Initial Comments:
Based on the findings of an on-site unannounced state re-licensure survey conducted on April 3, 2025, All Pros Healthcare, LLC was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
51.3 (f) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Observations:
Based on a review of the Department of Health (DOH) Event Reporting System (ERS), the agency's complaint and incident log, and email communication with the agency Administrator, the agency failed to report a reportable infectious disease and an incident of alleged neglect in the DOH ERS for one (1) of one (1) incidents reviewed. (Incident #1)
Findings Include:
A review of the agency's complaint and incident log on April 3, 2025, at approximately 10:05 A.M. revealed an incident report dated January 13, 2025, which noted that a consumer (Consumer #2), was taken to the hospital on January 7, 2025. The consumer was diagnosed with RSV (respiratory syncytial virus) and sent home via taxi. The taxi allegedly dropped the consumer off at the wrong address. The consumer fell and was returned to the hospital via ambulance, and was later discharged to home.
Per the Pennsylvania Department of Health Event Reporting System Manual, "...Purpose: To provide a system to enter events per 28 PA Code - 51.3 that is readily available to all appropriate PA-DOH [Pennsylvania Department of Health] facilities, a simple process to insure consistent data entry and submission, and a source for quick and meaningful feedback on event notification submissions...All facilities are required to submit notification of events as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery. The Electronic Event Reporting System [ERS] is the mechanism the Department will use to meet this regulatory requirement..."
Review of event reports in the DOH ERS on April 3, 2025, at approximately 9:00 A.M. revealed no documented event reports submitted by the agency for this event.
Email communication with the agency Administrator on April 3, 2025, at approximately 2:00 P.M. confirmed the above finding.
Plan of Correction:I acknowledge the Observation #0008 and will correct the actions that was taken by correctly summiting accident report for the consumer to the proper channels of the Deportment of Health. Moving forward for any future accidents, I now have the proper steps to take with filing. All future accident will be documented within 24hrs. To insure this wont happen again a notice of rules and requirements for accident report will be posted office of agency as a reminder to monitor all incidents.this will be done by office assistant and myself. shall be done by June 4th 2025 this will be done by june 1 by the office administration.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on April 3, 2025, All Pros Healthcare, 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 review of direct care worker personnel files (PF) and email communication with the agency Administrator, the agency failed to document a face-to-face interview and/or two (2) satisfactory references prior to employment for five (5) of seven (7) PF reviewed. (PF #2, 3, 4, 5, and 7).
Findings Include:
A review of PF's conducted on April 3, 2025, from approximately 10:45 A.M. to 11:30 A.M. revealed the following:
PF #2, date of hire Januray 12, 2022, contained documentation of only one (1) satisfactory reference.
PF #3, date of hire October 6, 2023, contained no documentation of a face-to-face interview and two (2) satisfactory references.
PF #4, date of hire February 5, 2022, contained no documentation of two (2) satisfactory references.
PF #5, date of hire Janaury 22, 2022, contained no documentation of two (2) satisfactory references.
PF #7, date of hire March 18, 2022, contained no documentation of a face-to-face interview and only one (1) satisfactory reference was documented.
Email communication with the agency Administrator on April 3, 2025, at approximately 2:00 P.M. confirmed the above findings.
Plan of Correction:I acknowledge the observation #0200 and will make notes and corrections. The face to face was documented at time of but documenting was missing from file, its now in employee's file. Moving forward a thoroughly check will be done for all files. A new hire check list will be put in place. And then regularly quarterly and randomly at least 10%. New hire will not be able to start until all documents received. this checklist will be signed and dated by administrator.
Satisfactory references check of two or more will be done upon hiring and application will be thoroughly checked for missing information. This will be done regularly for the future.
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 review of direct care worker personnel files (PF) and email communication with the agency Administrator, it was determined that the agency failed to ensure criminal background checks were obtained at the time of application for employment or within one year immediately preceding the date of application for three (3) of seven (7) PF reviewed. (PF# 1, 2, and 5)
Findings include:
Review of PF conducted on April 3, 2025, from approximately 10:45 A.M. to 11:30 A.M. revealed the following:
PF #1, date of hire March 25, 2022, contained a Pennsylvania State Police background check dated June 4, 2024, which was more than two (2) years after the date of hire.
PF #2, date of hire January 12, 2022, contained documentation of a Pennsylvania State Police criminal background check dated June 4, 2024, which was more than two (2) years after the date of hire.
PF #5, date of hire January 22, 2022, contained a Pennsylvania State Police background check dated June 4, 2024, which was more than two (2) years after the date of hire.
Email communication with the agency Administrator on April 3, 2025, at approximately 2:00 P.M. confirmed the above findings.
Plan of Correction:Audit will be completed of all personal files by office administrator. A thorough check will be done to make sure all backgrounds checks are done before working.A new check list will be conducted with updates for new and current care givers and applicants.A quarterly check will be done on at least 10 % of the files randomly to insure compliance is met. All corrections will be done by June 1 2025.
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 review of direct care worker personnel files (PF) and email communication with the agency Administrator, the agency failed to obtain a Federal criminal background check for one (1) of seven (7) PF reviewed. (PF #7)
Findings Include:
Review of PF on April 3, 2025, from approximately 10:45 A.M. to 11:30 A.M. revealed the following:
PF #7, date of hire March 18, 2022, contained a New Jersey driver's license issued March 20, 2021. The employment application listed a New Jersey address. There was no documentation of a Federal criminal background check completed upon hire.
Email communication with the agency Administrator on April 3, 2025, at approximately 2:00 P.M. confirmed the above findings.
Plan of Correction:Personal files for FBI background check will be corrected for those employee who were audited. If and FBI check is not needed other documentations will be accepted in its place from the list of accepted doc. showing proof of resisdency of 2yrs.A check will be do quarterly of at least 10% of the files for any issues. Moving forward only FBI checks, Patch, and supported docs will be accepted before starting work. This check will be done by the office administrator. this will be done june 1 2025
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 direct care worker personnel files (PF) and email communication with the agency Administrator, the agency failed to document proof of residency for the two years immediately preceding the date of hire for four (4) of seven (7) PF reviewed. (PF # 2, 3, 4, and 5).
Findings include:
Review of PF on April 3, 2025, from approximately 10:45 A.M. to 11:30 A.M. revealed the following:
PF #2, date of hire January 12, 2022, contained a Pennsylvania driver's license issued March 11, 2020. There was no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date hire.
PF #3, date of hire October 6, 2023, contained a Pennsylvania identification card issued April 12, 2022. There was no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date hire.
PF #4, date of hire February 5, 2022, contained a Pennsylvania identification card issued December 20, 2020. There was no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date hire.
PF #5, date of hire January 22, 2022, contained a copy of a Pennsylvania identification card that the year was not visible. There was no documentation that the applicant resided in Pennsylvania for two (2) years.
Email communication with the agency Administrator on April 3, 2025, at approximately 2:00 P.M. confirmed the above findings.
Plan of Correction:Personal files for FBI background check will be corrected for those employee who were audited. If and FBI check is not needed other documentations will be accepted in its place from the list of accepted doc. showing proof of resisdency of 2yrs.A check will be do quarterly of at least 10% of the files for any issues. Moving forward only FBI checks, Patch, and supported docs will be accepted before starting work. This check will be done by the office administrator. this will be done june 1 2025
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 review of direct care worker personnel files (PF) and email communication with the agency Administrator, the agency failed to ensure annual competency reviews were conducted for five (5) of seven (7) PF reviewed. (PF # 1, 3, 4, 5, and 7).
Findings include:
A review of PF's conducted on April 3, 2024, from approximately 10:45 A.M. to 11:30 A.M. revealed the following:
PF #1, date of hire March 25, 2022, contained no documentation of an annual competency review in 2024.
PF #3, date of hire October 5, 2023, contained no documentation of an annual competency review in 2024.
PF #4, date of hire February 5, 2022, contained no documentation of an annual competency review in 2024.
PF #5, date of hire January 22, 2022, contained no documentation of an annual competency review in 2024.
PF #7, date of hire March 18, 2022, contained no documentation of an initial competency review upon hire and annual competency reviews in 2023 and 2024.
Email communication with the agency Administrator on April 3, 2025, at approximately 2:00 P.M. confirmed the above findings.
Plan of Correction:Employees 1,3,4,5, and 7 a thoroughly check will be done for all files. A new hire check list will be put in place. And then quarterly and randomly at least 10% of files will be checked New hire will not be able to start until all documents received. this checklist will be signed and dated by administrator.For those who do not having the competency test a new one will be given and completed thias how it will be corrected.
This will be done by the office assistant and myself the owner before 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 upon review of direct care worker personnel files (PF) and email communication with the agency Administrator, the agency failed to ensure baseline testing, and/or a symptom screening questionnaire, and/or an individual TB risk assessment were conducted upon hire in accordance with CDC guidelines for seven (7) of seven (7) PF reviewed. (PF# 1, 2, 3, 4, 5, 6, and 7).
Findings Include:
The CDC (Centers for Disease and Control and Prevention) guidelines state baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or tuberculin skin test (TST), shall include a symptom screen questionnaire and an individual tuberculosis (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 PF's conducted on April 3, 2025, from approximately 10:45 A.M. to 11:30 A.M. revealed the following:
PF #1, date of hire March 25, 2022, contained a single TST completed on April 13, 2020, with no second-step TST documented. Another single TST was completed on December 11, 2023, with no second-step TST documented. There was no documentation that a symptom screening questionnaire and an individual TB risk assessment were completed upon hire.
PF #2, date of hire January 12, 2022, contained documentation of a single TST completed April 27, 2020, which was three (3) months after the date of hire, with no second-step TST documented. Additional single TST's were documented on January 3, 2022, and October 10, 2023, with no second-step TST documented. There was no documentation that a symptom screening questionnaire and an individual TB risk assessment were completed upon hire.
PF #3, date of hire October 6, 2023, contained documentation of a single TST completed on October 9, 2023, with no second-step TST documented. There was no documentation that a symptom screening questionnaire and an individual TB risk assessment were completed upon hire.
PF #4, date of hire February 5, 2022, contained documentation of a two-step TST completed on December 5, 2022, which was ten (10) months after the date of hire, with no second-step TST documented. A single-step TST was completed on April 4, 2023, with no second-step TST documented. There was no documentation that a symptom screen questionnaire and an individual TB risk assessment were completed upon hire.
PF #5, date of hire January 22, 2022, contained documentation of a single TST completed on January 22, 2022, with no second-step TST documented. A single TST was completed on June 4, 2023, with no second-step TST documented. There was no documentation that a symptom screen questionnaire and an individual TB risk assessment were completed upon hire.
PF #6, date of hire April 1, 2020, contained documentation of a single TST completed on April 6, 2019, with no second-step TST documented. There was no documentation that a symptom screening questionnaire and an individual TB risk assessment were completed upon hire.
PF #7, date of hire March 18, 2022, contained no documentation that a symptom screening questionnaire and an individual TB risk assessment were completed upon hire.
Email communication with the agency Administrator on April 3, 2025, at approximately 2:00 P.M. confirmed the above findings.
Plan of Correction:TB test results should be collected prior to start date, it should be negative. It should be recent within in one year.Along with educational reading and a questionaire about health that will be signed and dated by employee. To correct this issue a second TB shall be taken a second time within 3 weeks of the first one or a blood test. this will be added to the checklist of file with most recent TB result date and the following date for retesting the following year.This will be performed by office assistant or myself the owner.For those files that are missing TB testing and questionnaires they will be presented the same opportunities to correct it and giving the questionnaire. files will be checked quarterly with at least 10% of files by the office assistant and myself the owner.this will be done by june 1 2025
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 direct care worker personnel files (PF) and email communication with the agency Administrator, the agency failed to ensure annual TB education was conducted for seven (7) of seven (7) PF reviewed. (PF# 1, 2, 3, 4, 5, 6, and 7).
Findings Include:
The CDC (Centers for Disease and Control and Prevention) guidelines state baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or tuberculin skin test (TST), shall include a symptom screen questionnaire and an individual tuberculosis (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 PF's conducted on April 3, 2024, from approximately 10:45 A.M. to 11:30 A.M. revealed the following:
PF #1, date of hire March 25, 2022, contained no documentation of annual TB education completed in 2023 and 2024.
PF #2, date of hire January 12, 2022, contained no documentation of annual TB education completed in 2023 and 2024.
PF #3, date of hire October 6, 2023, contained no documentation of annual TB education completed in 2024.
PF #4, date of hire February 5, 2022, contained no documentation of annual TB education completed in 2023 and 2024.
PF #5, date of hire January 22, 2022, contained no documentation of annual TB education completed in 2023 and 2024.
PF #6, date of hire April 1, 2020, contained no documentation of annual TB education completed in 2021, 2022, 2023 and 2024.
PF #7, date of hire March 18, 2022, contained no documentation of annual TB education completed in 2023 and 2024.
Email communication with the agency Administrator on April 3, 2025, at approximately 2:00 P.M. confirmed the above findings.
Plan of Correction:TB test results should be collected prior to start date, it should be negative. It should be recent within in one year.The TB education will be provided annually, that will be signed and dated by employee. To correct this issue a second TB shall be taken a second time within 3 weeks of the first one or a blood test. this will be added to the checklist of file with most recent TB result date and the following date for retesting the following year.This will be performed by office assistant or myself the owner.For those files that are missing TB testing they will be presented the same opportunities to correct it. files will be checked quarterly with at least 10% of files by the office assistant and myself the owner.this will be done by june 1 2025
Initial Comments:
Based on the findings of an on-site unannounced home care agency state re-licensure survey conducted on April 3, 2025, All Pros Healthcare, LLC was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
35 P. S. § 448.809b LICENSURE
Photo Id Reg
Name - Component - 00
Law amended July 11, 2022 Act 79 2022 HB 2604
(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.
(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.
(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.
(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.
Observations:
Based on direct observation of the office staff, review of direct care worker personnel files (PF), staff interviews, and email communication with the agency Administrator, the agency failed to ensure that the identification badges issued to agency staff contained the job title of the employee for seven (7) of seven (7) PF reviewed. (PF # 1, 2, 3, 4, 5, 6, and 7).
Findings Include:
Upon arrival at the agency location at approximately 10:00 A.M. on April 3, 2025, the agency office staff member was observed not wearing an identification badge. When asked about an identification badge, the staff member stated that the agency caregivers are provided with a photo identification badge.
Review of PF on April 3, 2025, from approximately 10:45 A.M. to 11:30 A.M. revealed the following:
PF #1, date of hire March 25, 2022, contained a copy of a photo identification badge that did not contain the job title of the employee.
PF #2, date of hire January 12, 2022, contained a copy of a photo identification badge that did not contain the job title of the employee.
PF #3, date of hire October 6, 2023, contained a copy of a photo identification badge that did not contain the job title of the employee.
PF #4, date of hire February 5, 2022, contained a copy of a photo identification badge that did not contain the job title of the employee.
PF #5, date of hire January 22, 2022, contained a copy of a photo identification badge that did not contain the job title of the employee.
PF #6, date of hire April 1, 2020, contained a copy of a photo identification badge that did not contain the job title of the employee.
PF #7, date of hire March 18, 2022, contained a copy of a photo identification badge that did not contain the job title of the employee.
Email communication with the agency Administrator on April 3, 2025, at approximately 2:00 P.M. confirmed the above findings.
Plan of Correction:Work badges will be corrected of missing information and reprinted and given out.Badge will list agency's name, caregiver's name, and caregiver's position or title. So the problem will not recur and standard sample badge will be mocked up and attached to new check list in the employee files.Badges will made prior to hiring and checked with the standard example badge requirements.Making sure that they are correct on a monthly basis.this will be done by the office assistant and myself the owner. this will all be done before june 1 2025.
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