QA Investigation Results

Pennsylvania Department of Health
BELOVED HOMECARE AGENCY, LLC
Health Inspection Results
BELOVED HOMECARE AGENCY, LLC
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite unannounced relicensure survey completed November 30, 2018, Beloved Homecare Agency was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.







Plan of Correction:




Initial Comments:


Based on the findings of an onsite unannounced state relicensure survey completed November 30, 2018, Beloved Homecare Agency, LLC, was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.





Plan of Correction:




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 Act 13, facility policy, personnel files, and interview with the administrator, it was determined that prior to client assignment the agency failed to obtain a State Police criminal history record for seven (7) of seven, (7) Direct Care Workers (DCW) files reviewed. (DCW#1, 2, 3, 4, 5, 6, and 7).

Findings include:

According to the Act 169 of 1996 as amended by Act 13 of 1997,"If the applicant/employee has been a resident of the Commonwealth of Pennsylvania for 2 or more years prior to application for employment, the applicant will need to obtain a clearance from the Pennsylvania State Police. This clearance is obtained by doing the following: Request for Criminal Record Check Form (SP4-164)." "When the applicant/employee has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out of state, in addition to the Pennsylvania State Police Criminal History Check, the applicant/employee will also need to obtain an FBI Criminal History Check. Facilities are defined by the act to include: Domiciliary Care Homes, Home Health Care Agency, Nursing Facility (licensed by the Department of Aging), Personal Care Home (licensed by the Department of Public Welfare). A home Health Care Agency is further defined to include those agencies licensed by the Department of Health and any public or private organization which provides care to a care-dependent individual in their place of residence." "If entities run into special circumstances where they need to hire an employee before the results of their record checks are returned, there is a provision in CPSL that allows for a provisional hiring period. The period is to not exceed 30 days for in state residents and 90 for out of state residents."

1. Review of DCW #1 personnel file on November 30, 2018 at approximately 10:30 a.m. revealed the date of hire on November 19, 2018. There was no evidence that a Pennsylvania State Police Criminal History Check had been conducted.

2. Review of DCW #2 personnel file on November 30, 2018 at approximately 10:45 a.m. revealed the date of hire on June 29, 2018. On September 24, 2018, a background check was conducted through, "Access Public Records Now!" There was no evidence that a Pennsylvania State Police Criminal History Check had been conducted.

3. Review of DCW #3 personnel file, (owner), on November 30, 2018 at approximately 11:00 a.m. revealed a start date on November 2, 2017. On September 24, 2018, a background check was conducted through, "Access Public Records Now!" There was no evidence that a Pennsylvania State Police Criminal History Check had been conducted.

4. Review of DCW #4 personnel file on November 30, 2018 at approximately 11:15 a.m. revealed the date of hire on August 13, 2018. On September 24, 2018, a background check was conducted through, "Access Public Records Now!" There was no evidence that a Pennsylvania State Police Criminal History Check had been conducted.

5. Review of DCW #5 personnel file on November 30, 2018 at approximately 11:30 a.m. revealed the date of hire on April 15, 2018. On September 24, 2018, a background check was conducted through, "Access Public Records Now!" There was no evidence that a Pennsylvania State Police Criminal History Check had been conducted.

6. Review of DCW #6 personnel file on November 30, 2018 at approximately 11:45 a.m. revealed the date of hire on August 5, 2018. On September 24, 2018, a background check was conducted through, "Access Public Records Now!" There was no evidence that a Pennsylvania State Police Criminal History Check had been conducted.

7. Review of DCW #7 personnel file on November 30, 2018 at approximately 12:00 a.m. revealed the date of hire on August 16, 2018. On September 24, 2018, a background check was conducted through, "Access Public Records Now!" There was no evidence that a Pennsylvania State Police Criminal History Check had been conducted.

On November 30, 2018, at approximately 1:45 p.m., a review of the facility policy entitled, "Beloved Home Care Agency LLC," subtitled, "Criminal Background Check," "Exhibit B," revealed that, "Beloved Home Care, LLC, requires each caregiver under the direction of the agency undergo a criminal background check through the Pennsylvania State Police before becoming eligible to provide home care services to clients."

An interview with the administrator and the assistant on November 30, 2018, at approximately 2:00 p.m., confirmed that the Agency did not administer a criminal background check through the Pennsylvania State Police prior to assigning a DCW to a client. The Administrator said, "I was not aware that we had to use the state police for background checks".








Plan of Correction:

Beloved Homecare agency,LLC administrator(office manager) will monitor our caregivers files every 90 days to prevent absent of background check. Our hiring manager will inform each potential new hire of the importance of having a criminal background check done before and during interview. We have also created an employee pre-hire checklist so that way it will help keep us updated on each caregiver file , and also keep each caregiver updated on there employment process.


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 review of Center for Disease Control, (CDC) guidelines, personnel files, and administrator interview, it was determined the facility failed to ensure that all Direct Care Workers (DCW) were screened and free from active mycobacterium tuberculosis (TB) prior to assignment to clients. Review of personnel files, revealed that this did not occur for six (6) of seven (7) DCWs reviewed. (DCW #2, 3, 4, 5, 6, and, 7)

Findings include:

CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(RR-17), revealed that "all Health Care Workers (HCW) should receive a baseline tuberculosis screening upon hire, using a two-step Tuberculin Skin Test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, health care workers should receive TB screen annually. Health care workers with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease."

1. Review of DCW #1 personnel file on November 30, 2018 at approximately 10:30 a.m. revealed the date of hire on November 19, 2018. Step one of a TST occurred on August 5, 2018. There was no documented evidence that a second step to a TST sequence had occurred.

2. Review of DCW #2 personnel file on November 30, 2018 at approximately 10:45 a.m. revealed the date of hire on June 29, 2018. Step one of a TST occurred on October 9, 2018. There was no documented evidence that a second step to a TST sequence had occurred.

3. Review of DCW #3 personnel file, (owner), on November 30, 2018 at approximately 11:00 a.m. revealed a start date on November 2, 2017. There was no documented evidence that a one, or two-step TST sequence had occurred.

4. Review of DCW #4 personnel file on November 30, 2018 at approximately 11:15 a.m. revealed the date of hire on August 13, 2018. There was no documented evidence that a one, or two-step TST sequence had occurred.

5. Review of DCW #5 personnel file on November 30, 2018 at approximately 11:30 a.m. revealed the date of hire on April 15, 2018. There was no documented evidence that a one, or two-step TST sequence had occurred.

6. Review of DCW #6 personnel file on November 30, 2018 at approximately 11:45 a.m. revealed the date of hire on August 5, 2018. There was no documented evidence that a one, or two-step TST sequence had occurred.

7. Review of DCW #7 personnel file on November 30, 2018 at approximately 12:00 a.m. revealed the date of hire on August 16, 2018. There was no documented evidence that a one, or two-step TST sequence had occurred.

In interview with the Agency Administrator on November 30, 2018 at approximately 2:00 p.m., it was confirmed that a two-step tuberculin skin test for infection with tuberculosis did not occur for six personnel.









Plan of Correction:

Beloved Homecare agency, LLC Administrator manager have notified each caregiver to informed them that they are required to have a two-step ppd done. Our administrator will also conduct audits and monitor each caregiver file every 90 days to ensure that a tb screening was done an updated .



Initial Comments:


Based on the findings of an onsite unannounced relicensure survey completed November 30, 2018, Beloved Homecare Agency. LLC, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: