QA Investigation Results

Pennsylvania Department of Health
BELIEVE HOME CARE, LLC
Health Inspection Results
BELIEVE HOME CARE, LLC
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced complaint and state re-licensure survey conducted on May 15, 2024 and completed off-site on May 20, 2024, Believe Home Care, 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 unannounced complaint and state re-licensure survey conducted on May 15, 2024 and completed off-site on May 20, 2024, Believe Home Care, 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 review of personnel files (PF) and an interview with agency administrator, the agency failed to retain documentation of two satisfactory references prior to hiring or rostering for five (5) of the seven (7) PF's reviewed. (PF#1, PF#4, PF#5, PF#6, PF#7)

Findings include:
Personnel file (PF) review conducted on May 15, 2024 from approximately 2pm to 3pm and on May 20, 2024 form approximately 8AM to 11am revealed the following:

PF #1, DOH 1/25//2024: Contained no documentation of two satisfactory, verified references prior to hiring or rostering date.

PF#4, DOH 9/2/2021: Contained no documentation of two satisfactory, verified references prior to hiring or rostering date.

PF #5, DOH 7/31/29/21/20233: Contained no documentation of two satisfactory, verified references prior to hiring or rostering date.

PF#6, DOH 5/2/2024: Contained no documentation of two satisfactory, verified references prior to hiring or rostering date.

PF#7, DOH 12/13/2023: Contained no documentation of two satisfactory, verified references prior to hiring or rostering date.


An interview with the administrator on May 20, 2024 at approximately 12:25 pm confirmed the above findings.






Plan of Correction:

Issue: Reference checks were not performed prior to rostering (to place an individual on a list of individuals eligible to be assigned by a home care agency to provide home care services).

Resolution: All individuals will NOT be rostered until 2 reference checks are completed. Specifically, individuals will remain ineligible to provide care home care services until at least 2 satisfactory references from a former employer or other person not related to the applicant that affirms the ability of the candidate to provide home care services.

All references will be verified by the agency either verbally or in writing. All documentation will become part of the applicant's file. A diligent effort will be made to obtain information to evaluate the applicant's skills, aptitude and work history. However, in some situations only information relating to dates of employment may be obtained and direct supervision information may not be available. In such instances, a reasonable effort will be made to obtain alternative reference sources such as personal references.

Administration will ensure that this policy is implemented immediately for all individuals hired in the future, AND will review all currently employed / rostered individuals to ensure reference checks are completed in a timely manner.




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 personnel files (PF) and an interview with agency administrator, the agency failed to provide documentation of a Pennsylvania State Police Criminal Background Check (PATCH) at the time of application or within 1 year immediately preceding the date of application for three (3) of the seven (7) PF's reviewed. (PF#1, PF#2 and PF#3)

Findings include:
Personnel file (PF) review conducted on May 15, 2024 from approximately 2pm to 3pm and on May 20, 2024 form approximately 8am to 11am revealed the following:

PF #1, DOH 1/25//2024: Contained no documentation of a Pennsylvania State Police Criminal Background Check (PATCH) at the time of application or within 1 year immediately preceding the date of application.

PF#2, DOH 1/11/2024: Contained no documentation of a Pennsylvania State Police Criminal Background Check (PATCH) at the time of application or within 1 year immediately preceding the date of application.

PF#3, DOH 12/9/2021: Contained no documentation of a Pennsylvania State Police Criminal Background Check (PATCH) at the time of application or within 1 year immediately preceding the date of application.

An interview with the administrator on May 20, 2024 at approximately 12:25 pm confirmed the above findings.






Plan of Correction:

Issue: No documentation of Pennsylvania State Police Criminal Background Check (PATCH) performed at time of application.

Resolution: Individuals will NOT be hired until prescribed criminal background checks are performed. Specifically, individuals will not be hired until background checks are run, received and reviewed. Specifically,

If the candidate has been a resident of Pennsylvania for two or more years, the following background checks will be run: PA state police criminal record, SSN trace, national criminal record.

If the candidate has not been a resident of Pennsylvania for at least two years, the following background checks will be run: PA state police criminal record, SSN trace, national criminal record, and Department of Aging FBI background check.
The applicant is only eligible for hire if ...

No state prohibited convictions are found; and if applicable,the Department of Aging letter of determination indicates eligibility; and additional background checks run by Believe show no prohibited offenses.

Administration will ensure that this policy is implemented immediately for all individuals prior to hire in the future, AND will review all currently employed / rostered individuals to ensure criminal background checks are performed.

