Initial Comments:
Based on the findings of an unannounced, on-site, state re-licensure survey conducted on June 12, 2024, Better In 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 unannounced, on-site, state re-licensure survey conducted on June 12, 2024, Better In 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
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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 review of personnel files (PF) and employee (EMP) interview the agency failed to obtain two satisfactory references prior to hiring a direct care worker for five (5) of five (5) PF reviewed (PF#1-5).
Findings included:
Review of PFs conducted on June 12, 2024, between approximately 1:00pm and 2:00pm revealed:
PF#1, date of hire (DOH) and start of services (SOS) 7/27/2022, failed to include evidence of two satisfactory references.
PF#2, DOH/SOS 11/21/23, failed to include evidence of two satisfactory references.
PF#3, DOH/SOS 1/10/24, failed to include evidence of two satisfactory references.
PF#4, DOH/SOS 4/16/24, failed to include evidence of two satisfactory references.
PF#5, DOH/SOS 8/1/23, failed to include evidence of two satisfactory references.
Findings confirmed at exit interview with owner on June 12, 2024, at approximately 3:00pm.
Repeat deficiency, previously cited: 8/7/2020.
Plan of Correction:Better In Home Care has a face to face Interview checklist that requires physical appearance confirmation.Along with the required 2 non related references. That are contacted and completed before end of interview process. This procedure has also been added to the monthly in house audit checklist to ensure it is followed and to prevent any further issues with meeting requirements for 611.51.Because the document and policy were already in place. A retaining was conducted on 6/17/24 with all office staff to ensure policy and procedure is followed
611.52(b) LICENSURE
State Police Criminal History Record
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If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.
Observations:
Based on review of personnel files (PF) and employee (EMP) interview the agency failed to request a State Police criminal history report upon hire for two (2) of five (5) PF reviewed that provided evidence of residency of this states Commonwealth for 2 years preceding hire (P#1 & #2).
Findings included:
Review of PFs conducted on June 12, 2024, between approximately 1:00pm and 2:00pm revealed:
PF#1, date of hire (DOH) and start of services (SOS) 7/27/2022, PF failed to contain evidence of State Police criminal history report.
PF#2, DOH/SOS 11/21/23, PF contained State Police criminal history report dated 9/28/22, greater than one year preceding hire.
Findings confirmed at exit interview with owner on June 12, 2024, at approximately 3:00pm.
Plan of Correction:Better in Home Care will be performing Backgrounds state or federal which ever one applies on all New Hires and rehires regardless of the date of rehire even if the returning employee was gone for 6months. We will also add this to our internal Monthly audit to ensure the procedure is followed without error to prevent any further issues with meeting the requirements of 611.52 Are
A Training was conducted on 6/17/24 for all offices staff reviewing procedure to ensure it's compliance
611.52(c) LICENSURE
Federal Criminal History Record
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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 review of personnel files (PF) and employee (EMP) interview the agency failed to obtain a federal criminal history report and a letter of determination from the Department of Aging for two (2) of five (5) PFs reviewed who did not have evidence of residence of the Commonwealth within the preceding two years of hire. (PF#1 & #4)
Findings included:
Review of PFs conducted on June 12, 2024, between approximately 1:00pm and 2:00pm revealed:
PF#1, date of hire (DOH) and start of services (SOS) 7/27/2022, PF not containing evidence of residency in the state of Pennsylvania for the 2 years immediately preceding hire, failed to contain evidence of a federal criminal history report and a letter of determination from the Department of Aging obtained upon application or within 12 months preceding hire.
PF#4, DOH/SOS 4/16/24, PF not containing evidence of residency in the state of Pennsylvania for the 2 years immediately preceding hire, failed to contain evidence of a federal criminal history report and a letter of determination from the Department of Aging obtained upon application or within 12 months preceding hire.
Findings confirmed at exit interview with owner on June 12, 2024, at approximately 3:00pm.
Plan of Correction:Better In Home Care has implemented a process where we are requiring all applying individuals to arrive at interview with a check list provided before interview date listing everything need to even apply ie , DL, ID, SS, proof of residency. In cases where Proof of residency is not provided we will then run the required federal criminal History report and follow the requirements for 6PA code 15.144(b) as it relates. We will also in clude the process in our monthly internal audits to insure complaiance and avoid any other infractions with the requirements. Because the process policy and procedure already existed.A Training was conducted on 6/17/24 for all offices staff reviewing procedure to ensure it's compliance
611.56(a) LICENSURE
Health Screening
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The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.
Observations:
Based on review of Personnel Files (PF), Centers for Disease Control (CDC) Guidelines, and employee (EMP) interview, the agency failed to ensure that baseline tuberculosis (TB)screening was conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings (TB) for five (5) of five (5) PF reviewed (PF#1-#5).
Findings included:
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...HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease....A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST within the previous 12 months, a single TST can be administered in the new setting. 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).
Review of PFs conducted on June 12, 2024, between approximately 1:00pm and 2:00pm revealed:
PF#1, date of hire (DOH) and start of services (SOS) 7/27/2022, PF failed to include documentation of a second step baseline tuberculosis screening upon hire completed in accordance with CDC guidelines.
PF#2, DOH/SOS 11/21/23, PF failed to include documentation of a second step baseline tuberculosis screening upon hire completed in accordance with CDC guidelines.
PF#3, DOH/SOS 1/10/24, PF failed to include documentation of a second step baseline tuberculosis screening upon hire completed in accordance with CDC guidelines.
PF#4, DOH/SOS 4/16/24, PF failed to include documentation of a second step baseline tuberculosis screening upon hire completed in accordance with CDC guidelines.
PF#5, DOH/SOS 8/1/23,PF failed to include documentation of a second step baseline tuberculosis screening upon hire completed in accordance with CDC guidelines.
Findings confirmed at exit interview with owner on June 12, 2024, at approximately 3:00pm.
Plan of Correction:Better In Home Care requires the 2 step TB test to ensure compliance with the 2 step CDC process. Each caregiver is required to have 2 step test Upon hire. This will ensure compliance with CDC guidelines and 611.56. An additional TB questionnaire will be giving annaully. This process has also been added to the internal Monthly check list to ensure compliance Because the process policy and procedure already existed.A Training was conducted on 6/17/24 for all offices staff reviewing procedure to ensure it's compliance
Initial Comments:
Based on the findings of an unannounced, on-site, state re-licensure survey conducted on June 12, 2024, Better In 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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