QA Investigation Results

Pennsylvania Department of Health
COMFORCARE HOME CARE CHESTER COUNTY NORTH
Health Inspection Results
COMFORCARE HOME CARE CHESTER COUNTY NORTH
Health Inspection Results For:


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Initial Comments:


Based on the findings of an offsite licensure complaint survey conducted on November 10, 2020 and November 11, 2020, Comforcare Home Care Chester County North, 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:




611.57(c) LICENSURE
Information to be Provided

Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.

Observations:


Based upon email from the agency owner, it was determined the agency failed to ensure, prior to the commencement of services, to provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency for one (1) of one (1) consumer file (CF) requested (CF#1).

Findings include:

On 11/10/2020, at approximately 11:20 AM, an email was sent to the agency owner requesting the service agreement/welcome packet for CF#1 (Start of care 10/6/2020).

On 11/11/2020, at approximately 2:57 PM, an email was received from the agency owner confirming no documentation of a service agreement/welcome packet available, containing the following information : (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency.




Plan of Correction:

To ensure compliance with the PA Department of Health regulation 611.57(c) LICENSURE for existing consumers, the Provider will implement the following new internal policies:
1. Provider will immediately audit all existing active consumer files to determine if there are any missing required documents from the file. A list of missing documents will be compiled from the audit.
DATE COMPLETED: 12/30/2020
2. Based on the audit results mentioned in number 1 above, the Provider will:
a. Have supervisory staff return to the active consumer's home/facility to have any missing documents signed.
b. The original signed missing documents will be placed into the Active consumer's files at the Providers office.
c. Copies of the documents will be returned to the consumer's home/facility and will be placed in the ComForCare Welcome Kit binder.
DATE TO BE COMPLETED: 1/8/2021
3. The consumer that filed the complaint is no longer active; however if they were, we would follow steps 1 and 2 listed above to ensure that proper documentation is in the consumer's possession.

To ensure compliance with the PA Department of Health regulation 611.57(c) LICENSURE moving forward, the provider will implement the following new internal policies:

1. The provider will hire a Care Coordinator who will be responsible to deliver Provider's Welcome Kit including all of the documents listed below to the consumer prior to the commencement of services.
DATE COMPLETED: 12/7/2020

2. A task will be assigned in the Provider's Back Office system to the Care Coordinator reminding them of the requirement to deliver all of the signed documents to the consumer prior to the commencement of services.
DATE COMPLETED: 12/27/2020

3. Provider's Scheduler will confirm that the task mentioned in #2 above is completed before scheduling actual shifts for the consumer.
DATE COMPLETED: 12/27/2020

4. Frequency of the Provider's internal document audits will be increased from quarterly to monthly, to confirm that all of the appropriate documents are in the consumer's files.
DATE COMPLETED: November audit 11/27/2020 and December audit 12/30/2020

REQUIRED DOCUMENTS:
The following documents will be included in the Provider's Welcome Kit:
(1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services.
(2) The hours when those services will be provided.
(3) Fees and total costs for those services on an hourly or weekly basis.
(4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry.
(5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA).
(6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.
(7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency.