QA Investigation Results

Pennsylvania Department of Health
COMFORT KEEPERS #488
Health Inspection Results
COMFORT KEEPERS #488
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:

Based on the findings of an on-site state licensure survey conducted on May 16, 2018, Comfort Keepers was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, and Subpart A.







Plan of Correction:




Initial Comments:

Based on the findings of an on-site state licensure survey conducted on May 16, 2018, Comfort Keepers was found not to be in compliance with the following requirement of Title 28 Health and Safety Part IV, Health Facilities, Subpart H. Chapter 611 Home Care Agencies and Home Care Registries.






Plan of Correction:




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 the direct care worker (DCW) files and an interview with the administrator, the agency failed to ensure that direct care workers received tuberculosis screening per the Centers for Disease Control guidelines prior to providing service to the consumer for two (2) of ten (10) direct care workers files. DCW files # 5 and 10.

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 screening annually. HCWs 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 the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005 ;( RR-17) .

Review of direct care workers personnel files on May 16, 2018 from 1400 to 1500 revealed:
Direct care worker # 5 with date of hire February 13, 2018, no documentation that two-step tuberculin skin test (TST) was completed prior to providing services to a consumer.
Direct care worker file # 10 with hire date of October 14, 2015, no documentation that an annual tuberculin skin test (TST) or screening for calendar year 2016.
Interview with the administrator on May 16, 2018 at 1500 confirmed that the above findings.







Plan of Correction:

Upon on boarding with Comfort Keepers for the orientation the 2 Step PPD process will have been started at the time of orientation. Within 21 days from the orientation the 2 step PPD must be completed and on file. Comfort Keepers will supply site for 2 step PPD. The monitoring system will be through ClearCare tasks for each caregiver. The Staffing Coordinator, will be monitoring these caregivers and tasks. Also, the responsible party for monitoring will be the Senior Staffing Coordinator.
The two caregivers that were found cited are completing their two step to update their files. Continued auditing by our Staffing Coordinator and administrative assistance when onboarding is completed. Audit check list has been created and following to find these items and correct them. Files will be audited at the time of onboarding and then final filing in the administrative building and when uploaded. We will use Clear Care to document due dates and send updates when due as well as audit again once update is complete by the date. Audits will be completed using the created audited form.


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 the agency admission packet, consumer files and interview with the administrator, the agency failed to ensure that the consumer was provided the documentation regarding the hiring and competency requirements applicable to direct care workers employed by the home care agency for eight (8) of ten (10) consumer files. Consumer file # 1, 2, 4, 5, 6, 7, 9 and 10.

Findings:
Review of the admission packet on May 16, 2018 at 1000 revealed there was no documentation the hiring and competency requirements applicable to direct care workers employed by the home care agency.



Review of consumer files on May 16, 2016 from 1030 to 1230:

Review of consumer file # 1 with the start of care on February 16, 2018, no documentation of the hiring and competency requirements applicable to direct care workers employed by the home care agency.

Review of consumer file # 2 with the start of care on December 19, 2017, no documentation of the hiring and competency requirements applicable to direct care workers employed by the home care agency.

Review of consumer file # 4 with the start of care on March 5, 2018, no documentation of the hiring and competency requirements applicable to direct care workers employed by the home care agency.

Review of consumer file # 5 with the start of care on January 15, 2018, no documentation of the hiring and competency requirements applicable to direct care workers employed by the home care agency.

Review of consumer file # 6 with the start of care on December 21, 2017, no documentation of the hiring and competency requirements applicable to direct care workers employed by the home care agency.

Review of consumer file # 7 with the start of care on September 25, 2017, no documentation of the hiring and competency requirements applicable to direct care workers employed by the home care agency.

Review of consumer file # 9 with the start of care on January 2, 2018, no documentation of the hiring and competency requirements applicable to direct care workers employed by the home care agency.

Review of consumer file # 10 with the start of care on January 28, 2108, no documentation of the hiring and competency requirements applicable to direct care workers employed by the home care agency.


An interview with the administrator on May 16, 2018 at 1500 confirmed that the consumer was not informed by the home care agency of the hiring and competency requirements applicable to direct care workers employed by the home care agency.













Plan of Correction:

Caregiver Competency Records will continue to be annually and to monitor we have implemented recording and assigning alerts into the Clear Care system for the administrative to be reminded as well as the caregiver to be reminded it needs to be reviewed and completed. The administrative that is responsible for monitoring this is the Staffing Coordinators in the local offices. Also, we have positioned our administrative staff for a monthly audit of out personnel files for back up.

Also, the consumer welcome packet as been updated stating that the caregivers are not only insured and bonded and professional insurances also added in the caregivers onboarding training along with ongoing training and orientations. The staffing Coordinators are maintaining this process is complete and the External Care Coordinators communicate this with the consumers.


Initial Comments:

Based on the findings of an on-site state licensure survey conducted on May 16, 2018, Comfort Keepers was found to be in compliance with the requirements of 35 P.S. 448.809(b)






Plan of Correction: