VNA of Northwest Pa, LLC
A hospice in Bradford, Pennsylvania 16701
44 Bolivar Road, Bradford, Pennsylvania 16701. (814) 362-7466.
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The short answer
Record last released by CMS on Oct 23, 2026.
- 9 deficiencies cited in the last three years
- Not rated family caregiver rating
- 9of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean3
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
- Condition-level deficiency
- For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.
What did inspectors find?
9 deficiencies cited in the last three years
The middle of the 3 hospices serving ZIP code 16701 had 4.5.
The last inspection on record was on Sep 3, 2024: an infection control and recertification inspection by the state.
2 deficiencies at condition level, the more serious of CMS’s two levels
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
9 deficiencies in 1 month of the last 36. Last cited Jun 2024. Most serious: Condition-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Jun 7, 2024: infection control and recertification inspection by the state9 deficiencies
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Core services (42 CFR 418.64)
The inspectors’ words, 124 words
“Based on a review of agency employee roster, policy and procedures, agency interdisciplinary group (IDG) meeting sign in sheets, agency admission packet information provided to patients, and staff (EMP) interview, the agency failed to ensure that a social worker was employed by the agency to provide core services of social, emotional and spiritual Care. The agency failed to provide services in accordance with acceptable standards of practice: L594 - the agency failed to provide services of a medical social worker L595 - the agency failed to provide counseling services to the patient and family - social worker not employed This Condition is not met based on the above non-compliance but did not result in Immediate Jeopardy. Cross reference above mentioned tags for additional information.”
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Organizational environment (42 CFR 418.100)
The inspectors’ words, 132 words
“Based on a review of agency employee roster, patient clinical records, policy and procedures, agency interdisciplinary group (IDG) meeting sign in sheets, agency admission packet information provided to patients, governing body meeting minutes and staff (EMP) interview, the agency failed to organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness adn related conditions. 651 - the governing body failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services. 652 - the agency failed to provide medical social services. This Condition is not met based on the above non-compliance but did not result in Immediate Jeopardy. Cross reference above mentioned tags for additional information.”
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Content of comprehensive assessment (42 CFR 418.54(c))
The inspectors’ words, 573 words
“Based on a review of agency policy and procedures; patient clinical records (CR); agency interdisciplinary group (IDG) meeting sign in sheets; agency admission packet information provided to patients; and staff (EMP) interview, the agency failed to ensure that a social worker completed comprehensive assessments for 7 (seven) of 7(seven) clinical records reviewed. (CR1-7) Findings Included: A review on 6/4/2024 at approximately 11:30 a.m. of agency IDG meeting sign-in sheets from 2/28/2024 to 6/4/2024 revealed that the electronic signature date of attendance for the “Social Worker” was not signed [blank] and the “Name” indicated “services declined”. A review of patient Clinical Records (CR) conducted on 6/4/2024 and 6/5/2024, revealed the following: CR1 reviewed on 6/4/2024 at approximately 12:00pm - start of care (SOC) date 2/12/2023: Certification period 4/7/2024 through 6/5/2024. There was no documentation in the clinical record that a social worker completed comprehensive assessments. CR2 reviewed on 6/4/2024 at approximately 1:45pm - start of care (SOC) date 4/24/2024: Certification period 4/24/2024 through 7/22/2024. There was no documentation in the clinical record that a social worker completed comprehensive assessments CR3 reviewed on 6/4/2024 at approximately 2:45pm - start of care (SOC) date 5/14/2024: Certification period 5/14/2024 through 8/11/2024. There was no documentation in the clinical record that a social worker completed comprehensive assessments CR4 reviewed on 6/5/2024 at approximately 12:15pm - start of care (SOC) date 3/20/2024: Certification period 3/20/2024 through 6/17/2024. There was no documentation in the clinical record that a social worker completed comprehensive assessments CR5 reviewed on 6/5/2024 at approximately 12:50pm - start of care (SOC) date 2/23/2022: Certification period 4/13/2024 through 6/11/2024. There was no documentation in the clinical record that a social worker completed comprehensive assessments. CR6 reviewed on 6/5/2024 at approximately 1:30pm - start of care (SOC) date 5/20/2024: Certification period 5/20/2024 through 8/17/2024. There was no documentation in the clinical record that a social worker completed comprehensive assessments. CR7 reviewed on 6/5/2024 at approximately 2:15pm - start of care (SOC) date 5/30/2024: Certification period 5/30/2024 through 8/27/2024. There was no documentation in the clinical record that a social worker completed comprehensive assessments. A review on 6/4/2024 at approximately 3:00 p.m. of agency policy and procedures revealed: “Title: Interdisciplinary Group; Policy #: HOSP3037... POLICY: VNA of Northwest PA designates an IDG composed of qualified individuals who assess, plan, provide and evaluate the care and services provided to hospice patients/caregivers... PROCEDURE: 1. The IDG at VNA of Northwest PA includes, at a minimum, the following individuals: a. a doctor of medicine or osteopathy; b. a registered nurse; c. a Social Worker; d. a pastoral or other counselor...” A review on 6/4/2024 at approximately 3:15 p.m. of agency admission packet information provided to patients revealed: “Social, Emotional and Spiritual Care; Social Work Services: Hospice social work provides education, counseling, support and resources for patients and families...” An interview with EMP1 on 6/4/2024 at approximately 3:30 p.m. confirmed the above findings. When asked if the agency has a social worker or equivalent that attends IDG meetings, EMP1 stated “No. We have been actively recruiting for a replacement social worker since our previous one quit. Her last year of service with us was in 2022.” When asked about the above findings, EMP1 stated “If there is no signature, (he/she) was not there.” When asked why the “Name” of the social worker indicated “services declined”, EMP1 stated “We don’t have an employed social worker to fill the role, so we marked services declined.””
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Approach to service delivery (42 CFR 418.56(a)(1)(i)-(iv))
The inspectors’ words, 617 words
“Based on a review of agency policy and procedures; patient clinical records (CR); agency interdisciplinary group (IDG) meeting sign in sheets; agency admission packet information provided to patients; and staff (EMP) interview, the agency failed to include a social worker as a member of the IDG for 7 (seven) of 7(seven) clinical records reviewed. (CR1-7) Findings Included: A review on 6/4/2024 at approximately 11:30 a.m. of agency IDG meeting sign-in sheets from 2/28/2024 to 6/4/2024 revealed that the electronic signature date of attendance for the “Social Worker” was not signed [blank] and the “Name” indicated “services declined”. A review of patient Clinical Records (CR) conducted on 6/4/2024 and 6/5/2024, revealed the following: CR1 reviewed on 6/4/2024 at approximately 12:00pm - start of care (SOC) date 2/12/2023: Certification period 4/7/2024 through 6/5/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings. CR2 reviewed on 6/4/2024 at approximately 1:45pm - start of care (SOC) date 4/24/2024: Certification period 4/24/2024 through 7/22/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings. CR3 reviewed on 6/4/2024 at approximately 2:45pm - start of care (SOC) date 5/14/2024: Certification period 5/14/2024 through 8/11/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings. CR4 reviewed on 6/5/2024 at approximately 12:15pm - start of care (SOC) date 3/20/2024: Certification period 3/20/2024 through 6/17/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings. CR5 reviewed on 6/5/2024 at approximately 12:50pm - start of care (SOC) date 2/23/2022: Certification period 4/13/2024 through 6/11/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings. CR6 reviewed on 6/5/2024 at approximately 1:30pm - start of care (SOC) date 5/20/2024: Certification period 5/20/2024 through 8/17/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings. CR7 reviewed on 6/5/2024 at approximately 2:15pm - start of care (SOC) date 5/30/2024: Certification period 5/30/2024 through 8/27/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings. A review on 6/4/2024 at approximately 3:00 p.m. of agency policy and procedures revealed: “Title: Interdisciplinary Group; Policy #: HOSP3037... POLICY: VNA of Northwest PA designates an IDG composed of qualified individuals who assess, plan, provide and evaluate the care and services provided to hospice patients/caregivers... PROCEDURE: 1. The IDG at VNA of Northwest PA includes, at a minimum, the following individuals: a. a doctor of medicine or osteopathy; b. a registered nurse; c. a Social Worker; d. a pastoral or other counselor...” A review on 6/4/2024 at approximately 3:15 p.m. of agency admission packet information provided to patients revealed: “Social, Emotional and Spiritual Care; Social Work Services: Hospice social work provides education, counseling, support and resources for patients and families...” An interview with EMP1 on 6/4/2024 at approximately 3:30 p.m. confirmed the above findings. When asked if the agency has a social worker or equivalent that attends IDG meetings, EMP1 stated “No. We have been actively recruiting for a replacement social worker since our previous one quit. Her last year of service with us was in 2022.” When asked about the above findings, EMP1 stated “If there is no signature, (he/she) was not there.” When asked why the “Name” of the social worker indicated “services declined”, EMP1 stated “We don’t have an employed social worker to fill the role, so we marked services declined.””
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Medical social services (42 CFR 418.64(c))
The inspectors’ words, 614 words
“Based on a review of agency policy and procedures; patient clinical records (CR); agency interdisciplinary group (IDG) meeting sign in sheets; agency admission packet information provided to patients; and staff (EMP) interview, the agency failed to provide services of a qualified social worker for 7 (seven) of 7(seven) clinical records reviewed. (CR1-7) Findings Included: A review on 6/4/2024 at approximately 11:30 a.m. of agency IDG meeting sign-in sheets from 2/28/2024 to 6/4/2024 revealed that the electronic signature date of attendance for the “Social Worker” was not signed [blank] and the “Name” indicated “services declined”. A review of patient Clinical Records (CR) conducted on 6/4/2024 and 6/5/2024, revealed the following: CR1 reviewed on 6/4/2024 at approximately 12:00pm - start of care (SOC) date 2/12/2023: Certification period 4/7/2024 through 6/5/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings. CR2 reviewed on 6/4/2024 at approximately 1:45pm - start of care (SOC) date 4/24/2024: Certification period 4/24/2024 through 7/22/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings. CR3 reviewed on 6/4/2024 at approximately 2:45pm - start of care (SOC) date 5/14/2024: Certification period 5/14/2024 through 8/11/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings. CR4 reviewed on 6/5/2024 at approximately 12:15pm - start of care (SOC) date 3/20/2024: Certification period 3/20/2024 through 6/17/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings. CR5 reviewed on 6/5/2024 at approximately 12:50pm - start of care (SOC) date 2/23/2022: Certification period 4/13/2024 through 6/11/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings. CR6 reviewed on 6/5/2024 at approximately 1:30pm - start of care (SOC) date 5/20/2024: Certification period 5/20/2024 through 8/17/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings. CR7 reviewed on 6/5/2024 at approximately 2:15pm - start of care (SOC) date 5/30/2024: Certification period 5/30/2024 through 8/27/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings. A review on 6/4/2024 at approximately 3:00 p.m. of agency policy and procedures revealed: “Title: Interdisciplinary Group; Policy #: HOSP3037... POLICY: VNA of Northwest PA designates an IDG composed of qualified individuals who assess, plan, provide and evaluate the care and services provided to hospice patients/caregivers... PROCEDURE: 1. The IDG at VNA of Northwest PA includes, at a minimum, the following individuals: a. a doctor of medicine or osteopathy; b. a registered nurse; c. a Social Worker; d. a pastoral or other counselor...” A review on 6/4/2024 at approximately 3:15 p.m. of agency admission packet information provided to patients revealed: “Social, Emotional and Spiritual Care; Social Work Services: Hospice social work provides education, counseling, support and resources for patients and families...” An interview with EMP1 on 6/4/2024 at approximately 3:30 p.m. confirmed the above findings. When asked if the agency has a social worker or equivalent that attends IDG meetings, EMP1 stated “No. We have been actively recruiting for a replacement social worker since our previous one quit. Her last year of service with us was in 2022.” When asked about the above findings, EMP1 stated “If there is no signature, (he/she) was not there.” When asked why the “Name” of the social worker indicated “services declined”, EMP1 stated “We don’t have an employed social worker to fill the role, so we marked services declined.””
