approximately 12:40 PM confirmed the above findings.
Plan of Correction:
The HR team will go through all employees personal files and review TB questionnaire /symptom evaluation forms to make sure they are properly completed and follow ups completed.
All employees with missing or incomplete documents will be sent one to complete as soon as possible.
Employees missing TB test results will be required to submit them as soon as possible.
Employee for PF#6 has submitted the test results and it it properly filed.
All documents will be properly filed.
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 consumer files (CF) and an interview with the administrator, the agency failed to provide documentation that the consumer received information stating the agency will provide at least 10 calendar days advance written notice of the agency's intent to terminate services for eight (8) of ten (10) CFs reviewed, (CF #1, 3, 4, 6, 7, 8, 9, and 10).
Findings include:
A review of CFs was conducted on 5/15/25 from approximately 12:00 PM to 12:30 PM.
CF #1, Start of Care: 3/30/2025, did not contain any documentation stating the consumer received information stating the agency will provide at least ten (10) calendar days advance written notice of the agency's intent to terminate services.
CF #3, Start of Care: 3/14/2025, did not contain any documentation stating the consumer received information stating the agency will provide at least ten (10) calendar days advance written notice of the agency's intent to terminate services.
CF #4, Start of Care: 3/25/2024, did not contain any documentation stating the consumer received information stating the agency will provide at least ten (10) calendar days advance written notice of the agency's intent to terminate services.
CF #6, Start of Care: 4/29/2024, did not contain any documentation stating the consumer received information stating the agency will provide at least ten (10) calendar days advance written notice of the agency's intent to terminate services.
CF #7, Start of Care: 4/28/2025, did not contain any documentation stating the consumer received information stating the agency will provide at least ten (10) calendar days advance written notice of the agency's intent to terminate services.
CF #8, Start of Care: 10/31/2023, did not contain any documentation stating the consumer received information stating the agency will provide at least ten (10) calendar days advance written notice of the agency's intent to terminate services.
CF #9, Start of Care: 1/27/2025, did not contain any documentation stating the consumer received information stating the agency will provide at least ten (10) calendar days advance written notice of the agency's intent to terminate services.
CF #10, Start of Care: 12/12/2024, did not contain any documentation stating the consumer received information stating the agency will provide at least ten (10) calendar days advance written notice of the agency's intent to terminate services.
An interview with the administrator conducted on May 15, 2025, at approximately 12:40 PM confirmed the above findings.
Plan of Correction:The intake paperwork will be revised and the clause for the 10 day notice will be added.
This revised document will be sent out to all active clients.
The agency will document the proof that this document was sent out to all active clients.
The administrator is in charge of monitoring and ensuring that plan of correction is implemented.
The office will monitor the consumer files per intake and also every month to ensure that these remedies are sustained.
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 administrator, the agency failed to provide documentation that the consumer received information stating that no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency for eight (8) of ten (10) CFs reviewed, (CF #1, 3, 4, 6, 7, 8, 9, and 10).
Findings include:
A review of CFs was conducted on 5/15/2025 from approximately 12:00 PM to 12:30 PM.
CF #1, Start of Care: 3/30/2025, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.
CF #3, Start of Care: 3/14/2025, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.
CF #4, Start of Care: 3/25/2024, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.
CF #6, Start of Care: 4/29/2024, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.
CF #7, Start of Care: 4/28/2025, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.
CF #8, Start of Care: 10/31/2023, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.
CF #9, Start of Care: 1/27/2025, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.
CF #10, Start of Care: 12/12/2024, did not contain any documentation stating the consumer received information stating no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency.
An interview with the administrator on 5/15/25 at approximately 12:40 PM confirmed the above findings.
Plan of Correction:The intake paperwork will be revised and "no individual as a result of the individual's affiliation with the agency may assume power of attorney or guardianship over a consumer utilizing the services of the agency and that the agency may not require a consumer to endorse checks over to the agency" will be added.
This revised document will be sent out to all active clients.
The agency will document the proof that this document was sent out to all active clients.
The administrator is in charge of monitoring and ensuring that plan of correction is implemented.
The office will monitor the consumer files per intake and also every month to ensure that these remedies are sustained.
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 administrator, the agency failed to provide documentation that the consumer received information stating who to contact at the Department (717-783-1379) 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 for ten (10) of ten (10) CFs reviewed, (CF #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10).
Findings include:
A review of CFs was conducted on May 15, 2025 from approximately 12:00 PM to 12:30 PM
CF #1, Start of Care: 3/30/2025, did not contain any documentation that the agency provided information stating who to contact at the Department (717-783-1379) 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.
CF #2, Start of Care: 2/1/2023, did not contain any documentation that the agency provided information stating who to contact at the Department (717-783-1379) 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.
CF #3, Start of Care: 3/14/2025, did not contain any documentation that the agency provided information stating who to contact at the Department (717-783-1379) 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.
CF #4, Start of Care: 3/24/2024, did not contain any documentation that the agency provided information stating who to contact at the Department (717-783-1379) 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.
CF #5, Start of Care: 9/1/2023, did not contain any documentation that the agency provided information stating who to contact at the Department (717-783-1379) 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.
CF #6, Start of Care: 4/29/2024, did not contain any documentation that the agency provided information stating who to contact at the Department (717-783-1379) 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.
CF #7, Start of Care: 4/28/2025, did not contain any documentation that the agency provided information stating who to contact at the Department (717-783-1379) 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.
CF #8, Start of Care: 10/31/2023, did not contain any documentation that the agency provided information stating who to contact at the Department (717-783-1379) 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.
CF #9, Start of Care: 1/27/2025, did not contain any documentation that the agency provided information stating who to contact at the Department (717-783-1379) 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.
CF #10, Start of Care: 12/12/2024, did not contain any documentation that the agency provided information stating who to contact at the Department (717-783-1379) 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.
An interview with the administrator on May 15, 2025, at approximately 12:40 PM confirmed the above findings.
Plan of Correction:The intake paperwork will be revised and " call 717-782-1379 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." will be added.
This revised document will be sent out to all active clients.
The agency will document the proof that this document was sent out to all active clients.
The administrator is in charge of monitoring and ensuring that plan of correction is implemented.
The office will monitor the consumer files per intake and also every month to ensure that these remedies are sustained.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on May 15, 2025, Lightspring 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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