QA Investigation Results

Pennsylvania Department of Health
BELOVED HOME CARE AND DAYCARE SERVICES
Health Inspection Results
BELOVED HOME CARE AND DAYCARE SERVICES
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite State Re-Licensure Survey conducted on November 21, 2022, Beloved Home Care and Daycare Services 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 onsite State Re-Licensure Survey conducted on November 21, 2022, Beloved Home Care and Daycare Services 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:




611.4(c) LICENSURE
Requirements for HCA and HCR

Name - Component - 00
Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.

Observations:

Based on a review of personnel files (PF), an interview with the administrator, the City of Philadelphia Memorandum: Emergency Regulation Governing The Control and Prevention of COVID-19 Mandating Vaccines for Healthcare Workers and In Higher Education, Healthcare, and Related Settings ( " Vaccine Mandate Regulation " ) dated August 16, 2021; an Update to Mandatory Healthcare Vaccination from the City of Philadelphia, dated October 12, 2021; and a third update from the City of Philadelphia, Division of Disease Control dated October 5, 2022 pertaining to updates to vaccination and masking requirements for health care workers, the home care agency failed to provide evidence of direct care worker vaccination status or direct care worker exemption. The requirement was not evident in seven (7) of seven (7) PF's reviewed: PF#1, PF#2, PF#3, PF#4, PF#5, PF#6 and PF#7.

Findings include:

The City of Philadelphia Memorandum - Emergency Regulation Governing the Control and Prevention of COVID-19 Mandating Vaccines for Healthcare Workers and In Higher Education, Healthcare and Related Settings ( " Vaccine Mandate Regulation " ), dated August 16, 2021, and reviewed October 6, 2022 at approximately 1:30 PM provides the following definitions: 1. "Covered Healthcare Personnel - an individual who falls into one or more of the following categories - a) an employee, contract workers, student or volunteer affiliated with a Healthcare Institution who performs duties in a builing where patients, clients or their visitors are present; b) a Healthcare Worker;" 2. "Healthcare Institution - any person or entity that employs, coordinates, or otherwise engages the services of Covered Healthcare Personnel in the City;' 3. "Healthcare Worker - an individual who provides Healthcare Related Services in person to patients or clients.." The regulation further states, "Effective October 15, 2021, no Healthcare Worker may work at a Healthcare Institution or provide Healthcare Related Services to a patient or client in Philadelphia unless such Healthcare Worker (i) has been Fully Vaccinated; or (ii) has been granted an exemption under paragraph 3 of this Regulation from any applicable Healthcare Institution for whom such individual works and documents ongoing compliance with one or more accommodation(s) set forth in paragraph 4 of this regulation. Paragraph 3 - Exemptions: For the purposes of this Regulation only, a Healthcare Institution subject to this Regulation shall grant a Covered Individual an exemption from the vaccination requirements of this Regulation if such individual qualified for one or both of the exemptions and agrees in writing to abide by the accommodation required by the Healthcare Institution. Medical Exemption - for the purpose of this Regulation only, an exemption shall be granted if the Healthcare Institution determines that the administration of any COVID-19 vaccine is contraindicated because the administration would be detrimental to the health of the Covered Individual (CI). A CI shall request an exemption by submitting a certification from a licensed healthcare provider to the Healthcare Institution certifying that the exemption applies and stating the specific reason that the vaccine is contraindicated for the CI. Such certification must be signed by both the healthcare providers and the CI...... Religions Exemption - For the purpose of this Regulation only, an exemption shall be granted if the CI certifies in writing that such individual has a sincerely held religious belief that precludes such individual from receiving the COVID-19 vaccination. Such certification must be signed the CI. Accommodations: Routine Testing - For Healthcare Institutions and Healthcare Workers - Requiring exempt Covered Healthcare Personnel to submit to either a PCR or antigen test at least twice per week, timed appropriately under the circumstances."

