Initial Comments:
Based on the findings of an unannounced on-site state re-licensure survey conducted on July 16, 2024, Breathe Easy Independent Living Services, 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 July 16, 2024, Breathe Easy Independent Living Services, 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 review of personnel files (PF) and employee (EMP) interview, the agency failed to conduct a face-to-face interview for three (3) of five (5) PF reviewed (PF1-3). The agency also failed to obtain two satisfactory references prior to hiring a direct care worker for three (3) of five (5) PF reviewed (PF1-3).
Findings included:
Review of agency policy on July 16, 2024, at approximately 11:15am revealed:
"Breathe Easy Hiring Policy/Pre-Employment Check List
...each applicant must complete seven prerequisites and be clear of them all before they can become an employee of Breathe Easy...The Seven Prerequisites consist of: ...2. A face-to-face interview with management 3. Obtain at least two satisfactory references...
Prerequisite (3) two satisfactory references is a positive verifiable reference, either verbal or written, from a former employer or other persons not related to the applicant that affirms the ability of the applicant to provide home care services..."
Review of PFs conducted on July 16, 2024, at approximately 11:00am revealed:
PF#1, date of hire (DOH) 9/21/22, start of services (SOS) 10/1/22, PF failed to include evidence of face-to-face interview and failed to include evidence of 2 satisfactory references.
PF#2, DOH 5/12/21, SOS 5/29/21, PF failed to include evidence of face-to-face interview and failed to include evidence of 2 satisfactory references.
PF#3, DOH 3/23/21, SOS 10/18/22, PF failed to include evidence of face-to-face interview and failed to include evidence of 2 satisfactory references.
Findings confirmed at exit interview with owner and executive assistant on July 16, 2024, at approximately 3:00pm.
Repeat deficiency, previously cited: 8/6/21.
Plan of Correction:Every applicant that comes to Breathe Easy has a face to face interview!!
To show evidence of the interviews and to show evidence that we spoke with the references we will now keep our interview questioner for each applicant that is hired and on the botton page of the questionair we will have the responces we received from the refrences.
Whom ever does the interview will sign and date when the questionaire and they will sign and date when the refrences were contacted because this is usually done on a different date.
The executive assistant does all of the interviewing so the owner will check all new hire applications and full files monthly this way I can guarantee that there will be no more infractions. On top of that I will keep dates for when the files were monitored.
611.52(b) LICENSURE
State Police Criminal History Record
Name - Component - 00
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 agency policy, personnel files (PF), and employee (EMP) interview the agency failed to obtain a Pennsylvania State Police criminal history record (PATCH) at the time of application or within 1 year immediately preceding the date of application for two (2) of five (5) PF reviewed (PF2 & 3.)
Findings included:
Review of agency policy on July 16, 2024, at approximately 11:15am revealed:
"BREATHE EASY Background Check Policy
BREAHTE EASY is committed to protecting the safety, health, and wellbeing of all employees and other individuals in the workplace. Any individual who conducts business for our company must undergo a Child Abuse Clearance, Criminal Background check, and FBI clearance.
All background checks are conducted pre-employment...
Every applicant must submit or have applied for a criminal history reports and Child Line verification at the time of application. If there are no residents in the consumers home under 18, the background check needed for the employee can be either the PA STATE POLICE CHECK (if the employee can show Pennsylvania residency of 2 years or more preceding the application) or the FBI FINGERPRINT-Federal CHECK for those who cannot prove Pennsylvania residency for the 2 years preceding the application..."
Breathe Easy Hiring Policy/Pre-Employment Check List
...each applicant must complete seven prerequisites and be clear of them all before they can become an employee of Breathe Easy...The Seven Prerequisites consists of: ...4. Background check & Child Abuse clearance..."
Review of PFs conducted on July 16, 2024, at approximately 11:00am revealed:
PF#2, date of hire (DOH) 5/12/21, start of services (SOS) 5/29/21, PF included Pennsylvania State Police criminal history record (PATCH) dated 8/10/21. 91 days after hire.
PF#3, DOH 3/23/21, SOS 10/18/22, PF included Pennsylvania State Police criminal history record (PATCH) dated 3/30/20. 7 days after hire.
Findings confirmed at exit interview with owner and executive assistant on July 16, 2024, at approximately 3:00pm.
Plan of Correction:All background checks will continue to be done prior to hiring. To make sure no ones paperwork is misplaced and to protect our employees we will scann all paperwork in the computer and keep a paper file. Applicants whom bring in background checks, we will create a file to save their information on the computer until we recieve all of their prerequisties so this way we will not have to worry about anything being misplaced.
If an applicant does not submit a background check within a week of handing in their application and being interview, even if they say they have a current background check, if it is not produced in our office within a week we will just run a new background check.
The executive assistant is in charge of applications and employee files so the owner will check all new hire files monthly to make sure nothing is missing and everything is within the computer system and in the employees paper files.
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 review of agency policy, 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 two (2) PF reviewed who did not have evidence of residence of the Commonwealth within the preceding two years of hire (PF1&2).
Findings included:
Review of agency policy on July 16, 2024, at approximately 11:15am revealed:
"BREATHE EASY Background Check Policy
BREAHTE EASY is committed to protecting the safety, health, and wellbeing of all employees and other individuals in the workplace. Any individual who conducts business for our company must undergo a Child Abuse Clearance, Criminal Background check, and FBI clearance.
All background checks are conducted pre-employment...
Every applicant must submit or have applied for a criminal history reports and Child Line verification at the time of application. If there are no residents in the consumers home under 18, the background check needed for the employee can be either the PA STATE POLICE CHECK (if the employee can show Pennsylvania residency of 2 years or more preceding the application) or the FBI FINGERPRINT-Federal CHECK for those who cannot prove Pennsylvania residency for the 2 years preceding the application..."
Review of PFs conducted on July 16, 2024, at approximately 11:00am revealed:
PF#1, date of hire (DOH) 9/21/22, start of services (SOS) 10/1/22, PF, void of proof of residency, failed to include Federal criminal history reports and letter of determination from the Department of Aging.
PF#2, DOH 5/12/21, SOS 5/29/21, PF, void of proof of residency, failed to include Federal criminal history reports and letter of determination from the Department of Aging.
Findings confirmed at exit interview with owner and executive assistant on July 16, 2024, at approximately 3:00pm.
Plan of Correction:If an employees id is new we require a copy of their lease or tax statements. To ensure that employees will not be missing any paperwork we are scanning all employee files and checking to make sure what is in their computer file is also in their paper file.
Because the executive assistant handles the employee files the owner will go over ALL the files and make sure that they mirrior each other so our paper files wont be missing any information that is within the computer.
The owner will also leave a note in each paper file stating when it was reviewed.
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 agency policy, personnel files (PF), and employee (EMP) interview the agency failed to ensure personal files contained two years proof of residency for two (2) of five (5) PF reviewed (PF1 & 2).
Findings included:
Review of agency policy on July 16, 2024, at approximately 11:15am revealed:
Breathe Easy Hiring Policy/Pre-Employment Check List
...each applicant must complete seven prerequisites and be clear of them all before they can become an employee of Breathe Easy...The Seven Prerequisites consists of: ...The Applicant must also provide proof of residency through submission of any of the following documents: Valid Driver's License or State Identification cars, Housing records, such as mortgage records or receipt, Public utility record and receipt, such as electric bills, Local tax records, Federal, State, or Local tax return with applicants name and address preprinted on it..."
Review of PFs conducted on July 16, 2024, at approximately 11:00am revealed:
PF#1, date of hire (DOH) 9/21/22, start of services (SOS) 10/1/22, PF failed to include proof of residency of the Commonwealth of Pennsylvania (PA) for 2 years preceding hire. PA driver ' s license issued 1/11/21.
PF#2, DOH 5/12/21, SOS 5/29/21, PF failed to include proof of residency of the Commonwealth of Pennsylvania (PA) for 2 years preceding hire. PA driver ' s license issued 2/12/20.
Findings confirmed at exit interview with owner and executive assistant on July 16, 2024, at approximately 3:00pm.
Repeat deficiency, previously cited: 8/6/21.
Plan of Correction:(0320) We require all employees whom have not live in PA in the past two years to obtain a FBI background check.( sorry couldnt go back and add to last question)
#0330
If an employees id is new and doesnt show two years of residency we require a copy of their lease or tax statements. To ensure that employees will not be missing any paperwork we are scanning all employee files and checking to make sure what is in their computer file is also in their paper file.
Because the executive assistant handles the employee files the owner will go over ALL the files and make sure that they mirrior each other so our paper files wont be missing any information that is within the computer.
The owner will also leave a note in each paper file stating when it was reviewed.
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 agency policy, personnel files (PF), and employee (EMP) interview the agency failed to ensure competency review occurred at least once per year after initial competency established for five (5) of five (5) PF reviewed that had greater than 12 months employment. (PF1-5).
Findings included:
Review of agency policy on July 16, 2024, at approximately 11:15am revealed:
"... Annual Competency and Performance Evaluation Policy...Policy:
Every direct care worker must have an annual competency and performance evaluation in at least ten homecare agency/registry licensing requirements competency subject areas and the additional six personal care competency areas..."
Review of PFs conducted on July 16, 2024, at approximately 11:00am revealed:
PF#1, date of hire (DOH) 9/21/22, start of services (SOS) 10/1/22, PF failed to include evidence of annual competency for 2023.
