Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on September 16, 2024, Brighter Days 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 onsite unannounced state re-licensure survey conducted on September 16, 2024, Brighter Days Homecare Llc, was found to not 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(b) LICENSURE
Direct Care Worker Files
Name - Component - 00
Files for direct care workers employed or rostered shall include documentation of the date of the face-to-face interview with the individual and of references obtained. Direct Care Worker files also shall include other information as required by § 611.52, § 611.53, if applicable, § 611.54, § 611.55 and § 611.56 (relating to criminal background checks, child abuse clearance, provisional hiring, competency requirements; and health evaluations).
Observations:
Based on review of personnel files (PF) and an interview with agency administrator, the agency failed to obtain two (2) satisfactory references prior to hiring or rostering for seven (7) of the seven (7) PF's reviewed. (PF#1-7)
Findings include:
A personnel file review conducted September 16, 2024 from approximately 1:00 pm to 3:00 pm revealed the following:
PF#1 Date of hire (DOH) 6/1/23: Did not contain documentation of two (2) satisfactory references prior to the hire date.
PF#2 DOH 4/16/22: Did not contain documentation of two (2) satisfactory references prior to the hire date.
PF#3 DOH 9/20/22: Did not contain documentation of two (2) satisfactory references prior to the hire date.
PF#4 DOH 4/10/23: Did not contain documentation of two (2) satisfactory references prior to the hire date.
PF#5 DOH 1/2/24: Did not contain documentation of two (2) satisfactory references prior to the hire date.
PF#6 DOH 4/10/23: Did not contain documentation of two (2) satisfactory references prior to the hire date.
PF#7 DOH 3/19/24: Did not contain documentation of two (2) satisfactory references prior to the hire date.
An interview conducted with the administrator on September 16, 2024 at approximately 3pm confirmed the above findings.
Plan of Correction:Moving forward agency will provide a reference sheet to each direct care worker with the following information:
Reference #1: Date and time called prior to the hiring date and feedback from previous employer.
Reference #2 : Date and time called prior to the hiring date and feedback from previous employer.
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 agency personnel files (PFs) an interview with the administrator, the agency failed to obtain a federal criminal history report for five (5) out of seven (7) PFs reviewed that could not establish residency of this commonwealth for two years immediately preceding the date of hire (DOH) (PF#1, PF#3, PF#4, PF#6 and PF#7 )
Findings include:
A personnel file review conducted September 16, 2024 from approximately 1:00 pm to 3:00 pm revealed the following:
PF#1 Date of hire (DOH) 6/1/23: Contained a Pennsylvania driver's license issued on 2/11/22, which fails to ascertain PA residence of two (2) or more years, no other documentation on file to establish proof of residency. Additionally, there was no documentation to show that a federal criminal record check was completed.
PF#3 DOH 9/20/22: Contained a Pennsylvania driver's license issued on 1/21/21, which fails to ascertain PA residence of two (2) or more years, no other documentation on file to establish proof of residency. Additionally, there was no documentation to show that a federal criminal record check was completed.
PF#4 DOH 4/10/23: Contained a Pennsylvania driver's license issued on 10/3/23, which fails to ascertain PA residence of two (2) or more years, no other documentation on file to establish proof of residency. Additionally, there was no documentation to show that a federal criminal record check was completed.
PF#6 DOH 4/10/23: Contained a Pennsylvania driver's license issued on 8/6/22, which fails to ascertain PA residence of two (2) or more years, no other documentation on file to establish proof of residency. Additionally, there was no documentation to show that a federal criminal record check was completed
PF#7 DOH 3/19/24: NJ state license on file. There was documentation to show that a federal criminal record check was completed for this DCW who is not a resident of The Commonwealth of Pennsylvania.
An interview conducted with the administrator on September 16, 2024 at approximately 3pm confirmed the above findings.
Plan of Correction:Moving forward agency will ask direct care worker to provide 2 years proof of residency in the state of PA such as a utility bill, expired id, or previous W2. If direct care worker is not able to provide proof of residency agency will run an FBI background check on each direct care worker.
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 a review of personnel files (PF) and an interview with the administrator, the agency did not provide documentation of proof of residency in order to obtain a criminal history record through submission of any 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 for four (4) of seven (7) PFs reviewed. ( PF#1, PF#3, PF#4, and PF#6)
Findings include:
A personnel file review conducted September 16, 2024 from approximately 1:00 pm to 3:00 pm revealed the following:
PF#1 Date of hire (DOH) 6/1/23: Contained a Pennsylvania driver's license issued on 2/11/22, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency.
PF#3 DOH 9/20/22: Contained a Pennsylvania driver's license issued on 1/21/21, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency.
PF#4 DOH 4/10/23: Contained a Pennsylvania driver's license issued on 10/3/23, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency.
PF#6 DOH 4/10/23: Contained a Pennsylvania driver's license issued on 8/6/22, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency.
An interview conducted with the administrator on September 16, 2024 at approximately 3pm confirmed the above findings.
Plan of Correction:Moving forward agency will ask direct care worker to provide 2 years proof of residency in the state of PA such as a utility bill, expired id, or previous W2. If direct care worker is not able to provide proof of residency agency will run an FBI background check on each direct care worker.
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), and an interview with the administrator, the recommendations from the Centers for Disease Control (CDC), the agency did not provide documentation that the individual has completed a tuberculosis risk assessment upon hire for six (6) of seven (7) PF reviewed. (PF#1, PF#2, PF#3, PF#4, PF#6 and PF#7)
Findings include:
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. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs 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 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 personnel file review conducted September 16, 2024 from approximately 1:00 pm to 3:00 pm revealed the following:
PF#1 Date of hire (DOH) 6/1/23: Did not contain documentation of a completed tuberculosis risk and screen assessment upon hire.
PF#2 DOH 4/16/22: Did not contain documentation of a completed tuberculosis risk and screen assessment upon hire.
PF#3 DOH 9/20/22: Did not contain documentation of a completed tuberculosis risk and screen assessment upon hire.
PF#4 DOH 4/10/23: Did not contain documentation of a completed tuberculosis risk and screen assessment upon hire.
PF#6 DOH 4/10/23: Did not contain documentation of a completed tuberculosis risk and screen assessment upon hire.
PF#7 DOH 3/19/24: Did not contain documentation of a completed tuberculosis risk and screen assessment upon hire.
An interview conducted with the administrator on September 16, 2024 at approximately 3pm confirmed the above findings.
Plan of Correction:Moving forward agency will make sure to have a completed tuberculosis risk and screen assessment upon hire along with 2 step PPD. Agency will provide annual TB screening education to each direct care worker as well as their tuberculosis risk and screen assessment.
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 interview with the administrator, the home care agency failed to provide the consumer with the identity of the direct care worker (DCW) who will provide the services, the hours when those services will be provided and fees for those services on an hourly or weekly basis for seven (7) of the seven (7) consumers files reviewed. (Consumer files # 1-7).
Findings include:
A review of the consumer files conducted on September 16, 2024 from approximately 12:30pm to 3pm revealed the following:
CF#1 Start of service date (SOC) 3/13/23: Did not contain documentation that the consumer, the consumer's legal representative, or a responsible family member receiving the following information prior to the start of services: 1) the identity of the DCW who would be providing the services, 2) the hours when the services would be provided, and 3) the fees for those services on an hourly or weekly basis.
CF#2 SOC: 6/26/22: Did not contain documentation that the consumer, the consumer's legal representative, or a responsible family member receiving the following information prior to the start of services: 1) the identity of the DCW who would be providing the services, 2) the hours when the services would be provided, and 3) the fees for those services on an hourly or weekly basis.
CF#3 SOC: 3/12/24: Did not contain documentation that the consumer, the consumer's legal representative, or a responsible family member receiving the following information prior to the start of services: 1) the identity of the DCW who would be providing the services, 2) the hours when the services would be provided, and 3) the fees for those services on an hourly or weekly basis.
CF#4 SOC: 9/22/22: Did not contain documentation that the consumer, the consumer's legal representative, or a responsible family member receiving the following information prior to the start of services: 1) the identity of the DCW who would be providing the services, 2) the hours when the services would be provided, and 3) the fees for those services on an hourly or weekly basis.
CF#5 SOC: 4/10/23: Did not contain documentation that the consumer, the consumer's legal representative, or a responsible family member receiving the following information prior to the start of services: 1) the identity of the DCW who would be providing the services, 2) the hours when the services would be provided, and 3) the fees for those services on an hourly or weekly basis.
CF#6 SOC:4/6/22 : Did not contain documentation that the consumer, the consumer's legal representative, or a responsible family member receiving the following information prior to the start of services: 1) the identity of the DCW who would be providing the services, 2) the hours when the services would be provided, and 3) the fees for those services on an hourly or weekly basis.
CF#7 SOC/2/23: : Did not contain documentation that the consumer, the consumer's legal representative, or a responsible family member receiving the following information prior to the start of services: 1) the identity of the DCW who would be providing the services, 2) the hours when the services would be provided, and 3) the fees for those services on an hourly or weekly basis.
An interview conducted with the administrator on September 16, 2024 at approximately 3pm confirmed the above findings.
Plan of Correction:Moving forward agency will provide documentation on the consumers folder showing the identity of the direct care worker providing services for each consumer. Documentation will show the hours and days services will be provided along with fees for services provided on an hourly basis.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on September 16, 2024, Brighter Days 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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