The City of Philadelphia Updates to Mandatory Healthcare Vaccination, dated October 12, 2021 and reviewed October 6, 2022 at approximately 1:30 PM, provided timeline updates for three groups......"Group Two: Group Two includes those designated as healthcare worker or healthcare institution worker that are NOT working in a hospital or LTCF. Employers of workers in all 3 groups must complete a written policy detailing how the employer will verify compliance with extended deadlines." The Update also provided the following definitions: 1. "Direct Care Worker: a) the individual employed by a home care agency or referred by a home care registry to provide home care services to a consumer; or b) a person employed for compensation by a provider or participant who provides personal assistance services or respite services. 2. Healthcare Workers: any individual involved in providing any of the following healthcare regulated services in-person to patients or clients or any individual working in a Healthcare Institution....3. Personal Care, which may include services provided in a personal care home or at the home of a patient or client....." The Update further clarified the following: 1. " Who is Covered Under the Mandate: Healthcare Institution Workers.....includes Direct Care Workers; 2. Limited Vaccination Deadline Extensions..... All other Healthcare Workers and Healthcare Institution Workers are required to receive at least one dose of vaccine in a two-dose vaccination series or the single dose in a one-dose series by October 22, 2021 and comply with all Interim Precautions. The second dose of a two-dose vaccine must be received by November 22, 2021. All workers hired after the vaccination deadline must receive at least one shot in a two-dose series or a single dose in a one-dose series before beginning in-person shifts. Final doses must be received within one month of hire. 3. Limited Home-Based Services Enforcement Exception - The Department will not enforce the Healthcare Worker Vaccine Mandate against certain individuals providing care for a Relative as defined below UNTIL the end of calendar year 2021 or until federal mandates require vaccinations for these individuals, whichever occurs first. Such individuals should be treated as employee who have received a valid religious or medical exemption. 4. Full Summary: The Emergency Regulation Governing the Control and Prevention of COVID-19 Mandating Vaccines for Healthcare Workers and In Higher Education, Healthcare and Related Settings ("Vaccine Mandate Regulation"), effective August 16, 2021, will not be enforced against a Direct Care Workers employed by a Pennsylvania licensed Home Care Agency or Home Care Registry or Participant or a Direct Support/Service Professional employed by a Provider or Participant to provide Personal Assistance Services (Instrumental Activities of Daily Living or Activities of Daily Living) or Respite Services to a Relative in such Relative's home until December 31, 2021 or until such time as the Centers for Medical and Medicaid Services (CMS) issue federal directives on the application of mandatory vaccines to such individuals, whichever occurs first. The term "Direct Care Worker" may have the definition provided in 28 PA. Code 611.5 or 55 PA. Code 52.3, depending upon employing entity and services provided. 5. Exemptions - An individual may not simply opt out of vaccination. The must submit a medical or religions exemption to the Healthcare Institution where such individual works according to policies set by the Institution. Healthcare Institutions and organizations that are granting exemptions must create appropriate exemption policies to implement this regulation. Healthcare Institutions are required to keep records of vaccination status of all vaccinated individuals, exemptions requested and granted, and participation in accommodations granted."

The City of Philadelphia Updates to Vaccination and Masking Requirements for Healthcare Workers dated October 5, 2022 and reviewed October 5, 2022 at approximately 10:00 AM states that healthcare institutions are no longer required to perform asymptomatic screening testing of exempt individuals.

A review of personnel files (PF) was conducted on November 21, 2022 starting approximately 10:00 AM. The date of hire (DOH) is indicated below:

PF#1 DOH 03/22/2022 contained no evidence that the COVID-19 vaccination had been received, nor was there evidence of a religious exemption being granted by the agency, nor a medical exemption being granted by a medical provider.

PF#2 DOH 03/20/2021 contained no evidence that the COVID-19 vaccination had been received, nor was there evidence of a religious exemption being granted by the agency, nor a medical exemption being granted by a medical provider.

PF#3 DOH 03/25/2022 contained no evidence that the COVID-19 vaccination had been received, nor was there evidence of a religious exemption being granted by the agency, nor a medical exemption being granted by a medical provider.

PF#4 DOH 05/01/2022 contained no evidence that the COVID-19 vaccination had been received, nor was there evidence of a religious exemption being granted by the agency, nor a medical exemption being granted by a medical provider.

PF#5 DOH 01/19/2022 contained no evidence that the COVID-19 vaccination had been received, nor was there evidence of a religious exemption being granted by the agency, nor a medical exemption being granted by a medical provider.