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Counseling services (42 CFR 418.64(d))
The inspectors’ words, 683 words
“Based on a review of agency policy and procedures; patient clinical records (CR); agency interdisciplinary group (IDG) meeting sign in sheets; agency admission packet information provided to patients; and staff (EMP) interview, the agency failed to ensure that a social worker was employed by the agency to make counseling services available for the patient and family for 7 (seven) of 7(seven) clinical records reviewed. (CR1-7) Findings Included: A review on 6/4/2024 at approximately 11:30 a.m. of agency IDG meeting sign-in sheets from 2/28/2024 to 6/4/2024 revealed that the electronic signature date of attendance for the “Social Worker” was not signed [blank] and the “Name” indicated “services declined”. A review of patient Clinical Records (CR) conducted on 6/4/2024 and 6/5/2024, revealed the following: CR1 reviewed on 6/4/2024 at approximately 12:00pm - start of care (SOC) date 2/12/2023: Certification period 4/7/2024 through 6/5/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings, no record of social worker providing counseling visits. CR2 reviewed on 6/4/2024 at approximately 1:45pm - start of care (SOC) date 4/24/2024: Certification period 4/24/2024 through 7/22/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings, no record of social worker providing counseling visits. CR3 reviewed on 6/4/2024 at approximately 2:45pm - start of care (SOC) date 5/14/2024: Certification period 5/14/2024 through 8/11/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings, no record of social worker providing counseling visits. CR4 reviewed on 6/5/2024 at approximately 12:15pm - start of care (SOC) date 3/20/2024: Certification period 3/20/2024 through 6/17/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings, no record of social worker providing counseling visits. CR5 reviewed on 6/5/2024 at approximately 12:50pm - start of care (SOC) date 2/23/2022: Certification period 4/13/2024 through 6/11/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings, no record of social worker providing counseling visits. CR6 reviewed on 6/5/2024 at approximately 1:30pm - start of care (SOC) date 5/20/2024: Certification period 5/20/2024 through 8/17/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings, no record of social worker providing counseling visits. CR7 reviewed on 6/5/2024 at approximately 2:15pm - start of care (SOC) date 5/30/2024: Certification period 5/30/2024 through 8/27/2024. There was no documentation in the clinical record of a social worker assessment, no record of social worker attending IDG meetings, no record of social worker providing counseling visits. A review on 6/4/2024 at approximately 3:00 p.m. of agency policy and procedures revealed: “Title: Interdisciplinary Group; Policy #: HOSP3037... POLICY: VNA of Northwest PA designates an IDG composed of qualified individuals who assess, plan, provide and evaluate the care and services provided to hospice patients/caregivers... PROCEDURE: 1. The IDG at VNA of Northwest PA includes, at a minimum, the following individuals: a. a doctor of medicine or osteopathy; b. a registered nurse; c. a Social Worker; d. a pastoral or other counselor...” A review on 6/4/2024 at approximately 3:15 p.m. of agency admission packet information provided to patients revealed: “Social, Emotional and Spiritual Care; Social Work Services: Hospice social work provides education, counseling, support and resources for patients and families...” An interview with EMP1 on 6/4/2024 at approximately 3:30 p.m. confirmed the above findings. When asked if the agency has a social worker or equivalent that attends IDG meetings, EMP1 stated “No. We have been actively recruiting for a replacement social worker since our previous one quit. Her last year of service with us was in 2022.” When asked about the above findings, EMP1 stated “If there is no signature, (he/she) was not there.” When asked why the “Name” of the social worker indicated “services declined”, EMP1 stated “We don’t have an employed social worker to fill the role, so we marked services declined.””
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Governing body and administrator (42 CFR 418.100(b))
The inspectors’ words, 647 words
“Based on a review of agency policy and procedures; patient clinical records (CR); agency interdisciplinary group (IDG) meeting sign in sheets; agency admission packet information provided to patients; and staff (EMP) interview, the governing body failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services for 7 (seven) of 7(seven) clinical records reviewed. (CR1-7) Findings Included: A review on 6/4/2024 at approximately 11:30 a.m. of agency IDG meeting sign-in sheets from 2/28/2024 to 6/4/2024 revealed that the electronic signature date of attendance for the “Social Worker” was not signed [blank] and the “Name” indicated “services declined”. A review of patient Clinical Records (CR) conducted on 6/4/2024 and 6/5/2024, revealed the following: CR1 reviewed on 6/4/2024 at approximately 12:00pm - start of care (SOC) date 2/12/2023: Certification period 4/7/2024 through 6/5/2024. There was no documentation in the clinical record of a social worker completion of comprehensive assessment, no documentation of counseling provided by social worker. CR2 reviewed on 6/4/2024 at approximately 1:45pm - start of care (SOC) date 4/24/2024: Certification period 4/24/2024 through 7/22/2024. There was no documentation in the clinical record of a social worker completion of comprehensive assessment, no documentation of counseling provided by social worker. CR3 reviewed on 6/4/2024 at approximately 2:45pm - start of care (SOC) date 5/14/2024: Certification period 5/14/2024 through 8/11/2024. There was no documentation in the clinical record of a social worker completion of comprehensive assessment, no documentation of counseling provided by social worker. CR4 reviewed on 6/5/2024 at approximately 12:15pm - start of care (SOC) date 3/20/2024: Certification period 3/20/2024 through 6/17/2024. There was no documentation in the clinical record of a social worker completion of comprehensive assessment, no documentation of counseling provided by social worker. CR5 reviewed on 6/5/2024 at approximately 12:50pm - start of care (SOC) date 2/23/2022: Certification period 4/13/2024 through 6/11/2024. There was no documentation in the clinical record of a social worker completion of comprehensive assessment, no documentation of counseling provided by social worker.. CR6 reviewed on 6/5/2024 at approximately 1:30pm - start of care (SOC) date 5/20/2024: Certification period 5/20/2024 through 8/17/2024. There was no documentation in the clinical record of a social worker completion of comprehensive assessment, no documentation of counseling provided by social worker. CR7 reviewed on 6/5/2024 at approximately 2:15pm - start of care (SOC) date 5/30/2024: Certification period 5/30/2024 through 8/27/2024. There was no documentation in the clinical record of a social worker completion of comprehensive assessment, no documentation of counseling provided by social worker. A review on 6/4/2024 at approximately 3:00 p.m. of agency policy and procedures revealed: “Title: Interdisciplinary Group; Policy #: HOSP3037... POLICY: VNA of Northwest PA designates an IDG composed of qualified individuals who assess, plan, provide and evaluate the care and services provided to hospice patients/caregivers... PROCEDURE: 1. The IDG at VNA of Northwest PA includes, at a minimum, the following individuals: a. a doctor of medicine or osteopathy; b. a registered nurse; c. a Social Worker; d. a pastoral or other counselor...” A review on 6/4/2024 at approximately 3:15 p.m. of agency admission packet information provided to patients revealed: “Social, Emotional and Spiritual Care; Social Work Services: Hospice social work provides education, counseling, support and resources for patients and families...” An interview with EMP1 on 6/4/2024 at approximately 3:30 p.m. confirmed the above findings. When asked if the agency has a social worker or equivalent that attends IDG meetings, EMP1 stated “No. We have been actively recruiting for a replacement social worker since our previous one quit. Her last year of service with us was in 2022.” When asked about the above findings, EMP1 stated “If there is no signature, (he/she) was not there.” When asked why the “Name” of the social worker indicated “services declined”, EMP1 stated “We don’t have an employed social worker to fill the role, so we marked services declined.””
