Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on September 10, 2024, 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 September 10, 2024, 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:
611.52(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 upon personnel file (PF) review and interview with the agency's Administrator, it was determined that the agency failed to ensure documentation of a federal criminal history record and a letter of determination from the Pennsylvania Department of Aging, for direct care workers who have not been a resident of the Commonwealth for the previous two years for one (1) out of seven (7) personnel files reviewed (PF#5).
Findings include:
Personnel files were reviewed on 9/10/2024 from approximately 11:00 AM- 11:30 AM revealing the following:
PF#5 (Date of hire (DOH): 3/19/24): File contained a South Carolina Driver's License issued on 2/1/24. No documentation of a federal criminal history record and a letter of determination from the Pennsylvania Department of Aging.
An interview with the agency Branch Manager on 9/10/2024 at approximately 11:45 AM confirmed the above findings.
Plan of Correction:The Personnel file reviewed during survey will obtain a federal criminal history record and a letter of determination from the Pennsylvania Department of Aging, for direct care workers who have not been a resident of the Commonwealth and the documentation will be placed in the personnel file by 11/05/2024.
The HR Manager will review all current personnel files. A federal criminal history record and a letter of determination from the Pennsylvania Department of Aging, for direct care workers who have not been a resident of the Commonwealth for the previous two years will be completed and placed in the personnel files of individuals in similar situations by 11/05/2024.
A federal criminal history record and a letter of determination from the Pennsylvania Department of Aging, for direct care workers who have not been a resident of the Commonwealth for the previous two years will be completed for all new hires. The HR Manager will be responsible for monitoring the completion to ensure compliance with 611.52(c).
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 personnel files (PF), and interview with agency administrator it was determined the agency failed to ensure the direct care worker, prior to consumer contact, was screened for mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for seven (7) out of seven (7) personnel files (PF) reviewed (PF#1-PF#7).
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).
Findings include:
Personnel files were reviewed on 9/10/24 from approximately 10:30 AM-11:00 AM revealing the following:
PF#1 (Date of hire (DOH) 10/20/2023): No documentation of completed baseline testing. PF included documentation of only one (1) TST.
PF#2 (DOH: 1/26/24): No documentation of completed baseline testing. PF included documentation of only one (1) TST.
PF#3 (DOH: 5/24/24): No documentation of completed baseline testing. PF included documentation of only one (1) TST.
PF#4 (DOH: 1/26/24): No documentation of completed baseline testing. PF included documentation of only one (1) TST.
PF#5 (DOH: 3/19/24): No documentation of completed baseline testing. PF included documentation of only one (1) TST.
PF#6 (DOH: 3/01/24): No documentation of completed baseline testing. PF included documentation of only one (1) TST.
PF#7 (DOH: 1/25/24): No documentation of completed baseline testing. PF included documentation of only one (1) TST.
An interview with the agency administrator on 9/10/24 at approximately 11:45 AM confirmed the above findings.
Plan of Correction:Personnel files reviewed during survey will 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 and documentation will be placed in personnel files by 11/05/2024.
The HR Manager will review all current personnel files. The documentation for baseline tuberculosis screening, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis will be completed and placed in the personnel files of individuals in similar situations by 11/05/2024.
Baseline tuberculosis screening will be completed and placed in all personnel files. Files will be monitored by the HR Manager. Personnel files will be reviewed by the HR Manager prior to consumer contact to ensure compliance with 611.56(a).
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on September 10, 2024, Comfort Keepers, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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