Initial Comments:
Based on the findings of an unannounced onsite state relicensure survey completed May 6, 2025, Caring Family Home Care Services, Llc. was found not to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.
Plan of Correction:
51.3 (g)(1-14) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.
Observations:
Based on a review of the agency incident/complaint log and an interview with the agency Office Manager, the agency failed to ensure event reporting to the Pennsylvania (Pa.) Department of Health of alleged consumer financial abuse for one (1) of one (1) incident/complaint logs reviewed (Log #1).
Findings Include:
The agency incident/complaint log was reviewed on May 6, 2025 at approximately 11:00 a.m.
Log #1: 'Complaint Form' dated 07/31/24, 'Name of Patient'(Consumer #11), 'Name/title of who received the intitial complaint' (Office Manager), employee involved (employee #8), 'Description of the Complaint' "(Family member) called to tell me that (employee #8) direct care worker was taking money from (consumer #11). ...She stated that (employee #8) helps herself to (consumer #11) food stamps. ...."
No documentation provided of this event being entered into the Pa. Dept. of Health Event Reporting website.
An interview conducted with the agency Office Manager on May 6, 2025 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:1. The Company Administrator by 5/30/2025 will report incident report for consumer #11 to DOH ERS system. 2. The company Administrator will conduct training sessions for all staff involved in the event reporting on the importance of timely and accurate documentation. Ensure that every event reported is documented with the date, time, and the person responsible for the submission (Administrator). 3. The company administrator will conduct audits every 6 months to verify compliance with event reporting requirements. 4. The company administrator monitors any changes in the Pa. Dept. of Health's reporting requirements and adjust procedures accordingly.
Initial Comments:
Based on the findings of an unannounced onsite state relicensure survey completed May 6, 2025, Caring Family Home Care 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:
611.51(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 employee files and an interview with the agency Office Manager, the agency failed to obtain not less than two satisfactory references, prior to hire, for four (4) out of seven (7) employee files (EF) reviewed (EF#2, EF#4, EF#5, EF#6).
Findings include:
A review of EFs was conducted on May 6, 2025 at approximately 9:15 a.m. Employee date of hire (DOH) is listed below.
EF#2 DOH 12/31/24: Employees first work shift with a consumer was on 12/31/24. No documentation provided of obtaining not less than two satisfactory references (positive, verifiable). Documentation provided of obtaining two (2) references late on 01/03/25.
EF#4 DOH 09/08/24: Employees first work shift with a consumer was on 09/28/24. No documentation provided of obtaining not less than two satisfactory references (positive, verifiable). Documentation provided of obtaining two (2) references on an undated form.
EF#5 DOH 07/01/24: Employees first work shift with a consumer was on 07/01/24. No documentation provided of obtaining not less than two satisfactory references (positive, verifiable). Documentation provided of obtaining one (1) reference on 06/04/24. Documentation provided of obtaining one (1) reference on an undated form.
EF#6 DOH 12/30/23: Employees first work shift with a consumer was on 12/30/23. No documentation provided of obtaining not less than two satisfactory references (positive, verifiable). Documentation provided of obtaining two (2) references late on 01/03/24.
An interview conducted with the agency Office Manager on May 6, 2025 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:1. Company HR Manager on or before 5/30/2025 will locate/obtain two employment references for EF#4 and one employment reference for EF#5. 2. The company HR Manager within 45 days will verify that all employees' files include two satisfactory reference forms. 3. The office manager using the check-off sheet will verify that the employees' files include documents with two satisfactory references before employee assignment. 4. The agency administrator and office manager will audit 25% of the charts every six months to monitor the deficient practices will not occur.
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 employee files and an interview with the agency Office Manager, the agency failed to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application for four (4) out of seven (7) employee files (EF) reviewed (EF#1, EF#2, EF#3, EF#5).
Findings include:
A review of EFs was conducted on May 6, 2025 at approximately 9:15 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 12/16/24: No documentation provided of criminal history report being obtained at the time of application or within 1 year (365 days) immediately preceding the date of application. Pennsylvania State Police criminal history report obtained 12/17/24. (1 day after hire.)
EF#2 DOH 12/31/24: No documentation provided of criminal history report being obtained at the time of application or within 1 year (365 days) immediately preceding the date of application. Pennsylvania State Police criminal history report obtained 12/31/24. The criminal history results were obtained while the employee was working their first shift with a consumer on 12/31/24.
EF#3 DOH 08/14/24: No documentation provided of criminal history report being obtained at the time of application or within 1 year (365 days) immediately preceding the date of application.
EF#5 DOH 07/01/24: No documentation provided of criminal history report being obtained at the time of application or within 1 year (365 days) immediately preceding the date of application. Pennsylvania State Police criminal history report obtained 07/03/24. (2 days after hire.)
