Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on 3/27/24, Comfort Keepers #488, 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 unannounced home care agency state re-licensure survey conducted on 3/27/24, Comfort Keepers # 488, 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(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 a review of personnel files and an interview with the agency Administrator, agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for for eight (8) of ten (10) personnel files reviewed (PF #2, PF#3, PF#4, PF#5, PF#6, PF#7, PF#8, PF#9, PF#10)
Findings Include:
Review of personnel files (PF) conducted on 3/27/24 at approximately 9:15 AM revealed the following:
PF #2, date of hire (DOH): 8/14/23, No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging.
PF #3, date of hire (DOH):4/20/23, No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging.
PF #4, date of hire (DOH): 2/5/24, No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging.
PF #5, date of hire (DOH): 1/5/24, No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging.
PF #6, date of hire (DOH): 7/26/23, No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging.
PF #7, date of hire (DOH): 1/24/23, Documentation failed to show 2 years proof of residency
PF #8, date of hire (DOH): 4/20/23, No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging.
PF #9, date of hire (DOH): 1/24/24, No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging.
PF #10, date of hire (DOH): 2/2/24, No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging.
Interview with the Regional Operations Manager & Vice President of Operations on 3/27/24 approximately 3:00 PM confirmed the above findings
Plan of Correction:Issue: Running federal fingerprint background checks for Pennsylvania identification and/or driver's license holders when the issue date is less than 2 years before orientation and/or going on shift.
Background: Federal fingerprint background checks are a crucial part of ensuring the safety and security of personnel in sensitive roles. However, in cases where the identification or driver's license was issued less than 2 years before the individual's orientation or shift, there may be insufficient historical data to accurately assess the individual's background and potential risks.
Corrective Action Steps:
1. Policy Review:
- Review the current policy on federal fingerprint background checks to ensure it aligns with best practices and regulatory requirements.
- Specifically address the issue of identification or driver's license issue dates less than 2 years before orientation or shift.
2. Revised Criteria:
- Establish revised criteria for when federal fingerprint background checks are required, taking into consideration the issue date of the identification or driver's license.
- Consider other supplementary forms of background checks or verification for individuals with recent identification or driver's license issuances.
3. Communication:
- Communicate the revised criteria and policy changes to relevant personnel, including HR staff, hiring managers, and employees.
- Provide guidance on how to handle cases where the issue date of identification or driver's license is within 2 years of orientation or shift.
4. Exception Process:
- Develop an exception process for cases where individuals have identification or driver's licenses issued within the 2-year timeframe.
- Establish clear criteria for granting exceptions and ensure that appropriate documentation and approvals are obtained.
5. Training and Awareness:
- Conduct training sessions for HR staff, hiring managers, and relevant employees on the revised policy and procedures.
- Raise awareness about the importance of thorough background checks and the rationale behind the new criteria.
6. Monitoring and Compliance:
- Implement a monitoring system to track compliance with the revised policy and criteria.
- Regularly review and assess the effectiveness of the corrective actions taken and make adjustments as necessary.
By implementing these corrective actions, we aim to strengthen our background check processes and ensure that all personnel in sensitive roles are thoroughly vetted for the safety and security of our organization.
On our application, we have a section moving forward that if the issue date is less than 2 years, fingerprints are being completed prior to orientation and/or prior to going on shift. We will not move forward without fingerprints being completed and submitted with onboarding.
Our Communications Director will be auditing internally and monitoring the personnel files on a bi-weekly basis to ensure all new hires are following policy.
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 (PF) and interview with the the agency failed to have 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 for eight (8) of ten (10) personnel files reviewed (PF #2, PF#3, PF#4, PF#5, PF#7, PF#8, PF#9, PF#10)
Findings Include:
Review of personnel files (PF) conducted on 3/27/24 at approximately 9:15 AM revealed the following:
PF #2, date of hire (DOH): 8/14/23, Documentation failed to show 2 years proof of residency
PF #3, date of hire (DOH):4/20/23, Documentation failed to show 2 years proof of residency
PF #4, date of hire (DOH): 2/5/24, Documentation failed to show 2 years proof of residency
PF #5, date of hire (DOH): 1/5/24, Documentation failed to show 2 years proof of residency
PF #6, date of hire (DOH): 7/26/23, Documentation failed to show 2 years proof of residency
PF #7, date of hire (DOH): 1/24/23, Documentation failed to show 2 years proof of residency
PF #8, date of hire (DOH): 4/20/23, Documentation failed to show 2 years proof of residency
PF #9, date of hire (DOH): 1/24/24, Documentation failed to show 2 years proof of residency
PF #10, date of hire (DOH): 2/2/24, Documentation failed to show 2 years proof of residency
Interview with the Regional Operations Manager & Vice President of Operations on 3/27/24 approximately 3:00 PM confirmed the above findings
Plan of Correction:Issue: Running federal fingerprint background checks for Pennsylvania identification and/or driver's license holders when the issue date is less than 2 years before orientation and/or going on shift.
Background: Federal fingerprint background checks are a crucial part of ensuring the safety and security of personnel in sensitive roles. However, in cases where the identification or driver's license was issued less than 2 years before the individual's orientation or shift, there may be insufficient historical data to accurately assess the individual's background and potential risks.
Corrective Action Steps:
1. Policy Review:
- Review the current policy on federal fingerprint background checks to ensure it aligns with best practices and regulatory requirements.
- Specifically address the issue of identification or driver's license issue dates less than 2 years before orientation or shift.
2. Revised Criteria:
- Establish revised criteria for when federal fingerprint background checks are required, taking into consideration the issue date of the identification or driver's license.
- Consider other supplementary forms of background checks or verification for individuals with recent identification or driver's license issuances.
3. Communication:
- Communicate the revised criteria and policy changes to relevant personnel, including HR staff, hiring managers, and employees.
- Provide guidance on how to handle cases where the issue date of identification or driver's license is within 2 years of orientation or shift.
4. Exception Process:
- Develop an exception process for cases where individuals have identification or driver's licenses issued within the 2-year timeframe.
- Establish clear criteria for granting exceptions and ensure that appropriate documentation and approvals are obtained.
5. Training and Awareness:
- Conduct training sessions for HR staff, hiring managers, and relevant employees on the revised policy and procedures.
- Raise awareness about the importance of thorough background checks and the rationale behind the new criteria.
6. Monitoring and Compliance:
- Implement a monitoring system to track compliance with the revised policy and criteria.
- Regularly review and assess the effectiveness of the corrective actions taken and make adjustments as necessary.
By implementing these corrective actions, we aim to strengthen our background check processes and ensure that all personnel in sensitive roles are thoroughly vetted for the safety and security of our organization.
On our application, we have a section moving forward that if the issue date is less than 2 years, fingerprints are being completed prior to orientation and/or prior to going on shift. We will not move forward without fingerprints being completed and submitted with onboarding.
Our Communications Director will be auditing internally and monitoring the personnel files on a bi-weekly basis to ensure all new hires are following policy.
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 policies, personnel files (PF), survey history and interview with the Regional Operations Manager & Vice President of Operations, it was determined the agency failed to ensure direct care workers, prior to consumer contact, were screened for mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines & company policy, for four (4) of ten (10) personnel files (PF) reviewed personnel files (PF#1, PF#4, PF#5, PF#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) or 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').(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).
Review of policy Tuberculosis (TB) Screening on 3/27/24 at 1:00 PM states, "Policy Statement: It is the policy of Comfort Keepers to require all caregivres to undergo TB screening, either through a two-step TB test or Quantiferon-TB Gold+, prior to going on shift with clients. The TB screening is to be completed and submitted at the time of orientation for Comfort Keepers employees...Policy Details: 1.a. All new caregivers must undergo TB screening prior to going on shift with clients...5a. Failure to complete the TB screening as required may result in the caregivr being ineligible to work with clients until the screening is completed."
