Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on March 14, 2025, All About You Home Health Care Co, 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 unannounced state re-licensure survey conducted on March 14, 2025, All About You Home Health Care Co, 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 obtain not less than two satisfactory references for the individual that is a positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual for seven (7) of seven (7) PFs. PF# 1, 2, 3, 4, 5, 6, & 7.
Findings include:
A review of personnel files was conducted on 3/14/25 at approximately 9:30 AM. and revealed the following:
PF#1 Date of hire: 7/22/24. File contained only one satisfactory reference for the individual that is a positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
PF#2 Date of hire: 6/1/24. File contained no references for the individual that are positive, verifiable references, either verbal or written from a former employer or other person not related to the individual.
PF#3 Date of hire: 12/27/24. File contained only one satisfactory reference for the individual that is a positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
PF#4 Date of hire: 8/16/22. File contained no references for the individual that are positive, verifiable references, either verbal or written from a former employer or other person not related to the individual.
PF#5 Date of hire: 10/9/24. File contained only one satisfactory reference for the individual that is a positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
PF#6 Date of hire 3/4/25. File contained only one satisfactory reference for the individual that is a positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
PF#7 Date of hire: 9/14/24. File contained only one satisfactory reference for the individual that is a positive, verifiable reference, either verbal or written from a former employer or other person not related to the individual.
An interview with the administrator on 3/14/25 at approximately 12:30 PM confirmed the above findings.
Plan of Correction:Corrective Action Plan
Step 1: Obtain Missing References for Current Employees
Completion Date: 5/13/25
- The agency has begun obtaining a second verifiable reference for each affected employee.
- All missing references will be collected and documented in personnel files no later than 5/13/25.
Step 2: Implement a Mandatory Two-Reference Policy
Completion Date: 5/13/25
- The Hiring & Onboarding Policy has been updated to require at least two verifiable references before employment begins.
- Applicants will not proceed to final hiring or onboarding until both references are verified and documented in writing.
Step 3: Employee File Compliance Checklist
Completion Date: 5/13/25
- A Personnel File Checklist has been created and will be used for every new hire to verify that both references are received before employment begins.
- The checklist must be signed off by HR staff and included in the employee's file.
Step 4: Staff Training on Hiring & Compliance Requirements
Completion Date: 5/13/25
- HR and hiring staff will receive mandatory training on new hiring procedures, including verifying and documenting references.
- Training will include proper documentation for verbal and written references to ensure compliance.
Step 5: Ongoing Compliance Monitoring & Monthly File Reviews
Completion Date: 5/13/25 (Initial Implementation), Ongoing Monthly
- HR will conduct monthly personnel file reviews to ensure compliance with the two-reference policy.
- A quarterly compliance audit will be conducted, and any discrepancies will be addressed immediately.
- The results of file reviews and audits will be reported to the administrator for ongoing compliance verification.
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 three (3) of seven (7) PF's reviewed, (PF # 1, 3, & 7).
Findings include:
A review of PF's was conducted on 3/14/25 at approximately 9:30 am and revealed the following:
PF #1 Date of Hire: 7/22/24, contained documentation of a Pennsylvania State Police Criminal Background Check completed on 1/29/25 which is after the first day of employment.
PF #3 Date of Hire: 12/27/24, contained documentation of a Pennsylvania State Police Criminal Background Check completed on 1/29/25 which is after the first day of employment.
PF #7 Date of Hire: 9/14/24, contained documentation of a Pennsylvania State Police Criminal Background Check completed on 4/18/23 which is greater than 12 months prior to employment.
An interview with the administrator on 3/14/25 at approximately 12:30 PM confirmed the above findings.
Plan of Correction:Corrective Action Plan
Step 1: Implement a Two-Step Hiring Process
Completion Date: 5/13/25
- The hiring process has been modified to a two-step process to ensure background checks are completed before employment begins.
- Step 1: All required clearances, including the Pennsylvania State Police Criminal Background Check, will be requested and completed before moving forward.
- Step 2: The applicant will not proceed to final onboarding or client assignments until all background clearances are received.
Step 2: Update Hiring & Onboarding Policies
Completion Date: 5/13/25
- The agency's Hiring & Onboarding Policy has been updated to state that no applicant will begin employment until all required background checks are on file.
- HR staff will verify and sign off on each applicant's background check before employment is offered.
Step 3: Review & Correct Existing Personnel Files
Completion Date: 5/13/25
- A full audit of all current employee files will be conducted to identify and correct any additional background check deficiencies.
- Employees with missing or outdated background checks will be required to complete a new Pennsylvania State Police Criminal Background Check by 5/13/25.
Step 4: Implement Ongoing Compliance Monitoring
Completion Date: 5/13/25
- HR will maintain a Background Check Compliance Tracker to ensure all employees have valid background checks on file.
- A quarterly audit of personnel files will be conducted to verify compliance.
- Any future non-compliance will be immediately addressed with corrective actions.
611.55(a) LICENSURE
Competency Requirements
Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.
Observations:
Based on a review of personnel files (PF), and an interview with the administrator, the agency failed to provide evidence that competency requirements were met, prior to assigning a direct care worker (DCW) to provide services to a consumer for three (3) of seven (7) PF's reviewed: PF# 1, 2, & 7.
Findings include:
A review of PF's was conducted on 3/14/25 at approximately 9:30AM and revealed the following:
PF#1. Date of Hire: 7/22/24. File contained a written competency exam that did not contain DCW's name or the date when exam was taken. Therefore there was no evidence the identified DCW took the exam or that the exam was completed prior to providing services to consumers.
PF#2. Date of Hire: 6/1/24. File contained a written competency exam that did not contain DCW's name or the date when exam was taken. Therefore there was no evidence the identified DCW took the exam or that the exam was completed prior to providing services to consumers.
PF#7. Date of Hire: 9/14/24. File contained a written competency exam that did not contain DCW's name or the date when exam was taken. Therefore there was no evidence the identified DCW took the exam or that the exam was completed prior to providing services to consumers.
An interview with the administrator on 3/14/25 at approximately 12:30 PM confirmed the above findings.
Plan of Correction:Corrective Action Plan
Step 1: Update Competency Testing Process
Completion Date: 5/13/25
- The Aide Competency Test has been revised to include a mandatory section for the DCW's name and date of completion.
- All current personal care aides (PCAs) hired prior to this correction have been required to retake the competency exam with their name and date recorded by 5/13/25.
- Going forward, all new hires will not be assigned to clients until the competency test is properly completed with a name and date.
Step 2: Implement Personnel File Monitoring System
Completion Date: 5/13/25
- A Competency Test Verification Log will be introduced to track the completion of exams and ensure they are signed and dated.
- HR staff will conduct bi-weekly personnel file reviews to verify that all competency requirements are met before assigning DCWs to consumers.
- The Onboarding Policy will be updated to reflect this new requirement.
Step 3: Staff Training & Compliance Enforcement
Completion Date: 5/13/25
- HR and administrative staff will receive training on proper competency documentation by 5/13/25.
- Any DCW who fails to complete a properly documented competency exam will be removed from client assignments until compliance is met.
- A random quarterly audit of personnel files will be conducted to prevent future deficiencies.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.
Observations:
Based on a review of personnel files (PF), the Centers for Disease Control (CDC) guidelines and an interview with the administrator, the agency did not provide documentation that a direct care worker completed screening for mycobacterium tuberculosis according to guidelines prior to hire for seven (7) of seven (7) PF's reviewed (PF# 1, 2, 3, 4, 5, 6, & 7).
Findings include:
In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) 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, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease (CDC Guidelines for Preventing Transmission of Mycobacterium Tuberculosis in Health Care Settings, 2005. Morbidity and Mortality World Report 2005, RR-17) (http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf).
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
A review of PF's was conducted on 3/14/25 at approximately 9:30 AM and revealed the following:
PF#1 Date of Hire: 7/22/24 did not contain evidence that a individual TB risk assessment or TB symptom questionnaire was completed upon hire. File contained documentation of TST completed after hire on 3/5/25. In addition, there was no documentation of the second step of the initial 2-step TST.
PF#2 Date of Hire: 6/1/24 did not contain evidence that a individual TB risk assessment or TB symptom questionnaire was completed upon hire. File contained documentation of TST completed after hire on 6/18/24. In addition, there was no documentation of the second step of the initial 2-step TST.
PF#3 Date of Hire: 12/27/24 did not contain evidence that a individual TB risk assessment or TB symptom questionnaire was completed upon hire. File contained documentation of TST completed on 11/14/24. There was no documentation of the second step of the initial 2-step TST.
PF#4 Date of Hire: 8/16/22 did not contain evidence that a individual TB risk assessment or TB symptom questionnaire was completed upon hire. File contained documentation of TST completed after hire on 8/24/24. In addition, there was no documentation of the second step of the initial 2-step TST.
PF#5 Date of Hire: 10/9/24 did not contain evidence that a individual TB risk assessment or TB symptom questionnaire was completed upon hire. In addition, file contained documentation of QuantiFERON TB blood test completed after hire on 1/30/25.
PF#6 Date of Hire: 3/4/25 did not contain evidence that a individual TB risk assessment or TB symptom questionnaire was completed upon hire. File contained documentation of TST completed on 3/1/25. There was no documentation of the second step of the initial 2-step TST.
PF#7 Date of Hire: 9/14/24 did not contain evidence that a individual TB risk assessment or TB symptom questionnaire was completed upon hire. File contained documentation of TST completed after hire on 9/18/24. In addition, there was no documentation of the second step of the initial 2-step TST.
An interview conducted with the administrator on 3/14/25 at approximately 12:30 PM confirmed the above findings.
Plan of Correction:Corrective Action Plan
Step 1: Ensure Compliance with TB Screening Requirements
Completion Date: 5/13/25
- All direct care workers who did not receive a 2-step TST will be scheduled to complete the missing step no later than 5/13/25.
- All affected employees will complete the TB Risk Assessment and Symptom Questionnaire by 5/13/25.
- A new tracking system will be implemented to ensure all TB-related documentation is completed before a new employee's start date.
Step 2: Establish a Standardized TB Screening Process for Future Hires
Completion Date: 5/13/25
- The agency will establish an account with Concentra to ensure that all new hires receive a 2-step PPD test before their start date.
- A pre-filled TB screening form will be used in the Concentra system to ensure the correct test is performed and results are sent directly to the agency.
Step 3: Implement Personnel File Monitoring and Staff Training
Completion Date: 5/13/25
- A Personnel File Compliance Checklist will be created and used to verify that all required TB screening elements (Risk Assessment, Symptom Questionnaire, and 2-Step TST or QuantiFERON test) are completed before hiring.
- Monthly personnel file audits will be conducted by HR to ensure compliance with CDC guidelines.
- HR and administrative staff will receive training on TB screening requirements to prevent future occurrences.
- The agency's Onboarding Policy will be updated to reflect TB screening requirements and ensure compliance.
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 review of the consumer records (CRs) and interview with agency administrator, the agency failed to 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 prior to the commencement of services: telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). for five (5) of five (5) CRs reviewed. (CR # 1, 2, 3, 4 & 5)
Findings include:
Review of CRs conducted on 3/14/25 at approximately 11:00 A.M. and revealed the following:
CR# 1, Start of Care: 3/2/25, File did not contain telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
CR# 2, Start of Care: 12/15/24, File did not contain telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
CR# 3, Start of Care: 12/5/24, File did not contain telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
CR# 4, Start of Care: 4/22/24, File did not contain telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
CR# 5, Start of Care: 7/22/24, File did not contain telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
Interview with the administrator on 3/14/25 at approximately 12:30 P.M. confirmed the above findings.
Plan of Correction:We have updated our consumer files with an "Important Phone Numbers" form. On the form it includes the information for the Ombudsman Program with the local Area Agency on Aging for all of the counties we service. We have also since sent the updated form to our current consumers on file. We will include the new form in our consumer packet so the new consumer will have this information upon signing on.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on March 14, 2025, All About You Home Health Care Co, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|