An interview conducted with the agency Office Manager on May 6, 2025 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:1. The HR Manager on or before 5/20/2025 will locate/obtain the criminal history report for EF#3. 2. The company HR Manager within 45 days will verify that all employee files have a criminal background history report. 3. The office manager using the check-off sheet will verify that the employees' files include criminal background history report before employee assignment. 4. The agency administrator and office manager will audit 25% of the charts every six months to monitor the deficient practices will not occur.
611.52(c) LICENSURE
Federal Criminal History Record
Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code § 15.144(b) (relating to procedure).
Observations:
Based on a review of employee files and an interview with the agency Office Manager, agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for four (4) out of seven (7) employee files (EF) reviewed (EF#3, EF#4, EF#6, EF#7).
Findings include:
A review of EFs was conducted on May 6, 2025 at approximately 9:15 a.m. Employee date of hire (DOH) is listed below.
EF#3 DOH 08/14/24: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issued 07/25/23 with an expiration date of 09/11/26. 'Employment Application' form work history record was reviewed. Employer listed with a Pa. address 'From: "6-8-2023" 'To: "9-10-2023". No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 08/14/22 - 06/08/23.
EF#4 DOH 09/08/24: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issued 12/17/22 with an expiration date of 11/23/24. 'Employment Application' form work history record was reviewed. Employers listed with a California and a New Jersey address. No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 09/08/22 - 12/17/22.
EF#6 DOH 12/30/23: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issued 08/02/22 with an expiration date of 09/27/26. 'Employment Application' form work history record was reviewed. Employer listed with a Pa. address with incomplete dates 'From: "2021" 'To: "2021". No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 12/30/21 - 08/02/22.
EF#7 DOH 01/21/24: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issued 01/19/23 with an expiration date of 09/08/26. 'Employment Application' form work history record was reviewed. Employer listed with a New Jersey address. No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 01/21/22 - 01/19/23.
An interview conducted with the agency Office Manager on May 6, 2025 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:1. The company HR manager on or before 5/30/2025 will verify proof of residency information for EF#3, EF#4, EF#6 and EF#7 according with state regulations (Department of Aging). If unable to verify then FBI Criminal History. 2. The office manager within 45 days will verify the employee's files are completed with correct residency information. 3. The office manager using the check-off sheet will verify that the employees' files include proof of residency before employee assignment. 4. The Office manager will audit 25% of the charts every six months to monitor the deficient practices will not occur.
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 employee files and an interview with the agency Office Manager, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for six (6) out of seven (7) employee files (EF) reviewed (EF#1, EF#3 - EF#7).
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. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. 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).
A review of EFs was conducted on May 6, 2025 at approximately 9:15 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 12/16/24: Employees first work shift with a consumer was on 12/16/24. Documentation provided of a TB test conducted late on 02/28/25 and a chest x-ray obtained late on 01/20/25.
EF#3 DOH 08/14/24: Employees first work shift with a consumer was on 12/31/24. No documentation provided of a TB symptom screen questionnaire being conducted.
EF#4 DOH 09/08/24: Employees first work shift with a consumer was on 09/28/24. Documentation provided of a single step TST conducted on 12/07/24. No documentation provided of a second step TST being conducted.
EF#5 DOH 07/01/24: Employees first work shift with a consumer was on 07/01/24. Documentation provided of a TB test conducted late on 08/03/24.
EF#6 DOH 12/30/23: Employees first work shift with a consumer was on 12/30/23. Documentation provided of a TB test conducted late on 01/03/24.
EF#7 DOH 01/21/24: Employees first work shift with a consumer was on 04/20/24. Documentation provided of a TB test conducted late on 07/27/24.
An interview conducted with the agency Office Manager on May 6, 2025 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:1. The HR Manager on or before 05/30/2025 will locate/obtain the 2 step TB Test or x-ray for EF#4. The HR Manager and Office Manager on or before 05/30/2025 will conduct and file TB symptom screen questionary for EF#3.
2. The office manager and HR Manager within 45 days will verify all employees' files are complete to include valid two-step TB test/chest x-ray documents and TB symptom screen questionary. 3. The office manager using the check-off sheet will verify that the employee file is complete to include a two-step TB test/ x-ray and TB symptom screen questionary prior to employee assignment.
4. The agency administrator will audit 25% of the charts every six months to monitor the deficient practices will not occur.
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 a review of employee files and an interview with the agency Office Manager, 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 two (2) employee files (EF) annual documentation reviewed (EF#6, EF#7).
Findings Include:
The CDC (Center for Disease and Control) 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).
A review of EFs was conducted on May 6, 2025 at approximately 9:15 a.m. Employee date of hire (DOH) is listed below.
EF#6 DOH 12/30/23: No documentation provided of 2024 annual TB education.
EF#7 DOH 01/21/24: No documentation provided of 2025 annual TB education.
An interview conducted with the agency Office Manager on May 6, 2025 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:1. EF# 6, and EF#7 will complete annual tuberculosis education on or before 6/30/2025. 2. The company office manager and HR Manager within 45 days will verify all employees' files are complete with annual TB Education documents. 3. The HR Manager will update employee files check-off sheet with the dates completed tuberculosis education.
4. The Office Manager will audit 25% of the charts every six months to monitor if the deficient practices will not occur.
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, the consumer admission packet, and an interview with the agency Office Manager, the agency failed to provide the consumer, prior to the commencement of services, all or segments of the following: The identity of the direct care worker who will provide the services and the hours when those services will be provided, for ten (10) out of ten (10) consumer files (CF) reviewed (CF#1-CF#10).
Findings include:
A review of CFs was conducted on May 6, 2025 at approximately 9:15 a.m. Consumer start of service (SOS) is listed below.
CF#1 SOS 01/13/25: No documentation provided of the agency providing the consumer, prior to the commencement of services, all or segments of the following: The identity of the direct care worker who will provide the services and the hours when those services will be provided.
CF#2 SOS 07/02/24: No documentation provided of the agency providing the consumer, prior to the commencement of services, all or segments of the following: The identity of the direct care worker who will provide the services and the hours when those services will be provided.
CF#3 SOS 03/20/25: No documentation provided of the agency providing the consumer, prior to the commencement of services, all or segments of the following: The identity of the direct care worker who will provide the services and the hours when those services will be provided.
CF#4 SOS 01/15/25: No documentation provided of the agency providing the consumer, prior to the commencement of services, all or segments of the following: The identity of the direct care worker who will provide the services and the hours when those services will be provided.
CF#5 SOS 08/11/24: No documentation provided of the agency providing the consumer, prior to the commencement of services, all or segments of the following: The identity of the direct care worker who will provide the services and the hours when those services will be provided.
CF#6 SOS 08/16/24: No documentation provided of the agency providing the consumer, prior to the commencement of services, all or segments of the following: The identity of the direct care worker who will provide the services and the hours when those services will be provided.
CF#7 SOS 08/09/24: No documentation provided of the agency providing the consumer, prior to the commencement of services, all or segments of the following: The identity of the direct care worker who will provide the services and the hours when those services will be provided.
CF#8 SOS 09/09/24: No documentation provided of the agency providing the consumer, prior to the commencement of services, all or segments of the following: The identity of the direct care worker who will provide the services and the hours when those services will be provided.
CF#9 SOS 08/05/24: No documentation provided of the agency providing the consumer, prior to the commencement of services, all or segments of the following: The identity of the direct care worker who will provide the services and the hours when those services will be provided.
CF#10 SOS 01/10/25: No documentation provided of the agency providing the consumer, prior to the commencement of services, all or segments of the following: The identity of the direct care worker who will provide the services and the hours when those services will be provided.
A review was conducted of the agency 'Consumer Packet' on 05/06/25 at approximately 10:30 a.m. The packet contained two (2) telephone numbers to call the Department of Health for complaints. One (1) number provided (866-***-****) is incorrect. The number is a non-governmental phone number.
A number was provided for the 'Human Relations Commission at Harrisburg River Front Center' (717-***-****). There was no answer to this number when contact was attempted. A number was provided for 'Abuse Neglect Hotline' (800-***-****). This number is for the State of Maryland Licensing Agency.
The packet included the prior physical address for the Department of Health, Division of Home Health and does not include the present physical address.
An interview conducted with the agency Office Manager on May 6, 2025 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:1. The Office manager and HR Manager by 6/15/2025 will develop and update CF#1, CF#2, CF#3, CF#4, CF#5, CF#6, CF#7, CF#8, CF#9 and CF#10 with a new consumer form to include the identity of the direct care worker who will provide the services and the hours when those services will be provided. 2. The HR manager by 6/30/2025 will verify that all consumers' files are completed to include a new consumer form. 3. The office manager using the check-off sheet will verify that the consumer file is complete to include a new consumer form prior to conducting service for the new customer. 4. The agency administrator and Office Manager will audit 25% of the charts every six months to monitor whether the deficient practices will not occur.
Initial Comments:
Based on the findings of an unannounced onsite state relicensure survey completed May 6, 2025, Caring Family Home Care Services, 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 observation of Identification badges (ID) and an interview with the agency Office Manager, agency failed to format/issue ID badges per regulatory requirements for one (1) of one (1) observation (Observation #1).
Findings include:
Observation #1: Observation of employee Identification Badge (ID) on May 6, 2025 at approximately 11:00 a.m. revealed the current ID badge employee title does not occupy the bottom 1/2" of the badge, as large as possible. The employee title is located towards the left bottom side of the badge.
An interview conducted with the agency Office Manager on May 6, 2025 at approximately 12:45 p.m. confirmed the above findings.
Plan of Correction:1. By 7/30/2025 the company will have re-issued all ID BADGES. The employee's job title (DIRECT CARE WORKER, etc.) will be updated to occupy the bottom 1/2" of the badge and to be as large as possible. A spreadsheet will be created to track the successful completion of employees receiving updated ID badges. 2. All new employees will have a correct badge before starting an assignment.
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