Initial Comments:
Based on the findings of an offsite state re-licensure survey conducted on June 2 through 5, 2026, B' Home Homecare Llc was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an offsite home care agency state re-licensure survey conducted on June 2 through 5, 2026, B' Home Homecare 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 a review of personnel files (PF) and an interview with the administrator, the agency failed to obtain at least two satisfactory references prior to hiring or rostering a direct care worker for five (5) of seven (7) PFs (PF# 1, 2, 3, 4 and 5).
Findings include:
A review of personnel files (PF) was conducted on 6/2/2026 starting at 11:40 am, 6/3/2026 at 12:30 pm and 6/4/2026 starting at 2 pm. The Date of Hire (DOH) is indicated below.
PF#1, DOH:7/8/2024, did not have evidence that, prior to hiring or rostering the direct care worker, agency obtained two (2) satisfactory references from non-family members.
PF#2, DOH: 7/5/2023, did not have evidence that, prior to hiring or rostering the direct care worker, agency obtained two (2) satisfactory references from non-family members.
PF#3, DOH: 11/21/2023, did not have evidence that, prior to hiring or rostering the direct care worker, agency obtained two (2) satisfactory references from non-family members.
PF#4, DOH: 10/10/2023, did not have evidence that, prior to hiring or rostering the direct care worker, agency obtained two (2) satisfactory references from non-family members.
PF#5, DOH: 3/4/2024, did not have evidence that, prior to hiring or rostering the direct care worker, agency obtained two (2) satisfactory references from non-family members.
An interview with the agency ' s administrator on 6/4/2026 at approximately 1:30 pm confirmed the above findings.
Plan of Correction:PF# 1, 2, 3, 4 and 5 did not contain at least two satisfactory references prior to hiring or rostering a direct care worker
All personnel files were were re reviews and found to be missing the required 2 reference checks prior to start of care. Compliance checks will be done quarterly to assure
BHHC has a checklist thats implemented prior to hiring, this checklist will be updated to prevent reoccurrences in the future. The checklist will include all measures of hiring practices related to requirements for staff prior to the start of care. All required reference checks will be checked and verified as part of ongoing hiring process, these documents will be placed in the individuals file.
POC will be confirmed by quarterly audits of the personnel files to make sure the agency stays in compliance.
Managing Officer Is responsible for maintaining and updating changes.
Plan of correct completion date is 7/13/26
Action Plan
BHHC will adapt a new policy that includes another checklist to ensure all requirements are adhered to upon hire and quarterly thereafter. The checklist will be dated and signed by each staff prior to the start of care. The checklist will also include their printed name as well as signature with a notice of understanding no servicing will begin until everything on the checklist has been completed.
Preventative Actions
All policies for hiring will be updated. Checklists, and personnel documents will be verified through our normal channels.
PA State Police( background checks),
Tb Testing/ Education/
Personnel Files must have mandatory 2 references ( non- relation, personal. Professional)
Sign of sheet - upon hire /yearly/quarterly
Staff Training- upon hire/ yearly/ quarterly
DOH Training-upon hire /yearly/quarterly
References Checks-upon hire /yearly/quarterly
Agency Audit Document Timeline:
Upon Hire: 1-30 days ( Checklist will be completed and signed prior to providing care.
Quarterly- Every Quarter to make sure agency is in compliance with required documents.
Managing Officer is responsible for all updates and changes.
7/13/26
611.56(a) LICENSURE
Health Screening
Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.
Observations:
Based on a review of personnel files (PF), the Centers for Disease Control (CDC) guidelines and an interview with the administrator, the agency did not provide documentation that a direct care worker (DCW) was screened and free from active mycobacterium tuberculosis for two (2) of seven (7) PFs (PF# 2 and 4).
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 screen annually. HCWs with a baseline 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 personnel files (PF) was conducted on 6/2/2026 starting at 11:40 am, 6/3/2026 at 12:30 pm and 6/4/2026 starting at 2 pm. The Date of Hire (DOH) is indicated below.
PF#2, DOH: 7/5/2023, contained documentation of tuberculin skin test (TST) completed on 9/1/2023. There was no evidence that a 2nd step TST was completed.
PF#4, DOH: 10/10/2023, contains tuberculin skin tests (TST) completed on 2/7/2025 and 2/17/2025, which are late.
An interview with the agency ' s administrator on 6/4/2026 at approximately 1:30 pm confirmed the above findings.
Plan of Correction:PF# 2 and 4 documentation was not provided that a direct care worker (DCW) was screened and free from active mycobacterium tuberculosis.
All personnel files will be updated to include the 2 step ppd testing results for personnel included in the sample.
BHHC has a tb information checklist thats implemented prior to hiring, that will include the 2 step ppd testing thats required prior to start of care as well as the tb education/ and questionnaire thats by each personnel prior to start of care.
This checklist will be updated to prevent reoccurrences in the future. The checklist will include all measures of hiring practices related to tb requirements for staff prior to the start of care. All required tb checks will be checked and verified as part of ongoing hiring process, these documents will be updated and placed in the individuals file.
POC will be confirmed by quarterly audits of the personnel files to make sure the agency stays in compliance.
Managing Officer Is responsible for maintaining and updating changes.
Plan of correct completion date is 7/13/26
Action Plan
BHHC will adapt a new policy that includes another checklist to ensure all requirements are adhered to upon hire and quarterly thereafter. The checklist will be dated and signed by each staff prior to the start of care. The checklist will also include their printed name as well as signature with a notice of understanding no servicing will begin until everything on the checklist has been completed.
Preventative Actions
All policies for hiring will be updated. Checklists, and personnel documents will be verified through our normal channels.
PA State Police( background checks),
Tb Testing/ Education/
Personnel Files must have mandatory 2 references ( non- relation, personal. Professional)
Sign of sheet - upon hire /yearly/quarterly
Staff Training- upon hire/ yearly/ quarterly
DOH Training-upon hire /yearly/quarterly
References Checks-upon hire /yearly/quarterly
Agency Audit Document Timeline:
Upon Hire: 1-30 days ( Checklist will be completed and signed prior to providing care.
Quarterly- Every Quarter to make sure agency is in compliance with required documents.
Managing Officer is responsible for all updates and changes.
7/13/26
611.57(a) LICENSURE
Consumer Rights
Name - Component - 00
(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.
Observations:
Based on review of the consumer records (CR) and an interview with the administrator, it was determined the agency failed to provide consumers of home care services of their rights to receive notice regarding termination of the service agreement: (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk for four (4) of seven (7) CRs reviewed (CR# 2, 3, 6 and 7).
Findings include:
A review of consumer records (CR) was conducted on 6/2/2026 starting at 12 am, 6/3/2026 at 12:30 pm and 6/4/2026 starting at 2 pm. The Start of Care (SOC) is indicated below.
CR#2, SOC: 4/18/2024, did not contain evidence that agency provided written agreement of following consumer rights: (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.
CR#3, SOC: 1/31/2026, did not contain evidence that agency provided written agreement of following consumer rights: (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.
CR#6, SOC: 1/7/2026, did not contain evidence that agency provided written agreement of following consumer rights: (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.
CR#7, SOC: 1/5/2026, did not contain evidence that agency provided written agreement of following consumer rights: (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.
An interview with the agency ' s administrator on 6/4/2026 at approximately 1:30 pm confirmed the above findings.
Plan of Correction:(CR# 2, 3, 6 and 7 was not provided documentation that a advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.
BHHC will implement a new policy that directly covers the important crucial elements of consent of services before care begins, information explaining services being provided, benefits/ insurance of the individual/staff providing the care, frequency of services, the purpose of the effects of services, billing methods,and individuals rights. The consumers will renotified of these new polices and given a printed copy of the booklet as well as given signed agreeance of understand and service acceptance.
Documents will be monitored quarterly to check for compliance. All consumer documents if update quarterly will be reviewed with all families receiving care. Documentation will be placed in consumers file.
POC will be confirmed by quarterly audits of the personnel files to make sure the agency stays in compliance with all consumers file by creating a quarterly checklist of required documenation needed in consumers file.
Managing Officer Is responsible for maintaining and updating changes.
Plan of correct completion date is 7/13/26
Action Plan
BHHC will adapt a new policy that includes another checklist to ensure all requirements are adhered to upon beginning of services and quarterly thereafter. The checklist will be dated and signed by each family prior to the start of care and placed into the consumers file.
Preventative Action
Agency Audit Document Timeline:
Start of Care: 1-2 weeks (Checklist Individuals Document and booklet will be completed, explained and signed prior to providing care.
Quarterly- Every Quarter to make sure agency is in compliance with required documents needed for consumers file.
Managing Officer is responsible for all updates and changes.
*MF #6 is no longer with the agency, I will provide another sample for you to check in his place.
Expected Completion Date 7/13/26
Initial Comments:
Based on the findings of an offsite home care agency state re-licensure survey conducted on June 2 through 5, 2026, B' Home Homecare Llc was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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