Initial Comments:
Based on an unannounced, onsite home care agency state relicensure survey conducted on April 18, 2025, America's Home Health Services LLC, was found to be in compliance with requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on an unannounced, onsite home care agency state relicensure survey conducted on April 18, 2025, America's Home Health Services 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:
611.52(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 upon review of employee files (EFs) and an interview with agency Director of Compliance (EMP #1), it was determined agency failed to 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) for two (2) of ten (10) EFs reviewed. (EF# 3 and EF# 10)
Findings include:
Review of EFs conducted on April 18, 2025 between approximately 11:30 a.m. and 1:00 p.m. revealed the following:
EF# 3, Date of Hire (DOH), 2/28/2023: No Federal criminal history record and a letter of determination obtained from the Department of Aging.
EF# 10, DOH, 4/15/2024: No Federal criminal history record and a letter of determination obtained from the Department of Aging.
An interview with the agency EMP #1 conducted on April 18, 2025 at approximately 2:00 p.m. confirmed the above findings.
Plan of Correction:1. EF#3 & EF#10 will obtain proof of residency, if Proof of residency is not provided a Federal Criminal History will be completed.
2. Will complete a full branch audit of all active caregivers to check for proper proof of residency documentation.
3. All new hire applicants will be placed in New Hire slack channel for management approval to review all documents prior to hire.
4. Director of compliance or designee will review Slack channel daily to review and approve.
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 upon review of employee files (EFs) and an interview with agency Director of Compliance (EMP #1), it was determined agency failed to 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) for two (2) of ten (10) EFs reviewed. (EF# 3 and EF# 10)
Findings include:
Review of EFs conducted on April 18, 2025 between approximately 11:30 a.m. and 1:00 p.m. revealed the following:
EF# 3, Date of Hire (DOH), 2/28/2023: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. No evidence of Federal Bureau of Investigation (FBI) clearance requested. Contained PA. Driver's License issued: 3/9/2022-2/14/2026.
EF# 10, DOH, 4/15/2024: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. No evidence of Federal Bureau of Investigation (FBI) clearance requested. Contained PA. Driver's License issued: 3/14/2024-9/25/2024.
An interview with the agency EMP #1 conducted on April 18, 2025 at approximately 2:00 p.m. confirmed the above findings.
Plan of Correction:1. EF#3 & EF#10 will obtain proof of residency, if Proof of residency is not provided a Federal Criminal History will be completed.
2. Will complete a full branch audit of all active caregivers to check for proper proof of residency documentation.
3. All new hire applicants will be placed in New Hire slack channel for management approval to review all documents prior to hire.
4. Director of compliance or designee will review Slack channel daily to review and approve.
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 upon review of employee files (EFs) and an interview with agency Director of Compliance (EMP #1), it was determined agency failed to complete competency review at least once per year after initial competency for two (2) of ten (10) EFs reviewed. (EF# 4 and EF# 5).
Findings include:
Review of EFs conducted on April 18, 2025 between approximately 11:30 a.m. and 1:00 p.m. revealed the following:
EF# 4, Date of Hire (DOH), 9/1/2023: No documentation of completed annual competency exam for year 2024.
EF# 5, DOH, 2/18/2023: No documentation of completed annual competency exam for year 2024.
An interview with the agency EMP #1 conducted on April 18, 2025 at approximately 2:00 p.m. confirmed the above findings.
Plan of Correction:1. EF#4 & EF#5 did not complete their competency requirements for 2024. They will complete a new onboarding training to cover their competency that was missed.
2. Will complete a full audit of all active caregivers to check that 2024 competency has been completed.
3. Competency exam will be added to the 2025 annual in-service training
4. Director of Compliance will monitor completion annually using spreadsheet and posting in Slack for branch review.
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 upon review of employee files (EFs) and an interview with agency Director of Compliance (EMP #1), it was determined agency failed to ensure each direct care worker, other staff or contractors with direct consumer contact, was screened for and is free from active mycobacterium tuberculosis prior to consumer contact using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis for two (2) of ten (10) EFs reviewed. (EF# 1 and EF# 2); failed to ensure each direct care worker and other staff or contractors with direct consumer contact, prior to consumer contact, completed TB individual Risk Assessment for three (3) of ten (10) EFs reviewed. (EF# 2, EF# 3 and EF# 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. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. (CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
Review of EFs conducted on April 18, 2025 between approximately 11:30 a.m. and 1:00 p.m. revealed the following:
EF# 1, Date of Hire (DOH), 2/15/2024: No documentation of a baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB). Documentation of one TST on 2/12/2024.
EF# 2, DOH, 9/23/2023: No documentation of a baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB). Documentation of one TST on 9/21/2023. No documentation provided of a completed TB Individual Risk Assessment.
EF# 3, DOH, 2/28/2023: No documentation provided of a completed TB Individual Risk Assessment.
EF# 4, DOH, 9/1/2023: No documentation provided of a completed TB Individual Risk Assessment.
An interview with the agency EMP #1 conducted on April 18, 2025 at approximately 2:00 p.m. confirmed the above findings.
Plan of Correction:1. EF#1, EF#2 are missing their 2nd TB EF#3 & EF#4 did not complete the risk assessment required at hire. All caregivers will start their 2 step TB process again and complete the TB risk assessment.
2. Will complete a full active caregiver audit for TB completion as well as TB risk assessment.
3. All new hires applicants will be posted in slack for management approval to check for all required new hire documents prior to starting care
4. Branch will follow up weekly with caregivers in need of their 2nd TB to complete within the required timeline.
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 upon review of employee files (EFs) and an interview with agency Director of Compliance (EMP #1), it was determined agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, were provided with annual mycobacterium tuberculosis education for two (2) of ten (10) EFs reviewed. (EF# 4 and EF# 5)
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. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. (CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
Review of EFs conducted on April 18, 2025 between approximately 11:30 a.m. and 1:00 p.m. revealed the following:
EF# 4, Date of Hire (DOH), 9/1/2023: No documentation provided of annual 2024 TB education.
EF# 5, DOH, 2/18/2023: No documentation provided of annual 2024 TB education.
An interview with the agency EMP #1 conducted on April 18, 2025 at approximately 2:00 p.m. confirmed the above findings.
Plan of Correction:1. EF#4 & EF#5 did not complete the 2024 In-service training to include TB education. Both caregivers will complete a new onboarding training to receive the required education.
2. Complete audit of all active caregiver files will be reviewed to review all caregivers have their annual TB education.
3. Annual in-service will be monitored by Director of Compliance using Axiscare/Slack spreadsheet to monitor completion of all caregivers.
4. Director of compliance will keep spreadsheet of completed annual in-services for all caregivers.
Initial Comments:
Based on an unannounced, onsite home care agency state relicensure survey conducted on April 18, 2025, America's Home Health Services LLC, was found to be in compliance with requirements of 35 P. S.448.809 (b).
Plan of Correction:
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