Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on October 21, 2024, Benevolent Home Care, 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 21, 2024, Benevolent Home Care, 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 four (4) of four (4) PF's, (1, 2, 3 and 4).
Findings include:
A review of PF's was conducted on October 21, 2024 at approximately 10:15 a.m.
PF # 1 Date of Hire 7/23/2024 did not contain any documentation of a completed face to face interview.
PF # 2 Date of Hire 3/12/2024 did not contain any documentation of a completed face to face interview.
PF # 3 Date of Hire 6/7/2023 did not contain any documentation of a completed face to face interview.
PF # 4 Date of Hire 9/12/2022 did not contain any documentation of a completed face to face interview.
An interview with the administrator on October 21, 2024 at approximately 10:42 a.m. confirmed the above findings.
Plan of Correction:Benevolent home care conducts face to face interviews with each prospect candidate that is looking to get hire.
1) Benevolent Cares wrote an interview questioner that has to be completed on the face to face interview.
- We request 2 references.
-Complete criminal background checks.
2)Benevolent Cares will complete interviewing questioner with each of the hired individuals.
3)Benevolent Cares will keep record and notes of the interview including:
Employee/Contractor Information: Full name, contact details, date of interview, job title/role.
Interviewer Information: Name of the interviewer, their role within the organization.
Interview Date and Time: Exact date and time of the interview.
Location of Interview: Address where the interview took place.
Interview Notes: Detailed notes capturing key points discussed during the interview, including:
Relevant experience and qualifications
Availability and scheduling preferences
Any specific questions related to the role and responsibilities
Observations about the candidate's demeanor and communication skills
Signatures: Both the interviewer and the interviewee should sign and date the interview notes, confirming their attendance and participation.
4)Prospect Candidates will sign a document at the end of the interview confirming the face to face interview was completed for the position.
Operations Manager (Anthony Briddell) will review the completed documents after each interview and before offering the position.
-Operations manager will complete the interviewing tool and request documents with signature for each of our already hired employees by Friday November 8, 2024
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's), Centers for Disease Control Guidelines, and an interview with the administrator, the agency failed to provide: 2) documentation that the individual has completed a tuberculosis risk assessment upon hire for four (4) of four (4) PF's, (PF #1, 2, 3 and 4).
Findings include:
In May 2019, the Centers for Disease Control (CDC) updated its recommendation for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should receive 1) 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; 2) Completion of a tuberculosis symptom questionnaire, and 3) Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually. HCW's 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 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 21, 2024 at approximately 11:15 a.m.
PF # 1 Date of Hire: 7/23/2024, did not contain documentation of completion of a tuberculosis (TB) risk assessment. Personnel file only contained a completed TB symptom questionnaire upon hire.
PF # 2 Date of Hire: 3/12/2024, did not contain documentation of completion of a tuberculosis (TB) risk assessment . Personnel file only contained a completed TB symptom questionnaire upon hire.
PF # 3 Date of Hire: 6/7/2023, did not contain documentation of completion of a tuberculosis (TB) risk assesment. Personnel file only contained a completed TB symptom questionnaire upon hire.
PF # 4 Date of Hire: 9/12/2022, did not contain documentation of completion of a tuberculosis (TB) risk assesment. Personnel file only contained a completed TB symptom questionnaire upon hire.
An interview conducted with the administrator on October 21, 2024 starting at 11:44 am confirmed the above findings.
Plan of Correction:Benevolent Home care will complete an annual tuberculosis symptom questionnaire, and Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCW's should receive TB screening annually.
1) Benevolent Home Care will conduct annual Tuberculosis education including:
Tuberculosis symptom questionnaire and tuberculosis risk assessment with each of our active HCW's.
2) Schedule and complete the annual Tuberculosis training.
- complete the annual tuberculosis symptoms questioner with each of our active HCW's.
Operations Manager (Anthony Briddell) will complete and review the training and questionnaires for this year by November 8, 2024
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 a review of consumer files (CF's) and an interview with the administrator, the agency failed to provide documentation that the consumer received information stating: the telephone numbers of the Ombudsman Program located with the local Area Agency on Aging (AAA)for five (5) of five (5) CF's, (CF # 1, 2, 3, 4 and 5).
Findings include:
A review of CF's was conducted on October 21, 2024 at approximately 10:09 a.m.
CF #1, Start of Care: 6/6/2024, did not contain any documentation that the agency provided information stating the telephone numbers of the Ombudsman Program located with the local Area Agency on Aging (AAA).
CF #2, Start of Care: 11/28/2023, did not contain any documentation that the agency provided information stating the telephone numbers of the Ombudsman Program located with the local Area Agency on Aging (AAA).
CF #3, Start of Care: 4/15/2022, did not contain any documentation that the agency provided information stating the telephone numbers of the Ombudsman Program located with the local Area Agency on Aging (AAA).
CF #4, Start of Care: 6/13/2022, did not contain any documentation that the agency provided information stating the telephone numbers of the Ombudsman Program located with the local Area Agency on Aging (AAA).
CF #5, Start of Care: 7/2/2024, did not contain any documentation that the agency provided information stating the telephone numbers of the Ombudsman Program located with the local Area Agency on Aging (AAA).
An interview with the administrator on October 21, 2024 at approximately 10:55 a.m. confirmed the above findings.
Plan of Correction:1) Benevolent Home Care will add the correct contact information for the Ombudsman program located with the local area Agency on Aging to the member handbook which is provided to all our new members in the initial meeting.
2) Benevolent Home Care will provide the complete updated information to all our active members. Letting them know the information has been added and in what case to call that number.
Benevolent home care Operations Manager (Anthony Briddell) will update and send this information to our active members by November 8, 2024.
And for our future members we will provide them with the new updated information.
Initial Comments:
Based on the findings of an onsite home care agency state re-licensure survey conducted on October 21, 2024, Benevolent Home Care, 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 on an interview with the administrator, it was determined that the Agency failed to provide evidence of photo identification tags that would include the employee's name, title, picture and name of the Agency.
Findings include:
During discussion with the administrator on October 21, 2024 at approximately 11:43 a.m., the administrator was asked if the Agency is using photo identification tags for employees. The administrator stated that the Agency does not have photo identification tags.
In an interview conducted with the administrator on October 21, 2024 at approximately 11:48 a.m., the above findings were confirmed.
Plan of Correction:Benevolent Home Care will provide each of our HCW's with a identification tag which it will include a recent photo of the employee, the employees name, employees title and the home care agency name.
2) Benevolent Home Care will provide all our home care workers with their photo identification tag upon hire.
3) Benevolent home care will request our active home care workers to use their photo identification tag while at work.
Operations Manager will order the tags for each of our home care workers and will monitor home care workers using it during work hours.
All Home Care workers will have their Photo identification tag by November 15, 2024.
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