PF#2, DOH 5/12/21, SOS 5/29/21, PF failed to include evidence of annual competency for 2023, 2023, and 2024.
PF#3, DOH 3/23/21, SOS 10/18/22, PF failed to include evidence of annual competency for 2023.
PF#4, DOH 9/2/17, SOS 10/29/18, PF failed to include evidence of annual competency for 2023 and 2023.
PF#5, DOH 10/10/20, SOS 11/14/20, PF failed to include evidence of annual competency for 2022 and 2023.
Findings confirmed at exit interview with owner and executive assistant on July 16, 2024, at approximately 3:00pm.
Repeat deficiency, previously cited: 8/6/21.
Plan of Correction:We have an annual trining that every empoyee goes through annually to review compentancy, First aide, Covid and TB education to which they sign off on upon attendace. To statsfiy the surveyor we will now have every aide complete another compentancy test on the day of their annual training.
To make sure this is clear to the surveyor we will put their current competancy test in their files upon completion.
The owner will make sure after every training that compentacy test are done and dated and filed.
611.56(b) LICENSURE
Health Screening
Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.
Observations:
Based on review of personnel files (PF), the Centers for Disease Control guidelines, and employee (EMP) interview the agency failed to ensure each direct care worker with direct consumer contact, were provided with annual mycobacterium tuberculosis education for four (4) of five (5) PFs reviewed having at least one year of employment (PF 1, 2, 4, &5).
Findings included:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: "...1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray 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, HCWs should receive TB education 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;(5-16-19) ..."
Review of PFs conducted on July 16, 2024, at approximately 11:00am revealed:
PF#1, date of hire (DOH) 9/21/22, start of services (SOS) 10/1/22, PF failed to contain evidence of annual TB education for 2023.
PF#2, DOH 5/12/21, SOS 5/29/21, PF failed to contain evidence of annual TB education for 2022, 2023, and 2024.
PF#4, DOH 9/2/17, SOS 10/29/18, PF failed to contain evidence of annual TB education for 2022.
PF#5, DOH 10/10/20, SOS 11/14/20, PF failed to contain evidence of annual TB education for 2023.
Findings confirmed at exit interview with owner and executive assistant on July 16, 2024, at approximately 3:00pm.
Repeat deficiency, previously cited: 8/6/21.
Plan of Correction:We added the TB education to our annual training because thats what we were told to do in 2021.
Because the signing off of the annaull training is not good enough now we will add the tb education to the compentancy test as proof of TB education and each aide will take an annual compentancy test after their annual training.
The executive assistant will go over each compentancy test to make sure each aide has passed.
This will also be and add on to our pop up visits that are done annually to ensure aides compentancy and our client surveys.
The owner will check files after annuall training to ensure every attendee completed a compentancy test, and that they are signed and dated.
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 employee (EMP) interview the agency, prior to commencement of services, failed to provide 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 for four (4) of four (4) CF reviewed (CF1-4).
Findings included:
Review of CFs conducted on July 16, 2024, at approximately 12:30pm revealed:
CF#1, start of services (SOS) 4/2/24, CF failed to include evidence that the consumer was provided with the identity of the direct care worker who would be providing services 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, SOS 6/29/23, CF failed to include evidence that the consumer was provided with the identity of the direct care worker who would be providing services 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, SOS 5/15/23, CF failed to include evidence that the consumer was provided with the identity of the direct care worker who would be providing services 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, SOS 7/13/23, CF failed to include evidence that the consumer was provided with the identity of the direct care worker who would be providing services 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.
Findings confirmed at exit interview with owner and executive assistant on July 16, 2024, at approximately 3:00pm.
Repeat deficiency, previously cited: 8/6/21.
Plan of Correction:Our consumers are not provided with the identity of the direct care worker until after a meet and greet has been done and the consumer chooses thier aide.We do not just take it upon ourselves to throw aides in peoples homes.
To rectifiy the infraction the owner will go back and update consumer files and sign off on consumer files after their aide has been chosen. She will also update the consumer packet and make it state that the aide will be choosen by the client after a meet and greet has been done between the client and their prospective aide or aides. Our consumer service agreement addresses and informs consumers that their direct care worker is an employee of Breate EAsy and that we pay employee taxes and carry insuracne on every aide.
To satisfy the infraction we have mimicked the state consumer notice of direct care worker status and have had every client sign upon receiving it.
After each case has been opened and the aide has been choosen the owner will check the consumers file. The excutive assistant will check all consumer files after owner has compelted the opening of the case and input them in the system to make sure all paper work is completed and correct.
The Owner will check all consumer fies quarterly just to double check that everything is in order.
Initial Comments:
Based on the findings of an unannounced on-site state re-licensure survey conducted on July 16, 2024, Breathe Easy Independent Living Services, LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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