Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on October 7, 2024, Beloved Homecare Agency, 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 onsite home care agency state re-licensure survey conducted on October 7, 2024, Beloved Homecare Agency, Llc., was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.
Plan of Correction:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of § 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of § 611.53 (relating to child abuse clearance).
Observations:
Based on a review of personnel files (PF's) and an interview with the administrator, the agency failed to provide documentation of conducting a face to face interview for five (5) of five (5) PF's, (PF # 1, 2, 3, 4 and 5). The agency failed to provide documentation of obtaining two satisfactory and verifiable references for five (5) of the five (5) PF's, (PF # 1, 2, 3, 4 and 5).
Findings include:
A review of PF's was conducted on October 7, 2024 at approximately 10:15 a.m.
PF #1 Date of Hire: 3/11/2024, did not contain any documentation of a completed face to face interview. Also did not contain documentation of obtaining two satisfactory and verifiable references
PF #2 Date of Hire: 8/2/2024, did not contain any documentation of a completed face to face interview. Also did not contain documentation of obtaining two satisfactory and verifiable references
PF #3 Date of Hire: 1/24/2023, did not contain any documentation of a completed face to face interview. Also did not contain documentation of obtaining two satisfactory and verifiable references.
PF #4 Date of Hire: 3/12/2024, did not contain any documentation of a completed face to face interview. Also did not contain documentation of obtaining two satisfactory and verifiable references
PF#5 Date of Hire: 6/24/2022, did not contain any documentation of a completed face to face interview. Also did not contain any documentation of two completed satisfactory and verifiable references.
An interview with the administrator on October 7, 2024 at approximately 11:10 am confirmed the above findings.
Plan of Correction:Beloved Homecare's hiring manager will update our hiring application to ensure that our face-to-face form and two reference checks forms are updated and added to our 2024 application. Our Hiring manager will monitor our Direct Care Workers' files every 180 days to prevent the absence of Face-to-face and reference checks. Our hiring manager will also inform each Direct Care worker who's missing a reference check and have that form completed and filed. We will also update our employee pre-hire checklist to help keep us updated on each caregiver file and their employment process.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
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 a review of personnel files (PF), recommendations from the Centers for Disease Control (CDC), an interview with the administrator the agency failed to provide documentation of an initial tuberculosis screening for two (2) of five (5) PF's, (PF # 1 and 3 ). Also agency did not contain documentation that the individual had completed symptom screen questionnaire and an individual TB risk assessment for five (5) of five (5) PF's, (PF # 1, 2, 3, 4 and 5). The agency did not contain documentation that the individual had completed annual TB education for two (2) of five (5) PF's, (PF # 3 and 5).
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).
Findings include:
A review of PF's was conducted on October 7, 2024 at approximately 9:50 a.m.
PF # 1 Date of Hire: 3/11/2024 did not 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. Also did not contain documentation of completion of a tuberculosis (TB) symptom screen questionnaire nor a TB risk assessment upon hire.
PF # 2, Date of Hire: 8/2/2024, did not contain documentation of completion of a tuberculosis (TB) symptom screen questionnaire nor a TB risk assessment upon hire.
PF # 3 Date of Hire: 1/24/2023, did not contain documentation using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. Did not contain documentation of completion of a tuberculosis (TB) symptom screen questionnaire nor a TB risk assessment upon hire. Also did not contain any documentation of a completed annual TB education for 2024.
PF # 4 Date of Hire: 3/12/2024, did not contain documentation of completion of a tuberculosis (TB) symptom screen questionnaire nor a TB risk assessment upon hire.
PF # 5 Date of Hire: 6/24/2022, did not contain documentation of completion of a tuberculosis (TB) symptom screen questionnaire nor a TB risk assessment upon hire. Also did not contain any documentation of a completed annual TB education for 2023 and 2024.
An interview conducted with the administrator on October 7, 2024 starting at 11:42 a.m. confirmed the above findings.
Plan of Correction:Beloved Home Care administrator manager has notified each newly hired direct care worker that they must complete a two-step Ppd and a TB questionnaire upon hiring. Our administrator team will also reinform current employees. They are still required to have a one-step ppd done annually and a TB questionnaire. Our administrator team will also conduct audits and monitor each caregiver file every 90 days to ensure that a TB screening is done and updated. Direct Caregivers will also be notified annually prior before their ppd expires.
Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on October 7, 2024, Beloved Homecare Agency, Llc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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