Review of personnel records (PR) on 3/27/24 at approximately 9:15 AM revealed the following:
PR#1: First date worked 2/20/22, as of 3/27/24 there was no documentation of a two-step TB test or a Quantiferon Tuberculosis baseline test
PR#4: First date worked 2/8/24, as of 3/27/24 there was no documentation of a two-step TB test or a Quantiferon Tuberculosis baseline test
PR#5: First date worked 1/13/24, as of 3/27/24 there was no documentation of a two-step TB test or a Quantiferon Tuberculosis baseline test
PR#8: First date worked 4/28/23, as of 3/27/24 there was no documentation of a two-step TB test or a Quantiferon Tuberculosis baseline test
Review of survey history on 3/27/24 at 8:00 AM revealed the agency had been cited on 2/2/24 during a complaint survey for failing to ensure direct care workers, prior to consumer contact, had been screened for mycobacterium tuberculosis
Interview with the Regional Operations Manager & Vice President of Operations on 3/27/24 approximately 3:00 PM confirmed the above findings
Plan of Correction:All employees (caregivers and administration) will receive TB Education, Risk Assessment, and TB Screening.
Will create/implement an updated TB Education, Tb Rish Assessment, and TB Screening to be distributed to all of our employees.
Our Communications Director will be in direct contact to obtain and monitor this process and correction prior to caregiver going on shift.
Policy Statement:
It is the policy of Comfort Keepers to require all caregivers to undergo TB screening, either through a two-step TB test or QuantiFERON-TB Gold+, before going on shift with clients. The TB screening is to be completed and submitted at the time of orientation for Comfort Keepers employees. The screening will be conducted at Comfort Keepers' contracted labs, and Comfort Keepers will cover the cost of these screenings.
Purpose:
The purpose of this policy is to ensure the health and safety of both caregivers and clients by minimizing the risk of tuberculosis transmission. TB screening is an essential component of our commitment to providing a safe and healthy environment for our clients and staff.
Policy Details:
1. TB Screening Requirement:
a. All new caregivers must undergo TB screening before going on shift with clients.
b. Existing caregivers who have not previously undergone TB screening must complete the screening at the time of orientation.
2. Types of TB Screening:
a. Caregivers have the option to undergo either a two-step TB test or a QuantiFERON-TB Gold+ test.
b. The choice of screening method will be determined in consultation with Comfort Keepers' designated healthcare provider, preferred and expense covered is the QuantiFERON-TB Gold+ test.
3. Timing of Screening:
a. TB screening must be completed before the caregiver's first shift with a client.
b. The results of the TB screening will be provided directly to the Comfort Keepers compliance team from the contracted facility.
4. Conducting the TB Screening:
a. TB screenings will be conducted at labs contracted by Comfort Keepers.
b. Comfort Keepers will cover the cost of the TB screenings, and caregivers will not be responsible for any associated expenses.
5. Compliance and Consequences:
a. Failure to complete the TB screening as required may result in the caregiver being ineligible to work with clients until the screening is completed.
b. Non-compliance with this policy may also result in disciplinary action, up to and including termination.
6. Confidentiality:
a. All TB screening results will be kept confidential and will only be accessible to designated personnel in the HR and healthcare departments on a need-to-know basis.
b. Any information related to the TB screening will be handled in compliance with applicable privacy laws and regulations.
7. Updates and Renewal:
a. Caregivers will be required to undergo TB screening periodically as determined by Comfort Keepers' healthcare provider. QuantiFERON-TB Gold+ test. To be completed every two years.
b. Any changes to the TB screening policy will be communicated to all caregivers in a timely manner.
Implementation:
This policy will be effective immediately upon its issuance. All caregivers and relevant staff members will be informed of this policy, and the necessary steps will be taken to ensure compliance with the TB screening requirement.
Review and Revision:
This policy will be subject to periodic review to ensure its effectiveness and compliance with relevant regulations. Any necessary revisions will be made in consultation with appropriate stakeholders.
Conclusion:
By adhering to this policy, Comfort Keepers aims to uphold the highest standards of safety and care for both our clients and caregivers. We appreciate the cooperation of all caregivers in fulfilling this important health requirement.
Comfort Keepers will be completing this for all employees with the updated TB Education information. This will also continue annually Dec/Jan continuing for their employment file. Also, an internal audit of 10% of the personnel files will be audited every quarter by our Communication Supervisor to ensure that the deficient practice will not recur.
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 review of the agency's consumer records (CR) and interview conducted with the Regional Operatons Manager & Vice President of Operations it was determined the agency failed to notify consumers of the identity of the direct care worker who will be providing services for six (6) of six (6) CR reviewed (CR#1, CR#2, CR#3, CR#4, CR#5 & CR#6)
Findings include:
Review of consumer records (CR) conducted 3/17/24 at approximately 2:00 PM revealed the following:
CR #1 start of service 1/23/23 failed to contain documentation that consumers were made aware of the identity of the direct care worker who will be providing services
CR #2 start of service 10/11/23 failed to contain documentation that consumers were made aware of the identity of the direct care worker who will be providing services.
CR #3 start of service 1/3/23 failed to contain documentation that consumers were made aware of the identity of the direct care worker who will be providing services.
CR #4 start of service 2/12/24 failed to contain documentation that consumers were made aware of the identity of the direct care worker who will be providing services.
CR #5 start of service 12/6/23 failed to contain documentation that consumers were made aware of the identity of the direct care worker who will be providing services.
CR #6 start of service 5/21/23 failed to contain documentation that consumers were made aware of the identity of the direct care worker who will be providing services.
Interview with the Regional Operations Manager & Vice President of Operations on 3/27/24 approximately 3:00 PM confirmed the above findings
Plan of Correction:**Purpose:**
This policy outlines the procedures for documenting communication with new clients regarding the initial caregiver attending the first shift and ongoing scheduling changes. The goal is to ensure transparency, accuracy, and accountability in all client communications and scheduling processes.
**Procedure:**
1. **New Client Communication:**
- When a new client is onboarded, a designated staff member will contact the client or their family to communicate details about the initial caregiver attending the first shift.
- The staff member must record the date, time, and details of the communication in the HHAexchange system.
- The HHAexchange file will include the name of the caregiver attending the first shift and the name of the staff member who communicated this information to the client or family.
2. **Initial Caregiver Assignment:**
- The initial caregiver assigned to the new client's first shift must be accurately documented in the HHAexchange system.
- Any changes to the initial caregiver assignment must be promptly updated in the system and communicated to the client or family.
3. **Ongoing Scheduling Changes:**
- Any scheduling changes for the client must be documented in the HHAexchange system.
- If a new caregiver is assigned to the client, the name of the new caregiver and the reason for the change must be recorded in the system.
- The client or family must be informed of any scheduling changes in advance, whenever possible.
4. **Audit Trail:**
- All communication records, including details of the initial caregiver assignment and scheduling changes, must be maintained in the HHAexchange system.
- The time and date of each recorded phone call must be included in the documentation for reference during audits.
5. **Compliance and Training:**
- All staff members involved in client communication and scheduling must be trained on this policy and understand the importance of accurate documentation.
- Compliance with this policy is mandatory for all staff members, and any deviations must be reported to the appropriate supervisor.
**Review and Update:**
This policy will be reviewed annually and updated as needed to ensure compliance with regulations and best practices in client communication and scheduling.
**Effective Date:**
This policy is effective immediately upon approval and dissemination to all relevant staff members.
By following this policy, Comfort Keepers aims to maintain clear communication with clients and ensure that scheduling changes are documented accurately and transparently.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on 3/27/24, Comfort Keepers # 488, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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