QA Investigation Results

Pennsylvania Department of Health
BEING HOME MATTERS, LLC
Health Inspection Results
BEING HOME MATTERS, LLC
Health Inspection Results For:


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Initial Comments:



Based on the findings of an onsite unannounced state re-licensure survey conducted on October 24, 2022, Being Home Matters, 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 home care agency state re-licensure survey conducted on October 24, 2022, Being Home Matters, 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:




611.55(a) LICENSURE
Compentency Requirements

Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.

Observations:



Based upon review of personnel files (PF) and interview with owner (EMP # 1), agency failed to show documentation of initial competency upon hire for two (2) of three (3) active direct care workers (DCW). ( PF # 2-3).

Findings included:

Review of personnel files conducted on October 24, 2022 between 11:50 AM-12:10 PM.

Personnel file (PF) #2: Date of hire (DOH): 10/7/19; revealed no documentation of competency upon hire.

Personnel file (PF) #3: Date of hire (DOH): 7/13/21; revealed no documentation of competency upon hire.

Interview with EMP # 1 on 10/24/22 at approximately 12:40 PM confirmed above findings.











Plan of Correction:

In addition to the training assigned to each new hire on the Care Academy, each new hire has to provide a certificate of completion.

Updated file with signed annual review witnessing the following hands-on care: Bathing, shaving, grooming and dressing; Hair Skin, and mouth care; Assistance with ambulation; Meal preparation and feeding; toileting; assistance with self administered medication.

An agency, Hands-on Care Evaluation Sheet" has been developed to confirm accuracy of each skill as witnessed. This competency document has been added to the employees file for compliance.

The agency New Hire Procedure packet has been updated to include this requirement, for NON-CNA employees, to alleviate any future issues.

A review of New Hire files will be done by no less than two officers of the company to confirm compliance of this update prior to the first day of employment. Officers will initial and date the evaluation sheet to indicate the review has been completed.

Monitoring of this implementation will be assigned to the personnel associate handling all future new hires to the company.



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 upon review of personnel files (PF) and interview with owner (EMP # 1), agency failed to show documentation of annual competency review for two (2) of three (3) active direct care workers (DCW). ( PF # 1-2).

Findings included:

Review of personnel files conducted on October 24, 2022 between 11:50 AM-12:10 PM.

Personnel file (PF) #1: Date of hire (DOH): 5/15/18; revealed no documentation of annual competency review for 2020 and 2021.

Personnel file (PF) #2: Date of hire (DOH): 10/7/19; revealed no documentation of annual competency review for 2020 and 2021.


Interview with EMP # 1 on 10/24/22 at approximately 12:40 PM confirmed above findings.







Plan of Correction:

In addition to the training assigned to each new hire on the Care Academy, each new hire has to provide a certificate of completion.

Updated file with signed annual review witnessing the following hands-on care: Bathing, shaving, grooming and dressing; Hair Skin, and mouth care; Assistance with ambulation; Meal preparation and feeding; toileting; assistance with self administered medication.

An agency, Hands-on Care Evaluation Sheet" has been developed to confirm accuracy of each skill as witnessed. This competency document has been added to the employees file for compliance.

The agency New Hire Procedure packet has been updated to include this requirement, for NON-CNA employees, to alleviate any future issues.

A review of New Hire files will be done by no less than two officers of the company to confirm compliance of this update prior to the first day of employment. Officers will initial and date the evaluation sheet to indicate the review has been completed.

Monitoring of this implementation will be assigned to the personnel associate handling all future new hires to the company.



Initial Comments:


Based on the findings of an onsite home care agency state re-licensure survey conducted on October 24, 2022, Being Home Matters, Llc , was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction:




35 P. S. 448.809b LICENSURE
Photo Id Reg

Name - Component - 00
Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.


(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.



Observations:



Based upon observation of employee Identification badge (ID) and interview with owner (EMP # 1), agency failed to correctly format the employee ID badges as per requirement for three (3) of three (3) active direct care workers (DCW). ( PF # 1-3).

Findings included:

A request was made for a policy regarding the content for the staff ID badges on 10/24/22 at approximately 12:15 PM and none was provided.

Photo of employee ID badge showed title less than 1/2 inch tall strip as close as practicable to the bottom edge of the badge.

Interview with EMP # 1 on 10/24/22 at approximately 12:40 PM confirmed above findings.







Plan of Correction:

Plan of Correction for Identification Badges

The agency has included the House Bill No. 1482, Section 809.2 regarding Photo identification tag regulations in the new hire policy.

This requirement is also discussed as part of the code of conduct upon hire.

All employees have received a new identification badge including a recent picture, employees name, the employees title (caregiver) and the name of our company (the agency). The title of the employee is in block letter at least 1/2" along the bottom edge of the ID as indicated.

These ID requirements have been made part of the hiring process and new hire procedures to ensure compliance.
The Verification of Photo ID tags will be monitored with every opportunity available and at least on a monthly basis with the collection of time and attendance.


This will be the responsibility of the personnel associate managing time and attendance.