NOTE: Provisional Hire Pending Outcome of Criminal Background Check

Believe Home Care (BHC) completes prescribed background checks on all potential new employees per Believe's Background Check Policy. Per these policies, absent unique circumstances, BHC will not hire, engage the services of, or retain an employee; whose State Criminal History, or National Criminal Record reveals a prohibited offense.

However, sometimes the results of these background checks can take several weeks or months to be returned to BHC. In these circumstances, BHC will provisionally hire the new employee pending the results of the background check, monitoring the provisional hire's performance until the results are returned and appropriate actions taken.



611.55(e) LICENSURE
Competency Requirements

Name - Component - 00
The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.

Observations:


Based on review of personnel files (PF), and an interview with the agency administrator, it was determined the agency failed to perform a competency review, which must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction for one (1) of seven (7) PF reviewed. (PF#3)


Findings include:

Personnel file (PF) review conducted on May 15, 2024 from approximately 2pm to 3pm and on May 20, 2024 form approximately 8am to 11am revealed the following:

PF #3 Date of hire (DOH) 12/9/2021: Contained no documentation for direct care worker's annual competency to perform assigned duties through direct observation, testing, training, consumer feedback or other method approved by the Department.


An interview with the administrator on May 20, 2024 at approximately 12:25 pm confirmed the above findings.













Plan of Correction:

Issue: No documentation of direct care worker's annual competency to perform assigned duties.

Resolution: Direct care workers will NOT be rostered until they demonstrate competency in at least the 10 companion care licensing requirements subject areas; and if the direct care worker will provide personal care services to clients, the six personal care licensing requirements subject areas; in accordance with Chapter 611 of the Health Care Facilities Act.

Additionally, every rostered direct care worker will also have to complete competency training and testing each year. During their annual competency evaluation each direct care worker will need to demonstrate continued proficiency in at least the 10 companion care competency subject areas; and if the direct worker will provide personal care services, the six personal care competency areas; in accordance with Chapter 611 of the Health Care Facilities Act.

Competency will be verified by the agency and all documentation will become part of the direct care worker's file. Otherwise, they will be removed from the active roster, and thus become ineligible to provide care home care services, until completion and documentation of competency training and testing can be (re)established.

The agency will use its online scheduling system to implement this requirement / process. This system allows administrators to set an employee's work status to "ineligible to provide home care services" until a specific prerequisite / requisite is met.

Administration will ensure that this policy is implemented immediately for all direct care workers prior to rostering in the future, AND will review all currently employed / rostered individuals to ensure competency is (re)established.



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 CDC guidelines, personnel files (PF) and an interview with the administrator, it was determined the facility failed to ensure direct care workers were screened for and were free from active mycobacterium tuberculoses prior to assignment with clients for seven (7) out of seven (7) PF's reviewed. (PF1-7)

Findings include:

The CDC guidelines state that all Health Care Workers (HCW) should received 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, 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 file (PF) review conducted on May 15, 2024 from approximately 2pm to 3pm and on May 20, 2024 form approximately 8AM to 11am revealed the following:

PF #1, DOH 1/25//2024: Contained no documentation of a baseline tuberculosis symptom screening upon hire. One (1) TST dated 5/7/2024. No documentation showing a second step was completed.

PF#2, DOH 1/11/2024: Contained no documentation of a baseline tuberculosis symptom screening upon hire. One (1) TST dated 1/11/2024 on file. No documentation showing a second step was completed.

PF#3, DOH 12/9/2021: Contained no documentation of a baseline tuberculosis symptom screening upon hire. No documentation that any TB testing was completed.

PF#4, DOH 9/2/2021: Contained no documentation of a baseline tuberculosis symptom screening upon hire. One (1) interferon-gamma release assay dated 9/13/2023.

PF #5, DOH 7/31/29/21/20233: Contained no documentation of a baseline tuberculosis symptom screening upon hire. One (1) TST dated 10/9/2023 on file. No documentation showing a second step was completed.

PF#6, DOH 5/2/2024: Contained no documentation of a baseline tuberculosis symptom screening upon hire.

PF#7, DOH 12/13/2023: Contained no documentation of a baseline tuberculosis symptom screening upon hire. No documentation that any TB testing was completed.


An interview with the administrator on May 20, 2024 at approximately 12:25 pm confirmed the above findings.





Plan of Correction:

Issue: Upon hire documentation of initial tuberculosis risk & symptom screening results and/or proof of negative test results were not found. Additionally, annual tuberculosis symptom screening results were not found.

Resolution: Upon hire direct care workers will complete a baseline TB risk & symptom screener. If the screener(s) show risk of active TB, the individual will not be hired until they can provide evidence that they are free from active mycobacterium tuberculosis via a TB test result (negative 2-step TB skin test, negative interferon blood assay test, negative chest x-ray).

Additionally, all individuals will not be rostered (remain ineligible to provide care home care services) until they can provide evidence that they are free from active mycobacterium tuberculosis via a TB test result (negative 2-step TB skin test, negative interferon blood assay test, negative chest x-ray).

Every rostered direct care worker will also have to complete an annual TB risk & symptom screener. Otherwise, they will be removed from the active roster, and thus become ineligible to provide care home care services, until they provide documentation that they are free from risk or active mycobacterium tuberculosis.

The agency has contracted with a vendor to allow individuals to quickly get interferon blood assay tests which will be paid for by the agency. Additionally, the agency will use its online scheduling system to implement this requirement / process. This system allows administrators to set an employee's work status to "ineligible to provide home care services" until a specific prerequisite / requisite is met.

TB risk & symptom screeners, as well as, the initial TB testing requirements will be executed and verified by the agency's administration. And all documentation will become part of the direct care worker's file.

Administration will ensure that these policies are implemented immediately for all direct care workers prior to hiring and rostering. AND will review all currently employed / rostered individuals to ensure initial and annual TB screening and testing are completed and documented.



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 the consumer files (CF) and an interview with the administrator, the home care agency failed to provide the consumer the identity of the direct care worker who will provide the services, prior to the commencement of services for six (6) of six (6) consumers files reviewed. (CF#1-6)


Findings include:
Review of consumer files conducted on May 15, 2024 between approximately 12pm to 2pm revealed.

CF#1, Start of care (SOC) 1/30/2024: Contained no documentation the agency provided the identity of the direct care worker to the consumer, prior to the commencement of services.

CF#2, SOC 12/26/2023: Contained no documentation the agency provided the identity of the direct care worker to the consumer, prior to the commencement of services.

CF#3, SOC 7/5/2023: Contained no documentation the agency provided the identity of the direct care worker to the consumer, prior to the commencement of services.


CF#4, SOC 2/14/2022: Contained no documentation the agency provided the identity of the direct care worker to the consumer, prior to the commencement of services.

CF#5, SOC 7/5/2023: Contained no documentation the agency provided the identity of the direct care worker to the consumer, prior to the commencement of services.

CF#6, SOC 8/25/2023: Contained no documentation the agency provided the identity of the direct care worker to the consumer, prior to the commencement of services.

An interview with the administrator on May 20, 2024 at approximately 12:25 pm confirmed the above findings.









Plan of Correction:

Issue: Consumer's file did NOT contain documentation that the agency provided the identity of the direct care worker(s) assigned to the consumer prior to the start of care.

Resolution: This agency uses an online scheduling system to document and maintain the consumer's schedule. Access to this system is provided to the consumer. Specifically, this system details their most up-to-date weekly schedule including the list of services to be provided, the times those services will be provided; as well as, the name and picture of the direct care worker(s) assigned to each shift. Therefore, this system allows the consumer to see the shifts (times) scheduled, and the identity of the direct care worker who will be providing their care prior to the service start date, and at any time thereafter.

We (the agency) will enhance this process / online system by emailing AND calling / texting every consumer prior to the start of care. Specifically, we will send the customer's entire "initial" schedule which will contain hours of services and the identity of the direct care worker(s) assigned. We will request confirmation of receipt of this initial schedule, and include a copy in each customer's file. Additionally, on an ongoing basis, it is the agency's policy to contact the consumer every time there is a change to the consumer's weekly schedule.

Additionally, specific instructions on how to access this system are outlined in the 'How to contact Believe / Access Believe Online' document that is left behind during each initial consumer meeting prior to the start of care. That said, if the consumer does not want or cannot access this online scheduling system, a printed copy of the consumer's weekly schedule complete with hours of services and the identity of the direct care worker assigned is emailed, texted, and/or mailed to the consumer's home.

The fact that this agency uses this online system described above and that the consumer can assess it is outlined, shared and acknowledged to the consumer via the agency's 'Policies & Procedures' document: Section #4 - Online Care Plan & Health Record; and via the agency's 'Client Bill of Rights' document: Section #4 - "Receive an explanation for and provided access to who (direct care workers name) will be providing the services and hours those services will be delivered."

Administration will ensure that this process / policy update is implemented immediately as outlined.