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Services (42 CFR 418.100(c)(1))
The inspectors’ words, 569 words
“Based on a review of agency policy and procedures; patient clinical records (CR); agency interdisciplinary group (IDG) meeting sign in sheets; agency admission packet information provided to patients; and staff (EMP) interview, the agency failed to provide medical social services for 7 (seven) of 7(seven) clinical records reviewed. (CR1-7) Findings Included: A review on 6/4/2024 at approximately 11:30 a.m. of agency IDG meeting sign-in sheets from 2/28/2024 to 6/4/2024 revealed that the electronic signature date of attendance for the “Social Worker” was not signed [blank] and the “Name” indicated “services declined”. A review of patient Clinical Records (CR) conducted on 6/4/2024 and 6/5/2024, revealed the following: CR1 reviewed on 6/4/2024 at approximately 12:00pm - start of care (SOC) date 2/12/2023: Certification period 4/7/2024 through 6/5/2024. There was no documentation in the clinical record that the agency provided medical social services. CR2 reviewed on 6/4/2024 at approximately 1:45pm - start of care (SOC) date 4/24/2024: Certification period 4/24/2024 through 7/22/2024. There was no documentation in the clinical record that the agency provided medical social services. CR3 reviewed on 6/4/2024 at approximately 2:45pm - start of care (SOC) date 5/14/2024: Certification period 5/14/2024 through 8/11/2024. There was no documentation in the clinical record that the agency provided medical social services. CR4 reviewed on 6/5/2024 at approximately 12:15pm - start of care (SOC) date 3/20/2024: Certification period 3/20/2024 through 6/17/2024. There was no documentation in the clinical record that the agency provided medical social services. CR5 reviewed on 6/5/2024 at approximately 12:50pm - start of care (SOC) date 2/23/2022: Certification period 4/13/2024 through 6/11/2024. There was no documentation in the clinical record that the agency provided medical social services.. CR6 reviewed on 6/5/2024 at approximately 1:30pm - start of care (SOC) date 5/20/2024: Certification period 5/20/2024 through 8/17/2024. There was no documentation in the clinical record that the agency provided medical social services. CR7 reviewed on 6/5/2024 at approximately 2:15pm - start of care (SOC) date 5/30/2024: Certification period 5/30/2024 through 8/27/2024. There was no documentation in the clinical record that the agency provided medical social services. A review on 6/4/2024 at approximately 3:00 p.m. of agency policy and procedures revealed: “Title: Interdisciplinary Group; Policy #: HOSP3037... POLICY: VNA of Northwest PA designates an IDG composed of qualified individuals who assess, plan, provide and evaluate the care and services provided to hospice patients/caregivers... PROCEDURE: 1. The IDG at VNA of Northwest PA includes, at a minimum, the following individuals: a. a doctor of medicine or osteopathy; b. a registered nurse; c. a Social Worker; d. a pastoral or other counselor...” A review on 6/4/2024 at approximately 3:15 p.m. of agency admission packet information provided to patients revealed: “Social, Emotional and Spiritual Care; Social Work Services: Hospice social work provides education, counseling, support and resources for patients and families...” An interview with EMP1 on 6/4/2024 at approximately 3:30 p.m. confirmed the above findings. When asked if the agency has a social worker or equivalent that attends IDG meetings, EMP1 stated “No. We have been actively recruiting for a replacement social worker since our previous one quit. Her last year of service with us was in 2022.” When asked about the above findings, EMP1 stated “If there is no signature, (he/she) was not there.” When asked why the “Name” of the social worker indicated “services declined”, EMP1 stated “We don’t have an employed social worker to fill the role, so we marked services declined.””
