Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on April 2, 2025 and off-site on April 3, 2025, Bell Elite Senior Solutions, 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 state re-licensure survey conducted on April 2, 2025 and off-site on April 3, 2025, Bell Elite Senior Solutions, 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 review of personnel files (PF) and interview with the administrator, it was determined that personnel files did not include documentation that two (2) references were verified prior to hire for three (3) of eight (8) personnel files reviewed. (PF5, PF7, and PF8)
Findings Include:
Review of personnel files (PF) was conducted on 4/2/2025 from approximately 11:38AM until approximately 12:51PM revealed:
PF5 - (Date of Hire): 7/22/2024 - File did not contain documentation of two (2) verified references.
PF7 - (Date of Hire): 8/29/2024 - File did not contain documentation of two (2) verified references.
PF8 - (Date of Hire): 4/17/2023 - File did not contain documentation of two (2) verified references.
An interview with the administrator on 4/2/2025 at approximately 1:00PM confirmed the above findings.
Plan of Correction:1. Corrective Action for Identified Deficiency
By June 2 2025, the Human Resources Department will complete the missing
reference checks for the employee(s) cited.
Documentation will be filed in the appropriate personnel records.
2. Measures to Prevent Recurrence
Policy Revision: Updated hiring policy requires two documented reference
checks before an employee may begin work.
Staff Training:Will be Conducted on June 2, 2025, for HR and hiring personnel on
reference check procedures and compliance.
Standardized Forms: A "Reference Check Documentation Form" has been
created and implemented.
Pre-Employment Checklist: Revised to include mandatory reference checks;
HR cannot clear new hires without completion.
Monthly QA Audits: Ongoing monthly reviews by the HR Director of all new
employee files for compliance.
3. Responsible Party
Title: Human Resources Director
Responsibility: Oversight of hiring policy, file compliance, and training.
4. Completion Date
June 02, 2025
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 review of personnel files (PF), and interview with the administrator, it was determined that personnel files did not include documentation that annual TB education was conducted for three (3) of eight (8) personnel files reviewed (PF2, PF6, and PF8).
Findings Include:
"Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019 - Historically, U.S. health care personnel were at increased risk for latent TB infection (LTBI) and TB disease from occupational exposures, but recent data suggest that this is no longer the case. CDC and the National Tuberculosis Controllers Association have updated the 2005 CDC recommendations for testing health care personnel. The update includes 1) TB risk assessment, symptom screening, and TB testing upon hire with a TB blood test (e.g., interferon-gamma release assay) or tuberculin skin test for those without documented prior TB or LTBI; 2) no annual TB testing for most health care personnel without a known exposure or ongoing transmission; 3) for health care personnel with LTBI treatment is strongly encouraged; 4) annual symptom screening for health care personnel with untreated LTBI; and 5) annual TB education for all health care personnel. These recommendations apply to health care personnel and volunteers in all health care settings. However, state and local TB screening and testing regulations may have different requirements."
Review of personnel files (PF) was conducted on 4/2/2025 from approximately 11:38AM until approximately 12:51PM revealed:
PF2 - (Date of Hire): 6/14/2023 - File did not contain documentation of annual TB education for 2024.
PF6 - (Date of Hire): 4/15/2021 - File did not contain documentation of annual TB education for 2024.
PF8 - (Date of Hire): 4/17/2023 - File did not contain documentation of annual TB education for 2024.
An interview with the administrator on 3/4/2025 at approximately 1:00PM confirmed the above findings.
Plan of Correction:Regulatory Requirement: Pre-employment TB screening must include a completed
and documented TB questionnaire.
Date of Action Begins: June 2, 2025
1. Corrective Action for Identified Deficiency
By June 2, 2025, the missing TB questionnaire will be completed for the affected
employee and filed in their personnel and health record.
2. Measures to Prevent Recurrence
Policy Reinforcement: TB questionnaire is now clearly required before the
employee's first day.
Staff Training: Scheduled and conducted for HR team on June 4, 2025,
reviewing TB documentation requirements.
Checklist Integration: TB questionnaire is now part of the mandatory pre-
employment checklist.
Bi-weekly File Audits: HR will conduct bi-weekly audits for 90 days to ensure
TB forms are completed and filed.
3. Responsible Party
Title: Human Resources Director
Responsibility: Ensuring proper health documentation is completed for all new
hires.
4. Completion Date
June 02, 2025
Administrator
Initial Comments:
Based on the findings of an onsite state re-licensure survey conducted on April 2, 2025 and off-site on April 3, 2025, Bell Elite Senior Solutions, was found to be in compliance with the requirements of 35 P.S. 448.809(b).
Plan of Correction:
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