Initial Comments:
Based on the findings of an unannounced onsite home care agency state re-licensure survey conducted on May 19, 2025, 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 May 19, 2025, Comfort Keepers was found to be not 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 review of personnel files (PFs) and interview with agency owner, agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for two (2) of seven (7) PFs reviewed. (PF# 2 and PF# 5).
Findings include:
Review of PFs conducted on May 19, 2025 between approximately 11:40 AM to 1:30 PM revealed:
PF# 2 Date of Hire, 8/16/2023: No documentation provided federal criminal history record and a letter of determination was obtained.
PF# 5 DOH 8/9/2024: No documentation provided federal criminal history record and a letter of determination was obtained.
An interview with the agency owner, conducted on May 19, 2025 at approximately 2:15 PM confirmed the above findings.
Plan of Correction:Procedure according to regulations will be reviewed with HR by Owner with the clear understanding that each individual is required to submit or obtain a criminal history report if not been a resident of this Commonwealth for 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).This with the understanding it is completed prior to direct care workers being rostered.
PF#2 - Lease agreement or fingerprinting is being secured (by 6/28/2025)
PF#5 - Previous ID or fingerprinting is being secured (by 6/28/25)
Procedure has been revised to have documents secured prior to Orientation - giving ample time to having Federal fingering printing completed prior to being rostered.
The remainder of PF's will be reviewed on or before 6/28/2025 to assure the all are within regulation
All personal files will be audited on an annual basis by Office Manager.
611.55(a) LICENSURE
Competency 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 review of personnel files (PFs) and interview with agency owner, agency failed to demonstrate, prior to assigning or referring a direct care worker to provide services to a consumer, competency by passing a competency examination for two (2) of seven (7) PFs reviewed. (PF# 6 and PF# 7).
Findings include:
Review of PFs was conducted on May 19, 2025 between approximately 11:40 AM to 1:30 PM revealed:
PF# 6, Date of Hire (DOH), 3/26/2025: No documentation provided initial competency completed prior to assigning or referring a direct care worker to provide services to a consumer.
PF# 7, Date of Hire (DOH), 4/22/2025: No documentation provided initial competency completed prior to assigning or referring a direct care worker to provide services to a consumer.
An interview with the agency owner, conducted on May 19, 2025 at approximately 2:15 PM confirmed the above findings.
Plan of Correction:Procedure according to regulations will be reviewed with HR by Owner with the clear understanding that competency tests including all 16 competencies are completed prior to direct care workers being rostered and annually.
PF#6 - All competency trainings completed
PF#7 - All competency trainings completed
The remainder of PF's will be reviewed on or before 07/03/2025 to assure they all are within regulation.
Trainings will be verified weekly by HR to assure direct care workers are not rostered until all competencies are completed. Files will be spot audited annually by Office Manager.
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 (PFs) and interview with agency owner, agency failed to ensure each direct care worker and other staff or contractors with direct consumer contact, prior to consumer contact, were screened for/are free from active mycobacterium tuberculosis for four (4) of seven (7) PFs reviewed. (PF# 1, PF# 5, PF # 6, and 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 ' ). (.)
Findings include:
Review of PFs was conducted on May 19, 2025 between approximately 11:40 AM to 1:30 PM revealed:
PF# 1, Date of Hire (DOH), 2/1/2024: No documentation of 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.
PF# 5 Date of Hire (DOH), 8/9/2024: No documentation of 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.
PF# 6, Date of Hire (DOH), 3/26/2025: No documentation of 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.
PF# 7, Date of Hire (DOH), 4/22/2025: No documentation of 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. One step tuberculin skin test administered on 10/1/2024 and read on 10/3/2024.
An interview with the agency owner, conducted on May 19, 2025 at approximately 2:15 PM confirmed the above findings.
Plan of Correction:Procedure according to regulations will be reviewed with HR by Owner with the clear understanding 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.
Screenings will be scheduled at the time of job offer with staff nurse to assure completion prior to direct care workers being rostered.
PF#1 - screening scheduled for 05/29/2025
PF#5 - screening scheduled for 05/29/2025
PF#6 - screening scheduled for 05/29/2025 and 06/12/2025
PF#7 - screening scheduled for 05/29/2025
The remainder of PF's will be reviewed on or before 07/03/2025 to assure the are all within regulation.
This will be overseen by HR prior to rostering the direct care worker and annually. Files will be audited annually by Office Manager.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on May 19, 2025, 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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