Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on April 16, 2024, Assured Love 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 unannounced re-licensure survey conducted on April 16, 2025, Assured Love Home Care, 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:
611.52(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 and Office Manager, the agency failed to obtain final results of a Pennsylvania State Police Criminal Background report at the time of application or within one year immediately preceding the date of application for one (1) of seven (7) files reviewed. (PF #4).
Findings include:
A review of the personal files conducted on April 16, 2025 at approximately 11:00 am revealed the following:
PF#4 - Date of Hire: 9/25/2024 - PF did not contain documentation that final results were obtained from a Pennsylvania Criminal Background that was obtained on 9/25/2024. Report indicated that it was under review.
An interview with the Owner/ CEO and Office Manager on April 16, 2025 at approximately 12:15 pm confirmed the findings.
Plan of Correction:To ensure compliance, the administrator will obtain and document the results of the Pennsylvania State Police Criminal Background check for PF #4 on April 17, 2025.
Policy Review and Update:
The administrator will review the current policy for obtaining criminal background checks for prospective employees.
The administrator will update the policy to ensure that all background checks are obtained before or at the time of employment, clearly outlining the responsibilities of staff in this process.
The administrator will conduct training with the hiring manager on the importance of staff, to reiterate the importance of compliance with regulation 611.52(a).
Documentation Check:
The administrator will create a checklist for the hiring process that includes obtaining and documenting criminal background checks.
Monthly Audits:
The human resources team will conduct monthly audits of personnel files to ensure that all required documentation, including criminal background checks, is present and complies with state regulations. These audits will be documented and reviewed during staff meetings.
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 Owner and Office Manager determined that 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 three (3) of seven (7) PF's reviewed, (PF#1, 4 and 5).
Findings include:
A review of the personal files conducted on April 16, 2025 at approximately 11:00 am revealed the following:
PF#1 - Date of Hire: 9/13/2021 - PF did not contain documentation that proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire. File contained a Pennsylvania Driver's License issued 8/13/2020.
PF#4 - Date of Hire: 9/25/2024 - PF did not contain documentation that Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire. File contained a Pennsylvania Identification Card issued 3/8/2024.
PF#5 - Date of Hire: 8/21/2024 - PF did not contain documentation that proof of Pennsylvania residency for the two (2) consecutive years immediately preceding date of hire. File contained a Pennsylvania Driver's License issued 10/18/2023.
A interview with the Owner/ CEO and Office Manager on April 16, 2025 at approximately 12:15 pm confirmed the findings.
Plan of Correction:1. Identification of Affected Personnel:
The administrator will review all personnel files to identify other employees who may not have sufficient proof of residency documented. Each file will be checked for documentation by the guidelines provided in 611.52(d).
2. Documentation Retrieval:
For PF#1, PF#4, and PF#5, immediate outreach will be conducted to request one of the necessary documents listed below:
- Motor vehicle records (valid driver's license, state-issued ID)
- Housing records (mortgage or rent receipts)
- Public utility records (electric bills)
- Local tax records
- Completed tax returns with name and address
- Employment records
- FBI Background check
All DCW will be given a deadline of May 20th to submit the requested document to the agency.
3. Staff Training:
The administrator will conduct a training session for all administrative staff on the importance of proper documentation and compliance with licensing requirements regarding proof of residency.
The administrator will develop a checklist to be used during the hiring process to ensure all required documents are collected before an employee's start date.
4. Record Update and Compliance Review:
A follow-up review of personnel files will be conducted quarterly by the administrator to ensure future compliance and to prevent recurrence of this issue.
611.55(d) LICENSURE
Competency Requirements
Name - Component - 00
(d) The home care agency or home care registry shall include documentation of the direct care worker's satisfactory completion of competency requirements in the direct care worker's file.
Observations:
Based on a review of personnel files (PF) and an interview with the Office Administrator, the agency failed to include documentation of the direct care worker's satisfactory completion of competency requirements in the direct care worker's file for one (1) of seven (7) PF's reviewed. (PF#5).
Findings include:
A review of the personal files conducted on April 16, 2025 at approximately 11:00 am revealed the following:
PF#5 - Date of Hire: 8/21/2024 - PF contained a blank exam sheet that indicated a score of 100%. No other documentation of satisfactory completion of competency requirements on file.
A interview with the Owner/ CEO and Office Manager on April 16, 2025 at approximately 12:15 pm confirmed the findings.
Plan of Correction:The hiring manager will be sure that all direct care workers have complete documentation of their competencies.
The administrator will set up a system to track and organize competency completions.
Steps for Immediate Correction:
1. Review of DCW competency documentation:
- Check all personnel files to find any other missing competency documents.
2. Complete Competency for PF#5:
The human resources manager will contact PF#5 to set up an assessment to finish their paperwork and complete any necessary training or tests to meet competency requirements.
3. Update the File:
The human resources manager will add the new documentation to PF#5's file to show they have met the competency standards.
4. Train Staff:
The administrator will hold a training session for staff responsible for personnel files to explain documentation requirements and the importance of complete records.
The administrator and the human resources department will conduct quarterly audits on personnel files to ensure competency documentation is current and accurate.
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 and Office Manager, the agency failed to ensure that an annual competency was performed for two (2) of seven (7) PF's reviewed: (PF#1 and 2 )
Findings include:
A review of the personal files conducted on April 16, 2025 at approximately 11:00 am revealed the following:
PF#1 - Date of Hire: 9/13/2021 - PF did not contain documentation that annual competency was completed for 2024.
PF#2 - Date of Hire: 1/4/2024 - PF did not contain documentation that annual competency was completed for 2025.
A interview with the Owner/ CEO and Office Manager on April 16, 2025 at approximately 12:15 pm confirmed the findings.
Plan of Correction: Immediate Actions Taken: The administrator will
- Competency Review for PF#1 and PF#2:
- Complete the required competency assessments for PF#1 and PF#2 by May 20th 2025.
- Document the results in their personnel files.
Changes to Procedures:
The administrator will.
- Update the current policies on competency assessments to clarify expectations and processes.
- Competency Schedule Implementation:
- Create a yearly schedule for competency assessments for all staff, ensuring all hiring dates are covered.
The administrator will assign the Office Manager to oversee this process.
Staff Training:
- Train staff involved in competency evaluations on regulatory requirements and documentation practices.
Monitoring Actions:
The administrator and hiring manager will conduct quarterly audits of personnel files to confirm annual competency evaluations are complete and documented. The first audit will be by June 1, 2025.
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 and Office Manager, the agency failed to provide documentation that the direct care worker was screened for and free from active mycobacterium tuberculosis upon hire for five (5) of seven (7) PF's, (PF#1,2,3,4 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)
A review of the personal files conducted on April 16, 2025 at approximately 11:00 am revealed the following:
PF#1 - Date of Hire: 9/13/2021 - PF did not contain documentation that the direct care worker received a two (2) step PPD. File contained a one (1) step PPD dated for 9/10/2021.
PF#2 - Date of Hire: 1/4/2024 - PF did not contain documentation that the direct care worker 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. QuantiFERON Gold test on file dated for 6/6/2022.
PF#3 - Date of Hire: 1/6/2025 - PF did not contain documentation that the direct care worker received a two (2) step PPD. File contained a one (1) step PPD dated for 1/6/2025.
PF#4 - Date of Hire: 9/25/2024 - PF did not contain documentation that the direct care worker received 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. QuantiFERON Gold test on file dated for 3/20/2023.
PF#7 - Date of Hire: 3/17/2025 - PF did not contain documentation that the direct care worker received 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
A interview with the Owner/ CEO and Office Manager on April 16, 2025 at approximately 12:15 pm confirmed the findings.
Plan of Correction: 1. Immediate Actions:
Review Personnel Files: Check all personnel files to confirm that all direct care workers' tuberculosis screening records are complete.
The human resources manager will contact each of the five workers without the correct documentation (PF1, 2, 3, 4, and 7) and ask them to complete the required two-step PPD test or provide valid documentation of alternative testing.
2. Update Policies:
Change Hiring Procedures: Update the hiring process to make tuberculosis screening mandatory and ensure documentation is collected.
Create a Tracking System: Set up a system to keep track of TB screenings for new hires and schedule annual checks for all staff.
3. Staff Training:
Organize Training Sessions: Hold training for management and administrative staff about updated TB screening guidelines.
Educating on TB Screening Importance: Explain why tuberculosis screening is essential for the safety of everyone involved.
4. Monitoring and Compliance:
The administrator will schedule regular audits. The plan is to review personnel files quarterly to ensure screening compliance.
Check Documentation: Ensure the administrative team verifies all incoming tuberculosis screening documentation before finalizing personnel files.
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 and Office Manager 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#1 and 2).
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)
A review of the personal files conducted on April 16, 2025 at approximately 11:00 am revealed the following:
PF#1 - Date of Hire: 9/13/2021 - PF did not contain documentation that the direct care worker received annual mycobacterium tuberculosis education was for 2023 and 2024.
PF#2 - Date of Hire: 1/4/2024 - PF did not contain documentation that the direct care worker received annual mycobacterium tuberculosis education was for 2025.
A interview with the Owner/ CEO and Office Manager on April 16, 2025 at approximately 12:15 pm confirmed the findings.
Plan of Correction:1. Update Training Program:
The administrator will revise the training program to include annual TB education for all direct care workers and office staff interacting with consumers.
Ensure the updated materials follow CDC guidelines.
2. Conduct Training Sessions:
Schedule training for all direct care workers to cover the key aspects of TB education based on CDC guidelines.
- Make sure new hires receive this training during their onboarding.
3. Improve Documentation: The administrator will
- Create a standard form to document the completion of each employee's annual TB education.
- Set up a tracking system to remind both staff and management about annual documentation updates.
4. Audit Employee Files:
- Review all personnel files to confirm that each direct care worker has proof of completing their annual TB education.
- Identify and address any missing documentation for other staff members immediately.
5. Monitor Compliance: The administrator will
- Assign a staff member to oversee the training and documentation of annual TB education.
- Schedule quarterly audits of personnel files to make sure the agency is compliant.
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 and Office Manger conducted on April 16, 2025, 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: (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 for four (4) of the five (5) consumer files reviewed. (CF#2, 3, 4 and 5).
A review of the consumer files conducted on April 16, 2025 at approximately 10:45 am revealed the following:
CF#2 - Start of Care: 1/10/2025 - CF did not contain documentation that the consumer received the following information: (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.
CF#3 - Start of Care: 2/22/2025 - CF did not contain documentation that the consumer received the following information: (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.
CF#4 - Start of Care: 12/30/2024 - CF did not contain documentation that the consumer received the following information: (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.
CF#5 - Start of Care: 5/26/2023- CF did not contain documentation that the consumer received the following information: (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.
Agency did not have CF available for inspection by surveyor. Office Manager stated that the admission packet has not been completed by the consumer.
A interview with the Owner/ CEO and Office Manager on April 16, 2025 at approximately 12:15 pm confirmed the findings.
Plan of Correction:Immediate Actions Taken:
1. Staff Meeting: The administrator immediately met with all staff to explain the importance of following consumer rights rules. Staff were informed that it is critical to give consumers their rights when admitted.
2. Update Admission Packet: The administrator will revise the consumer admission packet to include a clear document stating consumer rights and add a signature section for consumers to confirm they received and understood this information.
3. Check Documentation: The administrator will implement a system to confirm that all consumer rights documents are completed and included in each consumer file before services begin.
Preventive Actions:
1. Staff Training: Mandatory training for the intake coordinator on consumer rights and the importance of documenting these rights in consumer files. This training will be held every three months and will include:
- A summary of consumer rights under 611.57(a).
- How to inform consumers about their rights.
- Proper documentation practices to stay compliant.
2. Set Review Process: The administrator will establish a process to review consumer files twice a month to ensure all necessary documentation, including consumer rights acknowledgment, is completed. A designated staff member will oversee checking this.
Monitoring and Evaluation:
1. Follow-Up Audit: Three months after these changes, we will conduct a follow-up audit to check compliance with documenting consumer rights. If we find ongoing issues, we will adjust our processes.
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 and Office Manager 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 four (4) of five (5) CF's reviewed: (CF#2, 3, 4 and 5).
Findings include:
A review of the consumer files conducted on April 16, 2025 at approximately 10:45 am revealed the following:
CF#2 - Start of Care: 1/10/2025 - CF did not contain documentation that the consumer received the following information: (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.
CF#3 - Start of Care: 2/22/2025 - CF did not contain documentation that the consumer received the following information: (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.
CF#4 - Start of Care: 12/30/2024 - CF did not contain documentation that the consumer received the following information: (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.
CF#5 - Start of Care: 5/26/2023- CF did not contain documentation that the consumer received the following information: (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.
Agency did not have CF available for inspection by surveyor. Office Manager stated that the admission packet has not been completed by the consumer.
A interview with the Owner/ CEO and Office Manager on April 16, 2025 at approximately 12:15 pm confirmed the findings.
Plan of Correction:1. Update Policies:
The administrator will review and change our policies to clearly state that no one affiliated with our agency can be a power of attorney or guardian for a consumer and that endorsement of checks is not allowed.
2. Improve Documentation: The Administrator will
- Create a form to record that we provided consumers with information about their rights, including the two rules mentioned.
- Include this form in each Consumer File and have consumers sign it when they start care.
3. Train Staff:
Train the client intake staff on the new document to cover consumer rights and new documentation requirements.
4. Revise Admission Packet:
The administrator will update the admission packet to include clear information about consumer rights
- Make sure the packet is complete before any consumer starts care.
5. Monitor Compliance:
- The administrator will create a checklist for the Office Manager to review all new consumer files before completion.
- Conduct monthly checks of consumer files to ensure we follow the new documentation rules and fix any files that are not compliant.
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 and Office Manager, 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 (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.
for four (4) of the five (5) CF reviewed. (CF#2, 3, 4 and 5)
Findings include:
A review of the consumer files conducted on April 16, 2025 at approximately 10:45 am revealed the following:
CF#2 - Start of Care: 1/10/2025 - CF did not contain documentation that the consumer received the following information upon admission: (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.
CF#3 - Start of Care: 2/22/2025 - CF did not contain documentation that the consumer received the following information upon admission: (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.
CF#4 - Start of Care: 12/30/2024 - CF did not contain documentation that the consumer received the following information upon admission: (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.
CF#5 - Start of Care: 5/26/2023- CF did not contain documentation that the consumer received the following information upon admission: (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.
Agency did not have CF available for inspection by surveyor. Office Manager stated that the admission packet has not been completed by the consumer.
A interview with the Owner/ CEO and Office Manager on April 16, 2025 at approximately 12:15 pm confirmed the findings.
Plan of Correction:1. The administrator will revise the Information Packet:
- Create a new information packet that includes all required details from 611.57(c). Ensure it is clear, simple, and easy to understand.
- Include information about available services, the identity of the direct care worker, service hours, fees, contact information for the Department, the Ombudsman Program, hiring requirements, and tax/insurance responsibilities.
2. Staff Training:
- Schedule a mandatory training session for all admissions staff on providing consumer information and completing required documentation.
3. Compliance Checklist:
- Implement a compliance checklist for admissions staff to use before starting services. This checklist will confirm that the information packet has been given and documented.
- Have the staff, the consumer, or their representative sign the checklist to confirm compliance.
4. Monitoring and Review:
- Set up a system to regularly check consumer files to ensure the information packet is given to all consumers.
The administrator, along with the intake coordinator, will conduct monthly audits for six months to confirm compliance, followed by quarterly audits.
611.57(d) LICENSURE
Documentation
Name - Component - 00
(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 observation and an interview with the Owner and Office Manager, it was determined that the agency failed to provide the
consumers documentation in files available for inspection by the Department for four (4) of the five (5) consumer files. (CF#2,3,4 and 5)
A review of the consumer files conducted on April 16, 2025 at approximately 10:45 am revealed the following:
CF#2 - Start of Care: 1/10/2025 - Agency did not have CF available for inspection by surveyor. Office Manager stated that the admission packet has not been completed by the consumer.
CF#3 - Start of Care: 2/22/2025 - Agency did not have CF available for inspection by surveyor. Office Manager stated that the admission packet has not been completed by the consumer.
CF#4 - Start of Care: 12/30/2024 - Agency did not have CF available for inspection by surveyor. Office Manager stated that the admission packet has not been completed by the consumer.
CF#5 - Start of Care: 5/26/2023- Agency did not have CF available for inspection by surveyor. Office Manager stated that the admission packet has not been completed by the consumer.
A interview with the Owner/ CEO and Office Manager on April 16, 2025 at approximately 12:15 pm confirmed the findings.
Plan of Correction:1. Immediate Actions: The administrator, along with the intake coordinator, will
- Check each consumer file to find any missing or incomplete documents.
- Contact Consumers #2, # 3, 4, and #5 to complete their admission packets as soon as possible.
- Set up appointments for the intake coordinator to visit the consumers and finish their paperwork.
2. Enhance Intake Procedures:
- Create a checklist for required documents to ensure all necessary information is collected during intake.
- Train staff about the importance of completing admission packets for compliance with state regulations.
3. Documentation System Update: The administrator will
- Create a digital filing system that allows easy access and tracking of consumer files, including reminders for missing documents.
- Require the Office Manager /Intake coordinator to check that all documents are complete before closing any consumer file.
4. Ongoing Compliance and Monitoring: The administrator will
- Conduct weekly audits of consumer files to ensure all documents meet compliance requirements.
- Hold weekly staff meetings to discuss progress and issues in completing consumer files.
5. Training Plan: The administrator will
- Schedule a training session for all staff on documentation standards and the importance of keeping thorough records.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey, Assured Love Home Care, LLC on April 16, 2025, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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