PF#6 DOH 11/11/2021 contained no evidence that the COVID-19 vaccination had been received, nor was there evidence of a religious exemption being granted by the agency, nor a medical exemption being granted by a medical provider.

PF#7 DOH 10/07/2022 contained no evidence that the COVID-19 vaccination had been received, nor was there evidence of a religious exemption being granted by the agency, nor a medical exemption being granted by a medical provider.

An interview conducted with the administrator on November 21, 2022 starting at 11:00 AM confirmed the above findings.




Plan of Correction:

Beloved Home Care and Day Care Services and it's Administration.
In accordance with 611.4(c) Requirement for HCA and HCR.
Home care agencies and home care registries licensed under this chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State and local authorities.
To ensure the deficient practice doesn't reoccur. The agency administrator will implement The City of Philadelphia Memorandum-Emergency Regulation Governing the Control and Prevention of Covid-19 Mandating Vaccines for Healthcare Workers and in Higher Education, Healthcare and Related Settings (Vaccine Mandate Regulation") dated August 16, 2021, and reviewed October 6, 2022. Providing PM's definitions, Regulations and Mandates for (PF's #1 #2 #3 #4 #5 #6 #7) including retaining copy of Covid-19 Vaccine Card, Medical or Religious Exemptions following the survey conducted 11/21/2022.



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 the administrator, there was no evidence that prior to hiring a direct care worker, the home care agency conducted an interview the individual for seven (7) of seven (7) PF's reviewed: PF#1, PF#2, PF#3, PF#4, PF#5, PF#6, and PF#7.

Findings include:

A review of personnel files was conducted on November 21, 2022 starting at approximately 10:00 AM. The date of hire (DOH) is indicated below.

PF#1 DOH 03/22/2022 did not contain evidence that prior to hiring the direct care worker, an interview with the individual was conducted by the home care agency.

PF#2 DOH 03/20/2021 did not contain evidence that prior to hiring the direct care worker, an interview with the individual was conducted by the home care agency.

PF#3 DOH 03/25/2022 did not contain evidence that prior to hiring the direct care worker, an interview with the individual was conducted by the home care agency.

PF#4 DOH 05/01/2022 did not contain evidence that prior to hiring the direct care worker, an interview with the individual was conducted by the home care agency.

PF#5 DOH 01/19/2022 did not contain evidence that prior to hiring the direct care worker, an interview with the individual was conducted by the home care agency.

PF#6 DOH 11/11/2021 did not contain evidence that prior to hiring the direct care worker, an interview with the individual was conducted by the home care agency.

PF#7 DOH 10/07/2022 did not contain evidence that prior to hiring the direct care worker, an interview with the individual was conducted by the home care agency.

An interview conducted with the administrator on November 21, 2022 starting at 11:00 AM confirmed the above findings.





Plan of Correction:

In accordance with 611.51(a) hiring and rostering perquisites the Beloved Home Care and Day Care Services agency and its administration, will obtain and document two satisfactory references for Direct Care Workers (PF's#1 #2 #3 #4 #5 #6 #7) following survey conducted 11/21/2022.
To ensure the deficient practice doesn't recur. The agency administrator will implement the agency's policy on hiring and rostering by providing all future employees an information package after a successful interview. The package will include a document informing employee that they must obtain two satisfactory references from a former employer or someone unrelated that affirms their ability to provide home care services.

The agency administrator will sustain corrective action by reviewing all new employees' chart on the day of hire to ensure that two satisfactory references are obtained


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 a review of personnel files (PF) and an interview with the administrator, the agency did not obtain a criminal history report at the time of application or within one (1) year immediately preceding the date of application for six (6) of seven (7) PF's reviewed: PF#1, PF#2, PF#3, PF#4, PF#5 and PF#6.

Findings include:

A review of PF's was conducted on November 21, 2022 starting at approximately 10:00 AM. The date of hire (DOH) is indicated below.

PF #1 DOH 03/22/2022 did not have a Pennsylvania Access to Criminal History (PATCH) report conducted by the State Police at the time of application or within one (1) year immediately preceding the date of application. The date of the PATCH was 08/27/2022 which was five (5) months after date of hire.

PF#2 DOH 03/20/2021 did not have a Pennsylvania Access to Criminal History (PATCH) report conducted by the State Police at the time of application or within one (1) year immediately preceding the date of application. The date of the PATCH was 04/15/2021 which was almost one (1) month after date of hire.

PF#3 DOH 03/25/2022 did not have a Pennsylvania Access to Criminal History (PATCH) report conducted by the State Police at the time of application or within one (1) year immediately preceding the date of application. The date of the PATCH was 08/27/2022 which was five (5) months after date of hire.

PF#4 DOH 05/01/2022 did not have a Pennsylvania Access to Criminal History (PATCH) report conducted by the State Police at the time of application or within one (1) year immediately preceding the date of application. The date of the PATCH was 08/27/2022 which was over three (3) months from date of hire.

PF#5 DOH 01/19/2022 did not have a Pennsylvania Access to Criminal History (PATCH) report conducted by the State Police at the time of application or within one (1) year immediately preceding the date of application. The date of the PATCH was 08/27/2022 which was over seven (7) months from date of hire.

PF#6 DOH 11/11/2021 did not have a Pennsylvania Access to Criminal History (PATCH) report conducted by the State Police at the time of application or within one (1) year immediately preceding the date of application. The date of the PATCH was 08/27/2022 which was over nine (9) months from date of hire.

An interview conducted with the administrator on November 21, 2022 starting at 11:00 AM confirmed the above findings.





Plan of Correction:

Criminal Background Check 611.52 Tag-0300
Beloved Home Care and Day Care Services and its Administrative Assistant / Office Manager will prior to hiring. The agency Administrator will monitor corrective action plan and review personal files quarterly and or as needed and require that 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. An applicant for employment as a member of the office staff for Beloved Home Care and Day Care Services and the owner or owners of the home care agency or home registry also are required to obtain a criminal history report in accordance with requirements contained in this section. From this day forward no applicant will be hired without having a current criminal background check submitted and received in a timely manner.
Beloved Home Care and Day Care Services and its Administrative Assistant / Office Manager will submit, prior to employment a Criminal Background Check to PATCH for each applicant and continue to monitor from hereafter, prior to employment, Beloved Home Care and Day Care Services and its Administrative Assistant / Office Manager will be responsible on a continuing bases to monitor and implement the plan of correction in compliance with 611.52(a) Criminal Background Checks.
The agency will implement a checklist and practice of checking prior to employment applicant acquires a criminal background check.
In order to confirm that the plan of correction is effective and sustained Administrative Assistant / Office Manager will audit personal files on a quarterly basis until 100% compliance is achieved for two consecutive quarters.
The plan of correction will be fully implemented 01/20/2023

To ensure that the practice will not recur for (PF's #1 #2 #3 #4 #5 #6).
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.
Prior to hiring an employee, Beloved Home Care and Day Care Services and its Administration shall obtain a criminal history check which is in compliance with the following for each employee who may have contact with a participant.
A report of criminal history record information from the Pennsylvania State Police or a statement from the Pennsylvania State Police that the Pennsylvania State Police Central Repository does not contain information relating to that person, under8Pa.C.S. Chapter 91 (relating to Criminal History Record Information Act), if the employee has been a resident of this Commonwealth for 2 years immediately preceding the date of application.
A report of Federal criminal history record information under the Federal Bureau of Investigation appropriation of Title II of the act of October 25, 1972 (Pub. L. No. 92-544, 86 Stat.1109) if the employee has not been a resident of this Commonwealth for the 2 years immediately preceding the date of application.
Criminal History checks shall be in accordance with the Older Adults Protective Services Act (35 P.S. ss 10225.102) and 6 Pa. Code Chapter 15 (relating to protective services for older adults).

the hiring polices shall be in accordance with the Department of Aging's Older Adults Protective Services
Act policy a posted on the Department of Aging's web site at http://www.portal.state.pa.us/portal/server.

A copy of the final report from the Pennsylvania State Police or the federal Bureau of Investigation, a applicable, shall be kept in accordance with 52.15 (relating to provider records).


Addendum:

Criminal Background Checks have been received for PF# 1,2,3,4,5, and 6.















611.52(c) LICENSURE
Federal Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code 15.144(b) (relating to procedure).

Observations:

Based on a review of personnel files (PF) and an interview with the administrator, the agency did not obtain a federal criminal history record and a letter of determination from the Department of Aging for an applicant who has not been a resident of Pennsylvania for the 2 years immediately preceding the date of hire for one (1) of seven (7) PFs. PF#7.

Findings include:

A review of PFs was conducted on November 21, 2022 starting at approximately 10:00 AM. The date of hire (DOH) is indicated below.

PF#7 DOH 10/07/2022 did not contain a federal criminal history record and a letter of determination from the Department of Aging. The file contained a State of Maryland Identification Card issued on 06/06/2018. There was no evidence contained in the file that the individual had been a resident of Pennsylvania for the 2 years immediately preceding the date of hire.

An interview with the administrator conducted on November 21, 2022 starting at 11:00 AM confirmed the above findings.





Plan of Correction:

Tag-0320
Beloved Home Care and Day Care Services and its Administrative Assistant / Office Manager will prior to hiring. The agency Administrator will monitor corrective action plan and review files quarterly and or as needed and require that each applicant for employment or referral as a direct care worker to submit an FBI criminal history report obtained at the time of application or within 1 year immediately preceding the date of application. An applicant for employment as a member of the office staff for Beloved Home Care and Day Care Services and the owner or owners of the home care agency or home registry also are required to obtain a criminal history report in accordance with requirements contained in this section. From this day forward no applicant will be hired without having a current criminal background check submitted and received in a timely manner by Administrative Assistant / Office Manager.
Beloved Home Care and Day Care Services and its Administrator will, prior to hiring will submit through the FBI a federal criminal history record check and obtain a letter of determination from the Department of Aging on applicants who has not been a resident of Pennsylvania for the 2 years immediately preceding the date of hire and continue to do so hereafter, Beloved Home Care and Day Care Services and its Administrator will be responsible to monitor and implement the plan of correction in compliance with 611.52(a) Criminal Background Checks.
The Administrative Assistant / Office Manager will implement a checklist and practice of checking to ensure that that FBI criminal history report is submitted and received in a timely manner on all applicants prior to employment.
To confirm that the plan of correction is effective and sustained Administrative Assistant / Office Manager will audit personal files quarterly basis until 100% compliance is achieved for two consecutive quarters.
The plan of correction will be fully implemented by 01/20/2022.

To be in compliance with 611.52(a) Criminal Background Checks.
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.
Prior to hiring an employee, a provider shall obtain a criminal history check which is in compliance with the following for each employee who may have contact with a participant.
A report of criminal history record information from the Pennsylvania State Police or a statement from the Pennsylvania State Police that the Pennsylvania State Police Central Repository does not contain information relating to that person, under8Pa.C.S. Chapter 91 (relating to Criminal History Record Information Act), if the employee has been a resident of this Commonwealth for 2 years immediately preceding the date of application.
A report of Federal criminal history record information under the Federal Bureau of Investigation appropriation of Title II of the act of October 25, 1972 (Pub. L. No. 92-544, 86 Stat.1109) if the employee has not been a resident of this Commonwealth for the 2 years immediately preceding the date of application.
Criminal History checks shall be in accordance with the Older Adults Protective Services Act (35 P.S. ss 10225.102) and 6 Pa. Code Chapter 15 (relating to protective services for older adults).

the hiring polices shall be in accordance with the Department of Aging's Older Adults Protective Services
Act policy a posted on the Department of Aging's web site at http://www.portal.state.pa.us/portal/server.

A copy of the final report from the Pennsylvania State Police or the federal Bureau of Investigation, a applicable, shall be kept in accordance with 52.15 (relating to provider records).


Addendum:
Submission of federal criminal history for has been submitted PF#7. Also, received copy of Utility bill and Lease for.PF#7





611.52(d) LICENSURE
Proof of Residency

Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation

Observations:

Based on review of personnel files (PF) and an interview with the administrator, the agency failed to document proof of Pennsylvania (PA) residency for two (2) consecutive years immediately preceding date of hire through submission of any one of the following documents: (1) Motor vehicle records, such as a valid driver's license or a State-issued identification; (2) Housing records, such as mortgage records or rent receipts; (3) Public utility records and receipts, such as electric bills; (4) Local tax records; (5) A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it; (6) Employment records, including records of unemployment compensation. Four (4) of seven (7) PF's reviewed did not meet the requirement: PF#1, PF#4, PF#5, and PF#7.

Findings include:

A review of personnel files (PF) was conducted on November 21, 2022 starting at approximately 10:00 AM. The date of hire (DOH) is indicated below.

PF#1 DOH 03/22/2022 contained a copy of a Pennsylvania Driver's License issued on 03/17/2022. There was no verifiable documentation contained in the PF of Pennsylvania residency for two (2) consecutive years immediately preceding date of hire from 03/22/2020 to 03/22/2022 through submission of any one of the following documents: (1) Motor vehicle records, such as a valid driver's license or a State-issued identification; (2) Housing records, such as mortgage records or rent receipts; (3) Public utility records and receipts, such as electric bills; (4) Local tax records; (5) A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it; (6) Employment records, including records of unemployment compensation.

PF#4 DOH 05/01/2022 contained a copy of a Pennsylvania Driver's License issued on 04/21/2022. There was no verifiable documentation contained in the PF of Pennsylvania residency for two (2) consecutive years immediately preceding date of hire from 05/01/2020 to 01/01/2022 through submission of any one of the following documents: (1) Motor vehicle records, such as a valid driver's license or a State-issued identification; (2) Housing records, such as mortgage records or rent receipts; (3) Public utility records and receipts, such as electric bills; (4) Local tax records; (5) A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it; (6) Employment records, including records of unemployment compensation.

PF#5 DOH 01/19/2022 contained a copy of a Pennsylvania Commercial Driver's License issued on 04/14/2021. There was no verifiable documentation contained in the PF of Pennsylvania residency for two (2) consecutive years immediately preceding date of hire from 01/19/2020 to 01/19/2022 through submission of any one of the following documents: (1) Motor vehicle records, such as a valid driver's license or a State-issued identification; (2) Housing records, such as mortgage records or rent receipts; (3) Public utility records and receipts, such as electric bills; (4) Local tax records; (5) A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it; (6) Employment records, including records of unemployment compensation.

PF#7 DOH 10/07/2022 contained a copy of a State of Maryland Identification Card issued on 06/06/2018. There was no verifiable documentation contained in the PF of Pennsylvania residency for two (2) consecutive years immediately preceding date of hire from 10/07/2020 to 10/07/2022. through submission of any one of the following documents: (1) Motor vehicle records, such as a valid driver's license or a State-issued identification; (2) Housing records, such as mortgage records or rent receipts; (3) Public utility records and receipts, such as electric bills; (4) Local tax records; (5) A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it; (6) Employment records, including records of unemployment compensation.

An inteview conducted with the administrator on November 21, 2022 starting at 11:00 AM confiremd the above findings.




Plan of Correction:

Tag-0330

Beloved Home Care and Day Care Services and its Administrative Assistant / Office Manager. In accordance with 611.52(d) Proof of Residency. Prior to employment proof of residency will be obtained. by the agency Administrative Assistant / Office Manager and will monitor corrective action plan and review files quarterly and or as needed.
The Administrative Assistant / Office Manager will implement a checklist and practice of checking to ensure Pennsylvania residency prior to employment. To confirm that the plan of correction is effective and sustained personal files will be audited on quarterly basis by Administrative Assistant / Office Manager until 100% compliance is achieved.
To ensure that practice will not recur Beloved Home Care and Day Care Services and its Administrative Assistant/ Office Manager prior to hiring will document proof of Pennsylvania (PA) residency for two (2) consecutive years immediately preceding date of hire through submission of any one of the following documents: (1) Motor vehicle records, such as a valid driver's license or a State-issued identification; (2) Housing records, such as mortgage records or rent receipts; (3) Public utility records and receipts, such as electric bills; (4) Local tax records; (5) A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it; (6) Employment records, including records of unemployment compensation.

Addendum:
Regarding PF's # 1, 4, 5, and .7 Beloved Home Care and Day Care Services, Administrative Assistant / Office Manager requested proof of residency in Pennsylvania within 24 hours.



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 completed a baseline tuberculosis symptom screen questionnaire and/or an individual tuberculosis risk assessment upon hire for six (6) of seven (7) PF's: PF#1, PF#2, PF#3, PF#5, PF#6, and PF#7.

Findings include:

In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) 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; 2) Completion of a tuberculosis symptom questionnaire, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease (CDC Guidelines for Preventing 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 PF's was conducted on November 21, 2022 starting at approximately 10:00 AM. The date of hire (DOH) is indicated below.

PF#1 DOH 03/22/2022 did not contain evidence that a baseline tuberculosis (TB) symptom screen questionnaire or an individual TB risk assessment was completed upon hire.

PF#2 DOH 03/20/2021 did not contain evidence that a baseline tuberculosis (TB) symptom screen questionnaire was completed upon hire.

PF#3 DOH 03/25/2022 did not contain evidence that a baseline tuberculosis (TB) symptom screen questionnaire or an individual TB risk assessment was completed upon hire.

PF#5 DOH 01/19/2022 did not contain evidence that a baseline tuberculosis (TB) symptom screen questionnaire or an individual TB risk assessment was completed upon hire.

PF#6 DOH 11/11/2021 did not contain evidence that a baseline tuberculosis (TB) symptom screen questionnaire was completed upon hire.

PF#7 DOH 10/07/2022 did not contain evidence that a baseline tuberculosis (TB) symptom screen questionnaire was completed upon hire.

An interview conducted with the administrator on November 21, 2022 starting at 11:00 AM confirmed the above findings.




Plan of Correction:

In accordance with The Center for Disease Control (CDC) guidelines, Beloved Home Care and Day Care Services and its Administration will ensure, prior to assignment to clients, all Direct Care Workers and specifically DCW #1,2,3,4,5,6, and 7, are screened and free from active mycobacterium tuberculosis (TB), an infectious bacterial disease characterized by the growth of nodules(tubercles) in the tissues especially in the lungs.
Review and necessary updates of procedure section of the policy #5.50.10 to reflect CDC guidelines. Handouts explaining the CDC guidelines for two step tuberculin skin test and the CDC website was distributed to DCW #1,2,3,4,5,6 and 7.
The Agency will review all Direct Care Worker files prior to hire to ensure that the CDW received the TST in accordance with the CDC guidelines. Including, 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). All DCW are required by regulation to follow procedure and given the guidelines outlining the CDC Guidelines for preventing the transmission of Mycobacterium Tuberculosis in health care setting.
The Agency will ensure that all DCWs receive a baseline tuberculosis screening upon hire, using a two-step tuberculin skin test or a test with an interferon-gamma release assay. After baseline testing for the Infection with tuberculosis, DCW will receive a TB risk assessment screen annually if determined to be in a low-risk area, and those with a baseline positive test for tuberculosis infection will receive a chest x-ray to exclude tuberculosis disease.
The Agency Administrator will monitor corrective action plan by reviewing the files every 6 months and informing DCW when TST needs to be updated.

Addendum: PF# 1,2,3,4,5,6 and 7 have been given the CDC guidelines, website, Handout, TB symptom screen questionnaire and TB risk assessment. Along with Contact information to "Worknet Clinic" to receive TB test.




611.57(c) LICENSURE
Information to be Provided

Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.

Observations:

Based on review of consumer files (CF) and an interview with the administrator, the agency failed to provide the following information to the consumer, the consumer's legal representative, or a responsible family member prior to the start of services: the listing of available home care services that would be provided to the consumer, the identity of the direct care worker (DCW) who would be providing the services, the hours when the services would be provided, the telephone number of who to contact at the Department regarding the home care agency's compliance information and licensure requirements, and a disclosure addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency. Five (5) of five (5) consumer files did not meet the requirement: CF#1, CF#2, CF#3, CF#4, and CF#5.

Findings include:

A review of consumer files (CF) was conducted on November 21, 2022 starting at approximately 0920 AM. The Start of Care (SOC) is indicated below.

CF#1 SOC 07/10/2022 did not contain evidence that the consumer, the consumer's legal representation or a responsible family member, prior to the start of services, received the following information: the listing of available home care services that would be provided to the consumer, the identity of the direct care worker (DCW) who would be providing the services, the hours when the services would be provided, the address or telephone number of who to contact at the Department regarding the home care agency's compliance information and licensure requirements, and a disclosure addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency.

CF#2 SOC 06/08/2022 did not contain evidence that the consumer, the consumer's legal representation or a responsible family member, prior to the start of services, received the following information: the listing of available home care services that would be provided to the consumer, the identity of the direct care worker (DCW) who would be providing the services, the hours when the services would be provided, the address or telephone number of who to contact at the Department regarding the home care agency's compliance information and licensure requirements, and a disclosure addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency.

CF#3 SOC 04/08/2022 did not contain evidence that the consumer, the consumer's legal representation or a responsible family member, prior to the start of services, received the following information: the listing of available home care services that would be provided to the consumer, the identity of the direct care worker (DCW) who would be providing the services, the hours when the services would be provided, the address or telephone number of who to contact at the Department regarding the home care agency's compliance information and licensure requirements, and a disclosure addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency.

CF#4 SOC 01/26/2022 did not contain evidence that the consumer, the consumer's legal representation or a responsible family member, prior to the start of services, received the following information: the listing of available home care services that would be provided to the consumer, the identity of the direct care worker (DCW) who would be providing the services, the hours when the services would be provided, the address or telephone number of who to contact at the Department regarding the home care agency's compliance information and licensure requirements, and a disclosure addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency.

CF#5 SOC 10/01/2021 did not contain evidence that the consumer, the consumer's legal representation or a responsible family member, prior to the start of services, received the following information: the listing of available home care services that would be provided to the consumer, the identity of the direct care worker (DCW) who would be providing the services, the hours when the services would be provided, the address or telephone number of who to contact at the Department regarding the home care agency's compliance information and licensure requirements, and a disclosure addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency.

An interview conducted with the administrator on November 21, 2022 starting at 11:00 AM confirmed the above findings.




Plan of Correction:

611.57 (c) information to be provided- Tag 0820

Prior to the commencement of services Beloved Home Care and Day Care Services agency and its Administrative Assistant / Office Manager, will monitor corrective action plan and review files quarterly and or as needed and shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the Service Plan, contracts along with Mandates, Regulations and Guidelines. From this day forward the Administrative Assistant / Office Manager will monitor and maintain Consumer folder packets which will contain all paperwork required by the state of Pennsylvania. The Administrative Assistant / Office Manager will implement a checklist and practice to confirm that the plan of correction will be implemented and review all paperwork to ensure that all required signatures are applied, and each field completed. The Administrative Assistant / Office Manager will complete all documents at time of Consumer interview. Consumer documents will be monitored, reviewed, and updated quarterly and or when Service Plan and or insurance require immediate changes. Along with updates on working hour changes of DCW by the Administrative Assistant / Office Manager. From this day forward no Consumer will be enrolled without all necessary signatures and documents.
To confirm that the plan of correction is effective and sustained the Administrative Assistant / Office Manager, concerning consumer files will be audited on a quarterly basis until 100% compliance is achieved for two consecutive quarters. The plan of correction will be fully implemented by 01/20/2023.


Consumer rights: And be informed of the following. To be involved in the service planning process and to receive services with reasonable accommodations of individual needs and preferences, except where the health and safety of the direct care worker is at risk.

Information to be Provided:
Prior to the commencement of services, Beloved Home Care and Day Care Services and it's Administration shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. Department of Health Licensing (717-783-1379) (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program (1-800-254-5164) located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.
To receive at 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 the health and welfare of the direct care worker is at risk.
Addendum:
Beloved Home Care and Day Care Services and its Administration, regarding CF's# 1,2,3,4 and 5 have been revisited along with current CF's charts to ensure that the required information is state approved.





Initial Comments:

Based on the findings of an onsite State Re-Licensure Survey conducted on November 21, 2022, Beloved Home Care and Daycare Services was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: