QA Investigation Results

Pennsylvania Department of Health
COMFORCARE SENIOR SERVICES
Health Inspection Results
COMFORCARE SENIOR SERVICES
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 June 16, 2021, Comforcare Senior Services 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 June 16, 2021, Comforcare Senior Services 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:




611.51(a) LICENSURE
Hiring or Rostering Prerequisites

Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of 611.53 (relating to child abuse clearance).

Observations:


Based on a review of personnel files (PF) and interview with the Client and Caregiver Coordinator, the agency failed to obtain and document references for two (2) of seven (7) direct care worker PF reviewed. (PF #'s 2 and 6).

Findings Include:

A review of PF conducted on June 16, 2021 from approximately 10:45 A.M. to 12:00 PM. revealed the following:

PF #2, date of hire April 2, 2020, contained no documentation of two (2) satisfactory references being obtained upon hire.
PF #6, date of hire December 21, 2020, contained documentation of only one (1) satisfactory reference being obtained upon hire.

Interview with the Client and Caregiver Coordinator on June 16, 2021, at approximately 1:30 P.M. confirmed the above findings.













Plan of Correction:

Upon accepting an applicant for orientation, references are to be obtained prior to the scheduled orientation the Client and Caregiver Coordinator.

At the time of orientation of applicant, file shall be reviewed by Administrative Assistant to ensure all references are present. The file will not be given to the scheduler until all documents are completed, wherein not allowing the caregiver to receive an assignment.
On a quarterly basis all active files will be reviewed by the RN to ensure all files are up to date.

Immediately before being placed on their first case, Client and Caregiver Coordinator shall check the DCW's file to make sure all three references are present.


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 Centers for Disease Control (CDC) guidelines, direct care worker personnel files (PF) and an interview with the Client and Caregiver Coordinator, the agency did not conduct testing for mycobacterium tuberculosis according to the Center for Disease Control (CDC) guidelines for two (2) of seven (7) PF reviewed. (PF #1 and 6).

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. 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).

A review of PF conducted on June 16, 2021, from approximately 10:45 A.M. to 12:00 P.M. revealed the following:

PF #1, date of hire July 14, 2020, contained documentation of only a one-step Tuberculin skin test (TST) completed on July 5, 2020. There was no documentation of a second-step TST being completed.

PF #6, date of hire December 21, 2020, contained documentation of a one-step TST completed on December 20, 2020. There was no documentation of a second-step TST being completed.

Interview with the Client and Caregiver Coordinator on June 16, 2021, at approximately 1:30 P.M. confirmed the above findings.












Plan of Correction:

Upon accepting an applicant for orientation, a two-step PPD shall be obtained prior to the scheduled orientation by the Client and Caregiver Coordinator.
At the time of orientation of applicant, file shall be reviewed by Administrative Assistant to ensure a two-step PPD is present.
The file will not be given to the scheduler until all documents are completed, wherein not allowing the caregiver to receive an assignment.
On a quarterly basis all active files will be reviewed by the RN to ensure all files are up to date.
The Client and Caregiver Coordinator shall review the file to make sure the DCW has a completed two-step PPD immediately before being placed on their first case.


Initial Comments:


Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on June 16, 2021, Comforcare Senior Services was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: