QA Investigation Results

Pennsylvania Department of Health
COMFORT KEEPERS
Health Inspection Results
COMFORT KEEPERS
Health Inspection Results For:


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Initial Comments:


Based upon the findings of an unannounced on site complaint investigation survey conducted on 9/21/2020, 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 upon the findings of an unannounced on site complaint investigation survey conducted on 9/21/2020, 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:




611.57(a) LICENSURE
Consumer Rights

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(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.

Observations:

Based upon review of agency policy, consumer files (CF), consumer schedules, and interview with owner ( EMP # 1) the agency failed to provide the approved services for one (1) of three (3) consumer files reviewed. ( CF # 1).


Findings included:

A request was made for a policy regarding the consumer information given prior to start of services and none was provided.

Consumer files reviewed on 9/21/2020 between approximately 1:00 PM-3:00 PM revealed:

CF # 1, Start of Service (SOS) 3/0/2020; consumer diagnoses included neck surgery, edema with hands, degenerated disc One or more of the discs between the vertebrae of the spinal column deteriorates or breaks down, leading to pain. There may be weakness, numbness, and pain that radiates down the leg. Consumer can not use his hands- left worse than right.
Consumer was authorized by Veterans Affairs for up to nine (9) hours/ week of personal assistance services to assist with bathing, dressing, meal preparation.

Review of consumer schedules on 9/21/2020 between approximately 1:00 PM-3:00 PM revealed:
Missed hours were noted on 8/7/2020 between 12:15 PM-2:15 PM ( 2 hours).
Missed hours were noted on 8/19/2020 between 12:30 PM-2:30 PM ( 2 hours).
Missed hours were noted on 8/21/2020 between 12:15 PM-2:15 PM ( 2 hours).
Missed hours were noted on 8/25/2020 between 1:00 PM-3:00 PM ( 2 hours).
Missed hours were noted on 8/26/2020 between 3:15 PM-5:15 PM ( 2 hours).
Missed hours were noted on 9/2/2020 between 12:30 PM-2:30 PM ( 2 hours).
Missed hours were noted on 9/7/2020 between 2:30 PM-4:30 PM ( 2 hours).
Missed hours were noted on 9/8/2020 between 1:15 PM-3:15 PM ( 2 hours).
Missed hours were noted on 9/9/2020 between 12:30 PM-2:30 PM ( 2 hours).
Missed hours were noted on 9/11/2020 between 12:15 PM-2:15 PM ( 2 hours).

Termination order received on 9/17/2020 to end care and services effective 9/10/2020.

Interview with EMP # 1 on 9/21/2020 at approximately 2:30 PM confirmed above findings.













Plan of Correction:

Our agency will send a duplicate copy of all documents signed by the consumer as well as our policy of termination. Direct Caregiver calls are handled as promptly as possible and we will retrain all administration as well as direct caregivers as to the proper process when a shift that someone is assigned to cannot be completed. A record of all shifts that could not be provided will be updated in files. A 10 day written notice will be given to social worker as well as client if our agency can no longer schedule consumer for service. Our agency will monitor activity on our online operations scheduling system. Our agencies's Client Care Manager will be responsible for continued checking that our policy is being enforced and maintained for efficiency. All client information is kept in our operations system as well as hard copy file. These files electronic and hard copy will be monitored monthly to make sure our corrective action solutions are ensured. Random spot checks by owner will take place to see that the on going policy is carried out by the client care manager. The notice we received from the VA was received 7 days after the said date that the client wished to cancel our service with our agency. If we initiate the termination we will make sure we give a full 10 day notice.


611.57(b) LICENSURE
Prohibitions

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(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

Observations:


Based upon review of agency policy, consumer files (CF), and interview with owner ( EMP # 1) the agency failed to show evidence consumer was given information about agency employees being prohibited from being power of attorney and/ or endorsing checks for three (3) of three (3) files reviewed. ( CF # 1-3).


Findings included:

A request was made for a policy regarding the consumer information given prior to start of services and none was provided.

Consumer files reviewed on 9/21/2020 between approximately 1:00 PM-3:00 PM revealed:

CF # 1, Start of Service (SOS) 3/0/2020; no documentation produced that consumer was informed agency may not be power of attorney and/ or endorse checks.

CF # 2, SOS 6/6/2015; no documentation produced that consumer was informed agency may not be power of attorney and/ or endorse checks.

CF # 3, SOS 5/11/2020; no documentation produced that consumer was informed agency may not be power of attorney and/ or endorse checks.



Interview with EMP # 1 on 9/21/2020 at approximately 2:30 PM confirmed above findings.










Plan of Correction:

In order to correct this deficiency we are going to add a separate page as an addendum to our aggrement with our clients. The addendum will need to be signed by both the client as well as our agency. The addendum will state that no one from our agency will act as a signer, endorser, or a POA (Power of Attorney) of the client, as well as any legal document of any kind. All Direct Caregivers will receive an additional written policy notification at the same time. There will be absolutely no acceptations to this policy in order to protect the client. All current clients will receive a copy of our policy by mail, and a return stamped envelope to sign, & return so we may include this document in their client file. This notice to all current clients will be sent by USPS. Any new client we add to our client base will receive this document as part of our completion of our agreement packet. We will monitor the return and signature of the written policy document as we receive them back from the current clients. We will check to see that all clients return these documents. If they do not return documents they will receive a follow up phone call as to why they haven't returned this document. At which time we will make arrangements to see that we receive their response to our request.


611.57(c) LICENSURE
Information to be Provided

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(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 review of agency policy, consumer files (CF), and interview with owner ( EMP # 1) the agency failed to show evidence consumer was given information about fees and costs of services prior to start of services for one (1) of three (3) files reviewed. ( CF # 3).


Findings included:

A request was made for a policy regarding the consumer information given prior to start of services and none was provided.

Consumer files reviewed on 9/21/2020 between approximately 1:00 PM-3:00 PM revealed:

CF # 3, Start of Service (SOS) 5/11/2020; no documentation produced that consumer was informed of agency fees and costs of services.


Interview with EMP # 1 on 9/21/2020 at approximately 2:30 PM confirmed above findings.








Plan of Correction:

Our agency will make sure that all consumers planning to use the services we provide have all information as to the start date of service, time, caregiver name, as well as an agreement that states the fees for our service. All clients receive our "leave behind packet" with our contact numbers, our address, our administration staff photos as well as cell phones and e mail information. A copy of our "fees" is listed on the back of our team card as well as our photos. A follow up call is made by our administration team to alert our consumers to exactly who the caregiver will be as well as the time they expect the caregiver to arrive. Our packet includes an agreement as well as additional documents that are signed at commencement of care.

We will correct our problem with the client that did not have a copy of t heir agreement with are rate for service. We will sign the agreement and make sure we have a signature from them for the consumer file. All administration staff will be retrain ed to make sure the documents are in our files before we begin service. A copy of the 28 PA Code Health Facilities Capter 611 is clearly known and followed by each employee responsible for the administration of home health care.


Initial Comments:


Based upon the findings of an unannounced on site complaint investigation survey conducted on 9/21/2020, Comfort Keepers was found to be not in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction:




35 P. S. 448.809b LICENSURE
Photo Id Reg

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(1) The photo identification tag shall include a recent photograph of the employee, the employee's FIRST name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.



Observations:

Based upon review of agency policy, observation of photo Identification (ID) badge, and interview with owner ( EMP # 1) the agency failed to correctly format the employee ID badges as per requirement for approximately twenty (20) active direct care workers (DCW).


Findings included:

A request was made for a policy regarding the contents for the staff ID badges on 9/21/2020 at approximately 1:00 PM and none was provided.


Photo of employee ID badge of PF # 4, viewed on 9/21/2020 at approximately 1:00 PM, showed title less than 1/2 inch tall strip and titled was abbreviated, HHA instead of written out fully as caregiver.

Interview with EMP # 1 on 9/21/2020 at approximately 2:30 PM confirmed above findings.









Plan of Correction:

Each employee of our agency name badge will be revised per compliance with Dept of Health Guidelines. All outdated formats we followed will be made obsolete in our system. Their first name will be as large as possible as well as a 1/2" in height their title of their position. Our agency & address will be identified on the badge. All administration staff will have a like badge with our titles written out in 1/2" format near the bottom of the badge. Our company policy will be written with the department of Health format guidelines and be made part of our HR departments company guidelines. All new employees as well as current employees will have a new badge made as well as a copy will be part of their personnel file. We realize that these badges identify our staff for us and their clients as well as protect them.