QA Investigation Results

Pennsylvania Department of Health
COMFORCARE SENIOR SERVICES
Health Inspection Results
COMFORCARE SENIOR SERVICES
Health Inspection Results For:


There are  9 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:

Based on the findings of an onsite unannounced state re-licensure survey conducted on May 23, 2024, 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 May 23, 2024, 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 an interview with agency ' s staff, the agency did not conduct a face-to-face interview with the individual and obtain not less than two satisfactory references for the individuals prior to hiring or rostering a direct care worker for five (5) of seven (7) PF' (PF# 1, 2, 4, 6 and 7).

Findings include:

A review of PF's was conducted on 5/23/24 starting at approximately 12:00 pm. The date of hire (DOH) is indicated below.

PF#1, DOH 9/14/22, did not have evidence that, prior to hiring or rostering the direct care worker, agency conducted a face-to-face interview with the individual and obtained two (2) satisfactory references from non-family members. The PF contained no satisfactory reference.

PF#2, DOH 4/23/21, did not have evidence that, prior to hiring or rostering the direct care worker, agency conducted a face-to-face interview with the individual.

PF#4, DOH 3/30/23, did not have evidence that, prior to hiring or rostering the direct care worker, agency obtained two (2) satisfactory references from non-family members. The PF contained no satisfactory reference.

PF#6, DOH 6/30/23, did not have evidence that, prior to hiring or rostering the direct care worker, agency obtained two (2) satisfactory references from non-family members. The PF contained no satisfactory reference.

PF#7, DOH 2/26/24, did not have evidence that, prior to hiring or rostering the direct care worker, agency conducted a face-to-face interview with the individual.


An interview with the agency ' s staff conducted on 5/23/24 starting at 2:00 PM confirmed the above findings.







Plan of Correction:

A. Face to Face Interview.

a. Each new hire will have a face to face interview with the following questions which will include name of applicant, name of interviewer and date interviewed:

1. Why are you interested in applying for this position?
2. Have you ever been terminated from a job: If yes, provide the details.
3. What do you think it takes to be a good caregiver?
4. Is there anything as a caregiver that you are uncomfortable with?
5. Tell me about a couple of your former positions, what type of individuals you cared for, and what your duties were.
6. On a scale of 1-10, when I talk to your previous supervisor , how will that person rate you overall and and why?
7. On a scale of 1-10, when I talk to your previous supervisor, who will that person rate you overall and why?
8. Where do you see yourself in 5 years career-wise?
9. Tell me about a difficult situation you had with a client and how you handled it.
10. What do you think is the toughest part of being a caregiver?

Each new hire will be given a few scenarios and tell how they would handle them.

ALL FACE TO FACE INTERVIEWS WILL BE CONDUCTED ON THE FIVE FILES THAT WERE DEFICIENT AND COMFIRMATION WILL BE PLACED IN THEIR FILE. ONGOING UPON HIRING THERE WILL BE A FACE TO FACE INTERVIEW DOCUMENTED TO THE FILE. MARIE, OFFICE MANAGER WILL SUPERVISE THAT ALL ARE COMPLETED PRIOR TO HIRING. ALL PLANS OF CORRECTION SET FORTH WILL BE IMPLEMENTED BY JUNE 28, 2024.


611.52(b) LICENSURE
State Police Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.

Observations:


Based on a review of personnel files (PF) and an interview with agency staff, the agency failed to provide documentation of a Pennsylvania State Police Criminal Background Check at the time of application or within 1 year immediately preceding the date of application for two (2) of seven (7) PF's reviewed (PF # 4 and 6).

Findings include:

A review of PF's was conducted on 5/23/24 at approximately 12:00 pm which revealed:

PF #4 Date of Hire: 3/30/23, contained no documentation of a Pennsylvania State Police Criminal Background Check completed.

PF #6 Date of Hire: 6/30/23, contained no documentation of a Pennsylvania State Police Criminal Background Check completed.

An interview with agency staff on 5/23/24 at approximately 2:00 PM confirmed the above findings.






Plan of Correction:

a NEW HIRE WILL NOT BE ASSIGNED TO A CLIENT UNTIL ALL BACKGROUND CHECKS ARE COMPLETED.
OFFICE ADMINISTRATION WILL SUPERVISE AND COMPLETE ALL BACKGROUND CHECKS. THE DEFICIENT DOCUMENTATION WILL BE CORRECTED AND WILL BE IN EACH PERSONNEL FILE BY JUNE 28, 2024. GOING FORWARD WE WIL ENSURE THAT FAMILY MEMBERS WHO ARE WORKING FOR THEIR FAMILY WILL HAVE BACKGROUND CHECKS ALSO COMPLETED.


611.55(e) LICENSURE
Competency Requirements

Name - Component - 00
The competency review must occur at least once per year after initial competency is established, and more frequently when discipline or other sanction, including, for example, a verbal warning or suspension, is imposed because of a quality of care infraction.

Observations:

Based on a review of personnel files (PFs) and an interview with the agency ' s staff, the agency failed to conduct annual competency review for three (3) of seven (7) personnel files reviewed (PF# 1, 2 and 4).

Findings include:

A review of PFs conducted on 5/23/24, at approximately 12:00 pm revealed the following:
PF#1, DOH (date of hire): 9/14/22, did not contain documentation of annual competency training for 2023.
PF#2, DOH: 4/23/21, did not contain documentation of annual competency training for 2022, 2023 and 2024.
PF#4, DOH: 3/30/23, did not contain documentation of annual competency training for 2024.
An interview with the agency ' s staff on 5/23/24, at approximately 2:00 pm confirmed the above findings.






Plan of Correction:

THE AGENCY WILL INCORPORATE AS ITS REQUIRED PROTOCAL THAT SUBSEQUENT TO THE INITIAL COMPETENCY TEST THE AGENCY WILL SCHEDULE AN ADDITIONAL COMPETENCY TEST AT LEAST ONCE A YEAR AND UPON ANY DISCIPLINARY OR OTHER SANCTION IN THE PROCESS OF THEIR CARE TO THE CONSUMER
THE, CAREGIVER COORDINATOR WILL REVIEW AND OVERSEE COMPETENCY TEST ON A YEARLY BASIS. ALL DEFICIENCYS WILL BE CORRECTED BY JUNE 28, 2024.


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), the Centers for Disease Control (CDC) guidelines, and an interview with the agency ' s staff, the agency did not provide documentation that a direct care worker (DCW) was screened for and free from active mycobacterium tuberculosis for five (5) of seven (7) PF's (PF#1, 2, 5, 6 and 7) and did not provide documentation that a direct care worker completed a baseline tuberculosis symptom screen questionnaire and individual tuberculosis risk assessment upon hire for four (4) of seven (7) PF's (PF# 3, 4, 5 and 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 screen annually. HCWs with a baseline 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 personnel files (PF) was conducted on 5/23/24 starting at approximately 12 pm. The date of hire (DOH) is indicated below.

PF#1 DOH 9/14/22 did not contain evidence that a two-step TST or TB single blood assay was completed upon hire for a direct care worker who is providing services to a consumer.

PF#2 DOH 4/23/21 contained documentation of tuberculin skin test (TST) completed on 7/22/20. There was no evidence that a 2nd step TST was completed.

PF#3 DOH 7/18/23 did not contain evidence that a TB symptom screen questionnaire, nor a TB risk assessment was completed upon hire.

PF#4 DOH 3/30/23 did not contain evidence that a TB symptom screen questionnaire, nor a TB risk assessment was completed upon hire.

PF#5 DOH 11/9/23 contained documentation of tuberculin skin test (TST) completed on 11/14/23. There was no evidence that a 2nd step TST was completed. The file did not contain evidence that a TB symptom screen questionnaire, nor a TB risk assessment was completed upon hire.

PF#6 DOH 6/30/23 contained documentation of tuberculin skin test (TST) completed on 6/27/23. There was no evidence that a 2nd step TST was completed.

PF#7 DOH 2/26/24 contained documentation of tuberculin skin test (TST) completed on 2/21/24. There was no evidence that a 2nd step TST was completed. The file did not contain evidence that a tuberculin (TB) symptom screen questionnaire, nor a TB risk assessment was completed upon hire.

An interview conducted with the agency staff on 5/23/24 starting at 2 pm 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 CAREGIVER COORDINATOR. AT TIME OF ORIENTATION THE ADMINISTRATIVE ASSISTANT WILL ENSURE A TWO STEP PPD HAS BEEN SUBMITTED. THE FILE WILL NOT PROCEED TO SCHEDULER UNTIL IT IS COMPLETED WITH THE NECESSARY DOCUMENTS. THE ADMINISTRATIVE ASSISTANT WILL ENSURE ALL FILES ARE UP TO DATE ON A QUARTERLY BASIS.
THERE WILL BE AN ANNUAL SCREENING REQUIRED FOR ALL CAREGIVERS OVERSEEN BY OFFICE ADMINISTRATOR. THE DEFICIENCYS WILL BE CORRECTED BY JUNE 28, 2024.

PF1 HAS RESIGNED, PF2 IS COMPLETED WITH THEIR SCREENINGS, PF-3 HAS RESIGNED,PF-4 HAS BEEN COMPLETED PF-5 COMPLETED 6/5/24,
PF-6 IS TO COMPLETE PRIOR TO 6/28/24 OR WILL BE REMOVED FROM CASE, AND PF-7 NEVER WAS AN ACTIVE EMPLOYEE WITH US



Initial Comments:

Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on May 23, 2024, Comforcare Senior Services was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: