Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted onsite on April 2, 2025 and offsite on April 9, 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 onsite on April 2, 2025 and offsite on April 9, 2025, 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:
611.51(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 the vice president of operations, the agency failed to document verification of at least two satisfactory and verifiable references for three (3) of seven (7) PF's reviewed, (PF #1, 2, and 3).
Findings include:
A review of PFs was conducted on 4/9/25 from approximately 10:30 AM to 12:00 PM.
PF #1, Date of Hire: 1/24/2025, contained documentation of only one (1)verification of satisfactory and verifiable reference.
PF #2, Date of Hire: 8/8/2024, contained documentation of only one (1) verification of satisfactory and verifiable references.
PF #3, Date of Hire: 7/25/2024, contained documentation of only one (1) verification of satisfactory and verifiable references.
An interview with the vice president of operations on April 9, 2025, at approximately 12:00 PM confirmed the above findings.
Plan of Correction:Our team has moved to a new HR system in 2025 that creates checkpoints to ensure 2 references are collected for each caregiver being considered for hire. Our team will review the process will all hiring managers.
In addition, our team will conduct an internal audit of all personnel files to determine how wide spread the issue of only 1 reference is and will be contacting additional references for any caregiver hired within the last 6 months.
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 (PF) and an interview with the vice president of operations, the agency failed to provide documentation of an annual competency evaluation for three (3) of seven (7) PF's reviewed, (PF #4, 6, and 7).
Findings include:
A review of PF's was conducted on 4/9/2025 from approximately 10:30 AM to 12:00 PM.
PF #4, Date of Hire: 5/11/2023, did not contain any documentation of an annual competency evaluation for 2024.
PF #6, Date of Hire: 10/10/2018, did not contain any documentation of an annual competency evaluation for 2023.
PF #7, Date of Hire: 2/8/2024, did not contain any documentation of an annual competency evaluation for 2025.
An interview with the vice president of operations on April 9, 2025 at approximately 12:00 PM confirmed the above findings.
Plan of Correction:Our team holds our Annual In-Service in April/May and it is mandatory that caregivers attend, in person, and complete the necessary training/yearly paperwork. We will continue to hold this training and will work to have all caregivers in compliance with attendance and completion of required paperwork.
If they do not attend during the scheduled dates we will have them attend at the office on a mutually agreed upon date within 30 days of the In-Service week.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.
Observations:
Based on a review of personnel files (PF), the Centers for Disease Control (CDC) guidelines, PA REVISED Guidance for Home Care Agencies, Home Health Care Agencies and Hospices During COVID-19 Pandemic dated May 20, 2020, and an interview with the vice president of operations, the agency did not provide documentation that a direct care worker was screened for and free from active mycobacterium tuberculosis, in accordance with CDC guidelines, for one (1) of seven (7) PF's reviewed, (PF#3)
Findings include:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. And 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education 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;(5-16-19)
PA REVISED Guidance for Home Care Agencies, Home Health Care Agencies and Hospices During COVID-19 Pandemic dated May 20, 2020, states, "9. Pre-employment Health Screening: The requirement for an initial baseline 2 step Mantoux skin test for tuberculin skin testing is temporarily suspended. All applicants must complete an individual risk assessment and symptom evaluation prior to hire. Any new employee who does not provide evidence of a Mantoux skin test within the previous 12 months must, as a condition of employment, receive the tuberculin skin test as soon as possible following termination of the Governor ' s COVID-19 Disaster Declaration."
A review of PF's was conducted on 4/9/2025 from approximately 10:30 AM to 12:00 PM.
PF#3, Date of Hire: 7/26/2024, contained documentation of only one (1) negative tuberculosis skin test dated 8/5/2024.
An interview with the vice president of operations conducted on April 9, 2025 at approximately 12:00 PM confirmed the above findings.
Plan of Correction:Our team moved to a new HR system in 2025 which will help ensure caregivers who are being considered for employment will not moved to hired until they complete their 2 step PPD test successfully or a Quantiferon Gold test successfully. We have conducted additional training with our Hiring Managers and will continue to reinforce the hiring practices that are in line with state regulations.
In addition, our team will review all personnel files for any caregivers who have only completed a 1 step PPD and will ask that they update with a 2 step or Quantiferon Gold test.
611.56(b) LICENSURE
Health Screening
Name - Component - 00
(b) A home care agency or home care registry shall require each direct care worker, and other office staff or contractors with direct consumer contact, to update the documentation required under subsection (a) at least every 12 months and provide the documentation to the agency or registry. The 12 months must run from the date of the last evaluation. The documentation required under subsection (a) shall be included in the individual's file.
Observations:
Based on review of personnel files (PFs), the Centers for Disease Control guidelines, and interview with the vice president of operations, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, were provided with annual mycobacterium tuberculosis education for three (3) of seven (7) PF's reviewed, (PF #4, 6, and 7).
Findings include:
In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. And 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education 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;(5-16-19)
A review of PF's was conducted on 4/9/2025 from approximately 10:30 AM to 12:00 PM.
PF #4, Date of Hire: 5/11/2023, did not contain any documentation of annual tuberculosis education provided for 2024.
PF #6, Date of Hire: 10/10/2018, did not contain any documentation of annual tuberculosis education provided for 2023.
PF #7, Date of Hire: 2/8/2024, did not contain any documentation of annual tuberculosis education provided for 2025.
An interview with the vice president of operations conducted on 4/9/2025 at approximately 12:00 PM confirmed the above findings.
Plan of Correction:Our team holds our Annual In-Service in April/May and it is mandatory that caregivers attend, in person, and complete the necessary training/yearly paperwork. We will continue to hold this training and will work to have all caregivers in compliance with attendance and completion of required paperwork. This includes completion of TB Education and attestation.
If they do not attend during the scheduled dates we will have them attend at the office on a mutually agreed upon date within 30 days of the In-Service week.
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted onsite on April 2, 2025 and offsite on April 9, 2025, Comfort Keepers, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|