QA Investigation Results

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


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Initial Comments:



Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on February 11, 2022, Comfort Keepers, 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 February 11, 2022, Comfort Keepers, 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:




611.55(a) LICENSURE
Compentency Requirements

Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.

Observations:


Based on reviews of Personnel files (PFs), and an interview with the agency office manager, the agency failed to ensure completed documentation demonstrating each direct care worker had satisfactorily completed an initial competency exam containing ten (10) areas of care and an additional six (6) areas of personal care for ten (10) of ten (10) files reviewed. (PFs #1- #10).


Reviews of personnel files conducted on 2/11/22 between 1:10 pm and 2:45 pm revealed the following:

PF#1, date of hire: 2/1/21, contained an incomplete written competency test containing all sixteen (16) areas required dated 2/1/22. There was no grade or signature of the person that reviewed the test.

PF#2, date of hire: 9/30/21, contained an incomplete written competency test containing all sixteen (16) areas required dated 9/30/21. There was no grade or signature of the person that reviewed the test.

PF#3, date of hire: 12/15/14, contained an incomplete written competency test containing all sixteen (16) areas required date 12/30/14. There was no grade or signature of the person that reviewed the test.

PF#4, date of hire: 6/9/09, contained an incomplete written competency test containing all sixteen (16) areas required dated 6/1/09. There was no grade or signature of the person that reviewed the test.

PF#5, date of hire: 5/11/19, contained an incomplete written competency test containing all sixteen (16) areas required dated 5/11/19. There was no grade or signature of the person that reviewed the test.

PF#6, date of hire: 4/22/21, contained an incomplete written competency test containing all sixteen (16) areas required dated 4/23/21. There was no grade or signature of the person that reviewed the test.

PF#7, date of hire: 6/24/21, contained an incomplete written competency test containing all sixteen (16) areas required dated 6/22/21. There was no grade or signature of the person that reviewed the test.

PF#8, date of hire 9/22/21, contained an incomplete written competency test containing all sixteen (16) areas required dated 9/22/21. There was no grade or signature of the person that reviewed the test.

PF#9, date of hire: 2/7/22, contained an incomplete written competency test containing all sixteen (16) areas required dated 2/7/22. There was no grade or signature of the person that reviewed the test.

PF#10, date of hire: 2/20/18, contained an incomplete written competency test containing all sixteen (16) areas required dated 2/20/18. There was no grade or signature of the person that reviewed the test.




An interview conducted with the agency office manager on 2/11/22 at approximately 3:15 pm confirmed the above findings.






Plan of Correction:

We have added a box to our new hire checklist that asks for the score of the Conditions Associated with Aging Quiz. This will ensure that the quiz is scored and signed off on. Operations will do weekly audits to ensure the tests are being scored sufficiently.

A task has been entered into our system (eRSP) with a due date and score reminder for the annual continuing education quiz. This task will pop up on Operations calendar and will need to be manually marked as completed once the quizzes are collected and scored.


Initial Comments:


Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on February 11, 2022, Comfort Keepers, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).


Plan of Correction: