Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed March 5, 2025, Better Is Better, LLC was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed March 5, 2025, Better Is Better, LLC was found not to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.
Plan of Correction:
611.52(b) LICENSURE
State Police Criminal History Record
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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 personnel files (PF) and employee (EMP) interview the agency failed to request a State Police criminal history report upon hire for three (3) of six (6) PF reviewed (PF 4-6).
Findings included:
Review of PF conducted on March 5, 2025, between approximately 10:30am and 11:30am revealed:
PF4, date of hire (DOH) 8/25/23, start of services (SOS) 8/25/23, PF contained Pennsylvania State Police criminal history report requested 9/13/23, 19 days after hire.
PF5, DOH 5/15/23, SOS 5/15/23, PF contained Pennsylvania State Police criminal history report requested 5/31/23, 16 days after hire.
PF6, DOH 1/23/23, SOS 1/23/23, PF contained Pennsylvania State Police criminal history report requested 5/5/23, 102 days after hire.
Findings confirmed at exit interview with owner, Chief Executive Officer, Compliance Officer, and Office Manager on March 6, 2025, at approximately 2:00pm.
Plan of Correction:State Police Criminal History Reports will be requested as part of the overall initial job position application, within three business days of the application being received. No applicant will have a hire date posted until the State Police Criminal History Report has been received. All new employee applications and processes, including the State Police Criminal History Report will be internally monitored (audited) monthly by compliances and operations personnel of Better is Better, LLC Home Care Agency.
611.55(e) LICENSURE
Competency Requirements
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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 personnel files (PF) and employee (EMP) interview the agency failed to ensure employees demonstrated competency annually after establishing initial competency for three (3) of three (3) PF reviewed with at least 12 months of employment (PF 4-6).
Findings included:
Review of PF conducted on March 5, 2025, between approximately 10:30am and 11:30am revealed:
PF4, date of hire (DOH) 8/25/23, start of services (SOS) 8/25/23, PF failed to contain an annual competency review for 2024.
PF5, DOH 5/15/23, SOS 5/15/23, PF failed to contain an incomplete annual competency review dated 12/20/24, 19 months after initial competency dated 5/15/23.
PF6, DOH 1/23/23, SOS 1/23/23, PF contained annual competency review dated 10/29/24, 21 months after initial competency dated 1/23/23.
Findings confirmed at exit interview with owner, Chief Executive Officer, Compliance Officer, and Office Manager on March 6, 2025, at approximately 2:00pm.
Plan of Correction:A full review of employees' files will be checked for Annual Competency Exam compliance and those found to be out of compliance will be called into the office to take the exam with additional internal support training conducted at that time.
All other employees currently in compliance will be tracked for maintaining compliance. Annual competency exams will be conducted during employee performance review or Agency mandatory trainings and tracked through a third-party human resources platform. Internal audits for this compliance will be conducted by Compliance and Operations personnel.
611.56(b) LICENSURE
Health Screening
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(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 two (2) of three (3) PF reviewed with at least 12 months of employment (PF 4-6).
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 PF conducted on March 5, 2025, between approximately 10:30am and 11:30am revealed:
PF4, date of hire (DOH) 8/25/23, start of services (SOS) 8/25/23, PF failed to contain evidence of annual TB education for 2024.
PF6, DOH 1/23/23, SOS 1/23/23, PF failed to contain evidence of annual TB education for 2024 and 2025.
Findings confirmed at exit interview with owner, Chief Executive Officer, Compliance Officer, and Office Manager on March 6, 2025, at approximately 2:00pm.
Plan of Correction:Upon hiring, TB1 will be required before employee can be placed in a home care environment and TB2 must be completed within 21 days of TB1 in order for DCW to continue receiving scheduled work hours.
Annual TB education including questionnaire form filled and submitted for folder, risk assessment, signs and symptoms will be tracked by Paychex and administered for annual deadlines by case managers and office managers.
All employee files will be audited monthly for CDC and PA state TB testing and education compliances. This will be conducted by compliances and operations department. All employee files will be screened for these compliances and brought up to date for the compliances.
Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey completed March 5, 2025, Better Is Better, LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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