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Criminal background checks (42 CFR 418.114(d)(1))
The inspectors’ words, 517 words
“Based on review of the Pennsylvania Older Adult Protective Services Act (OAPSA), volunteer files (VF) and employee personnel files (PF) and based on interview with the agency administrator (Employee (EMP)#1), the hospice failed to ensure a Pennsylvania State Police (PSP) criminal history report and/or Federal Bureau of Investigation (FBI) criminal history record was obtained for five (5) of six (6) hospice employees (PF#2, PF#3, PF#4, PF#5 and PF#6) and three (3) of nine (9) volunteers (VF#1, VF#4 and VF#9) who provided hospice services in Pennsylvania. Findings include: On 6/6/2024 from approximately 9:30 a.m. to 12:55 p.m. and 6/7/2024 from approximately 9:20 a.m. to 11:00 a.m. a review of the hospice employee personnel files and volunteer files revealed: PF#2, Date of Hire (DOH): 4/25/-2022 - no documentation present in PF of PSP and/or FBI criminal background check was completed. PF#3, Date of Hire (DOH): 1/17/2022 - no documentation present in PF of PSP and/or FBI criminal background check was completed. PF#4, Date of Hire (DOH): 4/10/2023 - no documentation present in PF of PSP and/or FBI criminal background check was completed. PF#5, Date of Hire (DOH): 10/17/2023 - no documentation present in PF of PSP and/or FBI criminal background check was completed. PF#6, Date of Hire (DOH): 12/18/2023 - no documentation present in PF of PSP and/or FBI criminal background check was completed. VF# 1, Date of Hire (DOH): 3/1/2007 - no documentation present in VF of PSP and/or FBI criminal background check was completed. VF# 4, Date of Hire (DOH): 2/1/2009 - no documentation present in VF of PSP and/or FBI criminal background check was completed. VF# 9, Date of Hire (DOH): 3/5/1991 - no documentation present in VF of PSP and/or FBI criminal background check was completed. On 6/7/2024 at approximately 1:55 PM, review of the Older Adult Protective Services Act (Pennsylvania Act 169 of 1996 as amended by Act 13 of 1997) revealed the following as documented on the Pennsylvania Department of Aging website: “The Act 169-1996 Amendment to OAPSA requires a criminal background check for all employees and administrators of a facility...In addition, the Pennsylvania Department of Health has defined home health care organization or agency to include hospices... and the criminal background check requirement is that all facility applicants must submit with their employment application a criminal history report from the Pennsylvania State Police... if the applicant is not a resident of Pennsylvania, or has not been a resident of Pennsylvania for the entire two years immediately preceding employment application, then in addition to the report from the PA State Police, a report of Federal (FBI) criminal history record information must be obtained from the Federal Bureau of Investigation through the PA Department of Aging which has been designated by statute as the intermediary... Notwithstanding section 502, administrators may employ applicants on a provisional basis for a single period not to exceed 30 days or, for applicants under section 502(a)(2), a period of 90 days”... Interview with agency administrator (EMP1) conducted on 6/6/2024 at approximately 3:00 p.m. and email correspondence with volunteer coordinator on 6/7/2024 at approximately 1:00 pm. confirmed the above findings.”
All 3 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Sep 3, 2024 | Infection control and recertification inspection by the state | No deficiencies cited |
| Jul 22, 2024 | Infection control and recertification inspection by the state | No deficiencies cited |
| Jun 7, 2024 | Infection control and recertification inspection by the state | 9 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Aug 16, 1984.
- Ownership: for-profit.
- Cited at For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. in the last three years: it didn’t meet a whole condition of Medicare’s rules.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 9.8 nurse care minutes per routine home care day, 9.5% of skilled nursing minutes at weekends and a visit near death for 81.8% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 76% at home, 2% in assisted living, 13% in a nursing facility, 8% in a skilled nursing facility, 1% in a hospital.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 9.8 min |
| Skilled nursing minutes at weekends | 9.5% |
| Visits near death | 81.8% of patients who died |
Who owns it?
- CMS’s ownership file has no owners listed for this hospice.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
What do families say?
- CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
- In CMS’s survey of family caregivers (Oct 1, 2023 to Sep 30, 2025): 86% rated it 9 or 10 out of 10, and 91% would definitely recommend it.
- CMS’s Hospice Care Index: 9 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 91.07% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025); 24.2% had visits from a nurse or social worker on at least 2 of their last 3 days (Jan 1, 2023 to Dec 31, 2024).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | Not rated |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 9 of 10 |
How does it compare nearby?
- Of the 3 hospices CMS’s data show serving patients in ZIP code 16701, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 4.5; this one had 9.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| VNA of Northwest Pa, LLC This hospice | 9 |
| Family Hospice | 0 |
| Penn Highlands Community Nurses | Not given |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.