COMFORT PLUS HOMECARE REGISTRY
Health Inspection Results For:
There are 9 surveys for this facility. Please select a date to view the survey results.
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Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
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Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on May 15, 2025, Comfort Plus Home Care, LLC., 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 15, 2025, Comfort Plus Home Care, LLC., 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:
611.56(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), Centers for Disease Control Guidelines, and an interview with the Owner and Administrative Assistant, the agency failed to provide documentation that the individual has received an initial symptom screening/risk assessment upon hire for seven (7) of seven (7) PF's, (PF#1, 2, 3, 4, 5, 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 conducted on May 15, 2025 at approximately 12:00 pm revealed the following:
PF#1 - Date of Hire: 6/27/2024. PF did not contain documentation that the agency conducted an initial tuberculosis symptom screening upon hire.
PF#2 - Date of Hire: 1/17/2025. PF did not contain documentation that the agency conducted an initial tuberculosis symptom screening upon hire.
PF#3 - Date of Hire: 12/4/2018. PF did not contain documentation that the agency conducted an initial tuberculosis symptom screening upon hire.
PF#4 - Date of Hire: 8/20/2019. PF did not contain documentation that the agency conducted an initial tuberculosis symptom screening upon hire.
PF#5 - Date of Hire: 7/28/2022. PF did not contain documentation that the agency conducted an initial tuberculosis symptom screening upon hire.
PF#6 - Date of Hire: 1/25/2023. PF did not contain documentation that the agency conducted an initial tuberculosis symptom screening upon hire.
PF#7 - Date of Hire: 2/12/2024. PF did not contain documentation that the agency conducted an initial tuberculosis symptom screening upon hire.
An interview conducted with the Owner and Administrative Assistant on May 15, 2025 at approximately 1:15 pm confirmed the above findings.
Plan of Correction:The assessment forms have been revised to include additional educational information that the previous TB assessment questionnaire form lacked according to the surveyor.
We will review files monthly to make sure all staff receive the TB risk assessment annually. Upon hiring, a two-step skin test, a single blood test, or a negative chest x-ray is required. TB symptom screening and risk assessment procedures will be implemented in accordance with 611.56(a).
In addition, we will ensure that the staff database is consistently reviewed to ensure all staff receive the required training and assessment, ensuring that all policies and procedures are followed.
The administrative assistant will diligently review files for new hires to ensure all test results received are in compliance. All staff files and the database will be reviewed monthly to ensure every caregiver has received TB educational information annually.
All corrective action will be completed by June 28, 2025
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 Owner and Administrative Assistant, the agency failed to ensure each direct care worker were provided with annual mycobacterium tuberculosis education for three (3) of seven (7) PF's reviewed, (PF#3, 4 and 5).
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 conducted on May 15, 2025 at approximately 12:00 pm revealed the following:
PF#3 - Date of Hire: 12/4/2018. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2019, 2020, 2021, 2022 and 2023.
PF#4 - Date of Hire: 8/20/2019. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2020, 2021, 2022, and 2023.
PF#5 - Date of Hire: 7/28/2022. PF did not contain documentation that annual mycobacterium tuberculosis education was provided for 2024.
An interview conducted with the Owner and Administrative Assistant on May 15, 2025 at approximately 1:15 pm confirmed the above findings.
Plan of Correction:The TB educational survey and assessment have been revised. The administrative team will review all staff files, and the database will be reviewed monthly to ensure that all staff receive the annual TB training and assessment.
All staff files are being reviewed for any missing documents and to determine training needs. The updated training documents will be distributed to all staff to ensure we are following the guidelines and maintaining the safety of all participants.
The administrator will correct all deficiencies by implementing the revised educational material and reviewing all staff files to ensure that Comfort Plus Home Care is in compliance with all regulations.
As noted above, the administrative assistant will review files and the database on a monthly basis. The POC correction action plan will be completed by 6/28/25
Initial Comments:
Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on May 15, 2025, Comfort Plus Home Care, LLC., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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