Initial Comments:
Based on the findings of an off-site unannounced state re-licensure survey conducted on March 8, 2024 and continued off-site March 12, 2024 and March 15, 2024, Blessed Hearts Home Care Agency, 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 off-site unannounced home care agency state re-licensure survey conducted on March 8, 2024 and continued off-site March 12, 2024 and March 15, 2024, Blessed Hearts Home Care Agency, 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:
611.52(b) LICENSURE
State Police Criminal History Record
Name - Component - 00
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 (PFs) and interview with agency administrator, it was determined agency failed to obtain a PA State Police criminal history record within 1 year immediately preceding the date of application for one (1) of ten (10) PFs reviewed. (PF# 3)
Findings include:
Review of PFs conducted on March 8, 2024 between approximately 11:00 AM and 1: 00 PM revealed the following:
PF # 3, Date of hire (DOH): 12/14/23: No documentation provided of PA State Police criminal history record within 1 year immediately preceding the date of application. PA State Police criminal history record dated 3/7/24 (eighty-four (84) days after hire).
An interview with the agency administrator conducted on March 15, 2024 at approximately 11:51 AM confirmed the above findings.
Plan of Correction:-The PATCH was done immediately after finding out it was not completed for PF #3.
-The administrator and director will run a PATCH screening immediately after potential employee completes their application.
-The employee personal file will be reviewed every 3 months to keep up with compliance.
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 review of personnel files (PFs) and interview with agency administrator, it was determined agency failed to 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) within 1 year immediately preceding the date of application for four (4) of ten (10) PFs reviewed. (PF# 3-4, # 6 and # 7)
Findings include:
Review of PFs conducted on March 8, 2024 between approximately 11:00 AM and 1: 00 PM revealed the following:
PF# 3, Date of Hire (DOH): 12/14/23: No Federal criminal history record and a letter of determination obtained from the Department of Aging within 1 year immediately preceding the date of application due to PF not providing proof of PA residency for the entire two (2) years (without interruption) immediately preceding the date of application.
PF# 4, DOH: 2/8/24: No Federal criminal history record and a letter of determination obtained from the Department of Aging within 1 year immediately preceding the date of application due to PF not providing proof of PA residency for the entire two (2) years (without interruption) immediately preceding the date of application.
PF# 6, DOH: 2/8/24: No Federal criminal history record and a letter of determination obtained from the Department of Aging within 1 year immediately preceding the date of application due to PF not providing proof of PA residency for the entire two (2) years (without interruption) immediately preceding the date of application.
PF# 7, DOH: 9/20/23: No Federal criminal history record and a letter of determination obtained from the Department of Aging within 1 year immediately preceding the date of application due to PF not providing proof of PA residency for the entire two (2) years (without interruption) immediately preceding the date of application.
An interview with the agency administrator conducted on March 15, 2024 at approximately 11:51 AM confirmed the above findings.
Plan of Correction:-The administrator and director have been re education on the process of when a FBI screening should be done.
-We have put in place reminders to of what the issue date on employees PA ID should be to verify PA residency. If residency can't be proven the agency will conduct an FBI Screening
-The administrator and director will audit the employee files immediately after hire.
-All compliance have to been completed before the employee can start working.
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 review of personnel files (PFs) and interview with agency administrator, it was determined agency failed to maintain documentation of proof of residency for four (4) of ten (10) PFs reviewed. (PF# 3-4, # 6 and # 7)
Findings include:
Review of PFs conducted on March 8, 2024 between approximately 11:00 AM and 1: 00 PM revealed the following:
PF# 3, Date of Hire (DOH): 12/14/23: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained PA Drivers License issued: 6/18/23 and receipt from PA department of transportation Bureau of Driver Licensing with processing date of 9/29/22.
PF# 4, DOH: 2/8/24: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained PA Drivers License issued: 6/20/23 with no other proof of residency.
PF# 6, DOH: 2/8/24: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained no proof of residency.
PF# 7, DOH: 9/20/23: No documentation of proof of Pa. residency for the entire two years (without interruption) immediately preceding the date of application. Contained PA Drivers License issued: 1/17/24 and 3/27/22.
An interview with the agency administrator conducted on March 15, 2024 at approximately 11:51 AM confirmed the above findings.
Plan of Correction:-Upon receiving employee PA ID, if the issue date of the ID does not show greater than 2 years. The agency will request the approved documentations for proof of residency.
-The agency will send employee for FBI Screening if they are unable to provide proof of residency.
-The agency will audit the employee file immediately after hire.
-The employee will not start work until the employee file is completed with all required compliances.
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 review of personnel files (PF) and interview with the agency administrator, it was determined the agency failed to ensure direct care workers were screened for and were free from active mycobacterium tuberculosis (TB) prior to assignment with consumers in two (2) of ten (10) files reviewed. (PFs # 7 and # 8)
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) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screen 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;(RR-17)
.
Review of PFs conducted on March 8, 2024 between approximately 11:00 AM and 1: 00 PM revealed the following:
PF # 7, Date of hire (DOH): 9/20/23, the file did not contain documentation that TB testing was completed upon hire. Documentation of one (1) step testing dated 9/27/23.
PF#8, DOH: 9/5/23, the file did not contain documentation that TB testing was completed upon hire. Documentation of one (1) step testing dated 9/13/23.
An interview with the agency administrator conducted on March 15, 2024 at approximately 11:51 AM confirmed the above findings.
Plan of Correction:-The admin and director will be audit the employees files immediately after hire date to ensure compliance is up to date. Effective 3/15/24.
-The employees who only had a 1 step PPD completed will be sent to complete a new TB screening. This will be completed by 4/8/24.
-Employees will not start work until employee file is completed with all compliances. Effective 3/15/24
Initial Comments:
Based on the findings of an off-site unannounced home care agency state re-licensure survey conducted on March 8, 2024 and continued off-site March 12, 2024 and March 15, 2024, Blessed Hearts Home Care Agency, 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 agency administrator, agency failed to correctly format the employee ID badges as per requirement for ten (10) of ten (10) active direct care workers (DCW). (PF # 1-# 10).
Findings included:
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 and contained no picture of the employee.
An email received from the agency administrator on March 12, 2024 at 7:00 PM revealed: "We did not have ID badges for the caregivers. But I ordered them on Friday, attached is a picture of how they will look. "
An interview with the agency administrator conducted on March 15, 2024 at approximately 11:51 AM confirmed the above findings.
Plan of Correction:-The admin and director have been educated on staff having the proper ID Badges on 3/12/24.
-Effective 3/12/24 the agency started processing ID badges for every employee. Going forward every employee upon hiring will receive an ID badge.
-The admin and director will audit employees immediately upon hiring for compliances before the employee starts to work. Effective 3/12/24.
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