Every finding on record at Penn Home Health, Inc.

Based on the findings of an onsite unannounced Medicare recertification and state relicense survey completed on 12/23/2025, Penn Home Health Inc. was found not to be in compliance with the following requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies – Emergency Preparedness.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on review of agency emergency preparedness plan (EPP) and staff (EMP) interview, the agency failed to ensure the emergency communication plan included contact information for emergency preparedness agencies and resources. Findings included: Review of the agency emergency preparedness plan was conducted on 12/18/2025 at approximately 2:40 PM which revealed, “POLICY The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations. The organization will establish an all-hazards approach to emergency preparedness that focuses on hazards and developing emergency preparedness capabilities. The organization shall review and update the emergency preparedness plan every two years. The organization shall maintain written documentation of the emergency management plan for at least four (4) years. Review of the agency emergency preparedness plan was conducted on 12/1/2025 at approximately 2:40 PM which revealed, “Communication Plan The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated at least every two (2) years. The plan includes the following…2. Contact information for the following: A. Federal, state, tribal, regional and/or local emergency preparedness staff B. Other sources of assistance… The surveyor reviewed the emergency preparedness binder on 12/18/2025 at approximately 3:10 PM. No documentation was available to confirm the agency had contact information for Federal state, tribal and /or local emergency sources. An exit interview was conducted with the chief operating officer and director of nursing on 12/19/2025 at approximately 3:15 PM which confirmed the findings.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on a review of the agency emergency preparedness documentation, policy and procedures and staff (EMP) interview, the agency failed to develop the communication plan that included a primary and alternate means to communicate with agency staff and local/regional/state/federal emergency preparedness agencies. Findings Included: Review of the agency emergency preparedness plan was conducted on 12/18/2025 at approximately 2:40 PM which revealed, “POLICY The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations. The organization will establish an all-hazards approach to emergency preparedness that focuses on hazards and developing emergency preparedness capabilities. The organization shall review and update the emergency preparedness plan every two years. The organization shall maintain written documentation of the emergency management plan for at least four (4) years. Review of the agency emergency preparedness plan was conducted on 12/18/2025 at approximately 2:40 PM which revealed, “Communication Plan The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated at least every two (2) years. The plan includes the following…2. Contact information for the following: A. Federal, state, tribal, regional and/or local emergency preparedness staff B. Other sources of assistance… The surveyor reviewed the emergency preparedness binder on 12/18/2025 at approximately 3:10 PM revealed, the agency's plan failed to include a primary and alternate means of communicating with facility staff, Federal, State, tribal, regional and local emergency management agencies. An exit interview was conducted with the chief operating officer and director of nursing on 12/19/2025 at approximately 3:15 PM which confirmed the findings.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of agency policy, emergency operations program and staff (EMP) interview, it was determined that the facility failed to conduct additional full-scale or tabletop exercise to test the Emergency Preparedness Plan. Findings included: Review of the agency emergency preparedness plan was conducted on 12/18/2025 at approximately 2:40 PM which revealed, “Testing: 1. (Agency) will test the emergency management plan, at each site included in the plan, at least annually, either in response to an actual emergency or within an individual, facility-based functional exercise. 2. The agency participates in a full-scale exercise that is community based or when a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every two (2) years. A. In the event an actual natural or man-made emergency occurred, the agency will be exempt from engaging in its next required full scale community based exercise or individual facility-based functional exercise following the onset of the emergency event. 3. The agency conducts an additional exercise every two (2) years, opposite the year the full scale or functional exercise is conducted, that may include, but ids not limited to: A. A second full-scale exercise that is community-based or individual facility-based functional exercise, or B. A mock disaster drill, or C. A table top exercise or workshop that is led by a facilitator and includes group discussion, using a narrated, clinically relevant emergency scenarios and set of problem statements, directed messages or prepared questions designed to challenge an emergency plan…” The agency documentation confirmed collaboration fire drill exercises were conducted on 11/20/2025. During an interview with EMP2 documentation was not available related to a full-scale exercise, community-based, facility-based or tabletop exercise for 2022, 2023 or 2024. EMP2 confirmed the agency did not experience an actual natural or man-made emergency that requires activation of this emergency plan For 2022, 2023, 2024 or 2025. An exit interview was conducted with the chief operating officer and director of nursing on 12/19/2025 at approximately 3:15 PM which confirmed the findings.

Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed 12/23/2025, Penn Home Health Inc. was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on review of agency policy, observations (OBV), medical records (MR) and staff (EMP) interviews, the agency failed to maintain an accurate medication profile and to ensure review of potential adverse effects for one (1) of three (3) facility OBV’s reviewed (OBV5). Findings included: Review of the agency policy was conducted on 12/23/2025 at approximately 2:00 PM which revealed, “Medication Reconciliation Policy…Policy, The agency will complete medication reconciliation at required points of care to ensure all medications are accurate, current, and clearly understood by the patient and care team…When Reconciliation is Completed Medication reconciliation will be performed by an RN at: Start of care (SOC)-Resumption of Care (ROC)-Recertification-Discharge-Any medication change or transition of care(hospital/ER/MD visit)…Procedure The RN will: 1. Review all medications the patient is taking, including prescriptions, OTC drugs, and supplements. 2. Compare the list to current physician orders. 3. Identify and clarify any discrepancies. 4. Update the medication list in the record. 5. Communicate changes to the care team and patient…” During a home visit observation (MR6 OBV5), on 12/19/2025 at approximately 10:47 AM the surveyor requested the facilities “MEDICATION PROFILE” for MR6. A review of MR6 was conducted on 12/18/2025 at approximately 1:48 PM, start of care 11/11/2025 which revealed the following. Certification period 11/11/2025 to 1/9/2026 with a primary diagnosis Age related osteoporosis with current pathological fracture, left pelvis. Review of the two documents was conducted on 12/23/2025 at approximately 11:10 AM. Review of the home health care current plans of care listed Allergies: Benadryl. Listed on the facilities medication profile listed “ALLERGIES No Known Drug Allergy…” The facility had listed on the medication profile “DIPHENHYDRAMINE 25MG TAB, TAKE 1 TABLET ORALLY EVERY 6 HOURS AS NEEDED FOR ITCHINESS…Date Written 21-OCT-2025…” The allergy information did not match the documents. The agency staff was notified on 11:23 AM 12/23/2025. An exit interview was conducted with the chief operating officer and director of nursing on 12/19/2025 at approximately 3:15 PM which confirmed the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on a review of agency policy, review of medical records (MR), and staff (EMP) interview the agency failed to conduct services or provide documentation that wound care was provided as ordered in the plan of care for two (2) of seventeen (17) MR’s reviewed (MR11 and MR13) Findings include: Review of the agency policy was conducted on 12/23/2025 at approximately 2:00 PM which revealed, “Wound Care Policy…Policy The agency shall provide wound care services only upon physician or authorized practitioner orders in accordance with CMS Conditions of Participation (42 CFR Part 484), 28 Pa. Code Chapter 611, and the Pennsylvania Nurse Practice Act. All wound care must be performed by appropriately licensed personnel within their scope of practice…Assessment An RN performs the initial and ongoing wound assessment including measurements (length, width, depth), tissue type, drainage odor, peri wound conditions pain level, and signs of infection. Pressure injuries are staged per current guidelines. Reassessment occurs at each skilled visit…Wound Care Treatment, Provide care exactly as ordered. Cleanse and dress wounds using prescribed products and techniques. Do not change products or frequency without new orders…” Review of MR11 was conducted on 12/18/2025, Start of Care: 11/1/2025: Certification period reviewed 11/1/25 through 12/30/25. “Primary Diagnosis: 11/1/2025 Encounter for change of surgical wound dressing…” Review of the wound measures was conducted, wound measurements were taken on 11/1/2025 the next measurements provided were dated 12/1/2025. The surveyor confirmed on 12/18/2025 with EMP2 that wound measurements are to be conducted weekly. Review of MR13 was conducted on 12/18/2025 at approximately 2:20 PM, Start of Care: 11/18/2024, Certification period reviewed 3/18/2025 through 5/16/2025. “Primary Diagnosis: 1/17/2025 Pressure ulcer of sacral region stage 3…Orders/Treatments…Additional Services Cleanse pressure wound to coccyx with NSS, apply Aquacel AG, cover with 4x4 bordered foam. Change dressing daily…” “Skilled Nursing Visit Note…Date of Visit 3/21/2025…NARRATIVE NOTES… Area cleansed and dressing applied this visit…” “Skilled Nursing Visit Note…Date of Visit 4/23/2025…NARRATIVE NOTES… Area cleansed and dressing applied…” The surveyor was unable to confirm wound care services were provide per physician orders. An exit interview was conducted with the chief operating officer and director of nursing on 12/19/2025 at approximately 3:15 PM which confirmed the findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on review of agency policy and procedure, observations (OBV) during home visits, medical records (MR) and staff (EMP) interview, the agency failed to ensure staff followed infection control standards of practice for one (1) of seven (7) (OBV’s) providing direct care to patients (OBV5). Findings Included: Review of the agency policy was conducted on 12/18/2025 at approximately 3:28 PM which revealed, “BAG TECHNIQUE…PROCEDURE…Bag Technique 1. The bag will be placed on a clean surface…4. The bag will contain a designated clean and dirty area. The clean area contains unused or cleaned supplies/equipment, and the dirty area is designated for contaminated materials (i.e., used equipment, etc.). 5. When the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag. 6. Hands will be decontaminated prior to returning clean equipment to bag. 7. If paper towels/newspapers have been used as protective barrier for bag placement in the patient’s home, they will be discarded…” During a home visit observation (MR6 OBV5), on 12/19/2025 at approximately 10:47 AM EMP4 provided direct patient care. EMP4 placed a chuck/barrier on a dresser with the nursing/supply bag and equipment on top of the chuck/barrier. The chuck/barrier did not cover the left hand corner of the dresser. An electronic tablet was placed covering the left-hand corner of the dresser with the tablet projecting over the left-hand corner chuck/barrier and dresser. EMP4 picked up the tablet twice during the session and placed it in the same position. An exit interview was conducted with the chief operating officer and director of nursing on 12/19/2025 at approximately 3:15 PM which confirmed the findings.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on a review of agency policy, personnel files (PF) and staff (EMP) interviews, the agency failed to assure that criminal background checks was completed upon hire for one (1) of six (6) PF's reviewed (PF7). Findings included: Review of the agency policy was conducted on 12/18/2025 at approximately 3:28 PM which revealed, “HUMAN RESOURCES…PROCEDURE 1. Professional personnel recruited and hired by (Agency) will be graduates of schools approved or accredited by their respective professional organizations. 2. Pre-employment interviews will be conducted and documented with a copy retained in the personnel file. 3. Prior to hire, the organization will secure multiple reference checks, health reports as required by the state or policy, criminal record checks when required by law, and proof of citizenship or documentation of resident status. A review of PF3 was conducted on 12/18/2025 at approximately 10:43 AM. PF3 date of hire was 3/21/2024. There was Pennsylvania Access to Criminal History (PATCH) report contained in the PF dated 12/17/2025. No additional documentation was provided by the agency. An exit interview was conducted with the chief operating officer and director of nursing on 12/19/2025 at approximately 3:15 PM which confirmed the findings.