QA Investigation Results

Pennsylvania Department of Health
COMFORT KEEPERS #488
Health Inspection Results
COMFORT KEEPERS #488
Health Inspection Results For:


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Initial Comments:


Based on the findings of an unannounced onsite state re-licensure survey completed May 22, 2024, Comfort Keepers #488 was found not to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.





Plan of Correction:




51.3 (f) LICENSURE
NOTIFICATION

Name - Component - 00
51.3 Notification

(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.

Observations:


Based on an interview with the agency Administrator, the agency failed to ensure to ensure event reporting to the Pennsylvania (Pa.) Department of Health for one (1) of one (1) rejected event reports (ER) submitted (ER#1).

Findings Include:

'28 PA Code - 51.3 Notification Confidential Information'
"Welcome to the Department of Health, Division of Home Health site for electronic submission of the Event Reporting Form. The information submitted by your facility, following acceptance by Division of Home Health professional staff, will be used to investigate facility events and become part of an electronic repository of event information. This repository will provide easier access to event information as well as the capability to evaluate event trends by regions, facilities, event categories, date ranges, and other criteria. All information is considered confidential and shall not be released without consent of the facility or by a Court Order as outlined in 28 PA Code 51.3 (i). All facilities are required to submit notification of events as defined in 28 Pa Code Chapter 51 to the Department of Health within 24 hours of occurrence or discovery. The Electronic Event Reporting System is the mechanism the Department will use to meet this regulatory requirement. After facility submission of an event, Department of Health professional staff will review each submitted event and either accept or reject the submission. When a submitted event is rejected, the facilities have three (3) calendar days to either correct and resubmit the event information or to withdraw the original submission. It is expected that only a small number of events will have to be withdrawn. An example of when a facility would withdraw an event would be if they made a duplicate submission of the same event in error. "

ER #1: Agency incident/complaint log was reviewed on May 22, 2024 at approximately 11:30 a.m. 'Date Received' 4/29/2024, 'Complaint Title/Offense' 'Hospitalization' 'Situation' "(Consumer #6) told caregiver she took 15 Tylenol and wanted to die." The event was not submitted to the Department of Health Event Reporting System.


An interview conducted with the agency Administrator on May 22, 2024 at approximately 12:45 p.m. confirmed the above findings.





Plan of Correction:

ER #1/Consumer #6 filing timely report to ERS while reporting to EIM.

This event will be entered into the DOH ERS.

Conduct a thorough review of the current event reporting processes to identify gaps and deficiencies. Analyze historical data to understand patterns of underreporting and areas for improvement.

Comfort Keepers Internal Client Care Coordinators will report into the EIM system for OLTL and MCO's. Reports in EIM will then be evaluated for each event by Operations Manager and VP of Operations for further reporting into DOH ERS.

We will audit events quarterly to ensure reporting to the ERS.


Initial Comments:


Based on the findings of an unannounced onsite state re-licensure survey completed May 22, 2024, Comfort Keepers #488 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 employee files and an interview with the agency Administrator, the agency failed to obtain not less than two satisfactory references prior to hire, for four (4) out of seven (7) employee files (EF) reviewed (EF#3, EF#4, EF#6, EF#7).

Findings include:

A review of EFs was conducted on May 22, 2024 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.

EF#3 DOH 01/22/24: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) prior to hire. One (1) positive/verifiable reference was obtained on 01/19/24. A second reference was obtained on 01/22/24 by a person related to the employee.
EF#4 DOH 10/05/23: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) prior to hire.
EF#6 DOH 03/10/23: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) prior to hire. One (1) positive/verifiable reference was obtained on 04/28/23. A second reference was obtained on 04/28/23 by a person related to the employee.
EF#7 DOH 04/25/23: No documentation provided of obtaining not less than two satisfactory references (positive, verifiable) prior to hire. One (1) positive/verifiable reference was obtained on 05/01/23. A second reference was obtained on 05/01/23 by a person related to the employee.

An interview conducted with the agency Administrator on May 22, 2024 at approximately 12:45 p.m. confirmed the above findings.










Plan of Correction:

**Purpose:**
This policy is established to ensure that all caregivers hired by Comfort Keepers undergo a thorough screening process, including face-to-face interviews and positive reference checks. We aim to maintain the highest standards of quality and professionalism in our caregiving services.

**Procedure:**
1. **Face-to-Face Interview Forms:**
- Prior to on-boarding/hiring a caregiver, a face-to-face interview must be conducted by a designated representative, Staffing Coordinator, of Comfort Keepers.
- During the interview, the Staffing Coordinator will fill out a standardized interview form, documenting relevant information about the candidate's qualifications, experience, skills, and suitability for the caregiving role.
- The completed face-to-face interview form must be submitted as part of the candidate's on-boarding documentation.

2. **Reference Checks:**
- Two positive references for each caregiver candidate must be obtained prior to on-boarding.
- The references must be contacted by a representative of Comfort Keepers, who will document the reference checks in full detail.
- The reference checks should focus on the candidate's work ethic, reliability, interpersonal skills, and ability to provide quality care to clients.
-References obtained will not be any relation to the candidate.

3. **Documentation Submission:**
- All completed face-to-face interview forms and positive reference documentation must be submitted at the time of the candidate's orientation.
- If any of the documentation is found to be inaccurate, incomplete, or unsatisfactory, the orientation process will not proceed.
- Candidates will be notified of the reason for the delay in their orientation and given an opportunity to rectify any discrepancies in the documentation.

**Compliance:**
- It is the responsibility of the Staffing Coordinator to ensure compliance with this policy for all caregiver candidates.
- Any deviations from this policy must be approved by the Communications Department before proceeding with the on-boarding process.

**Implementation:**
This policy will be communicated to all relevant personnel involved in the recruitment and on-boarding process at Comfort Keepers. Training will be provided to ensure understanding and adherence to the policy guidelines.

**Review and Updates:**
This policy will be reviewed periodically to ensure its effectiveness and relevance. Any necessary updates or modifications will be made in accordance with the changing needs of the organization.

This policy is effective immediately upon approval and supersedes any previous policies or practices related to the on-boarding of caregivers at Comfort Keepers.


611.52(c) LICENSURE
Federal Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual shall obtain a federal criminal history record and a letter of determination from the Department of Aging, based on the individual ' s Federal criminal history record, in accordance with the requirements at 6 PA. Code 15.144(b) (relating to procedure).

Observations:


Based on a review of employee files and an interview with the agency Administrator, agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for four (4) out of seven (7) employee files (EF) reviewed (EF#1, EF#2, EF#6, EF#7).

Findings include:

A review of EFs was conducted on May 22, 2024 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.

EF#1 DOH 12/14/23: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issue date 08/27/22 with an expiration date of 09/04/26. 'Employment Application' record was reviewed. Most recent Pa. employer listed with 'Employment Dates' "1/19 to 1/20." No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 12/14/21-08/27/22.

EF#2 DOH 10/11/23: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issue date 10/05/23 with an expiration date of 04/13/27. 'Employment Application' record was reviewed. Most recent employer listed with incomplete address and no employment dates listed. 'Reason for Departure' "Moved out of state." Documentation provided of a paid receipt dated 10/04/23 for a Department of Aging criminal check. No documentation of the employee obtaining the criminal check. No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 10/11/21-10/05/23.

EF#6 DOH 03/10/23: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Pa. Drivers License issue date 09/20/21 with an expiration date of 09/17/23. 'Employment Application' record was reviewed. Previous employer section blank with no entries. No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 03/10/21-09/20/21.

EF#7 DOH 04/25/23: No documentation provided to show that the applicant was a resident of Pennsylvania (Pa.) for the 2 years immediately preceding application for employment. Agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging. Arkansas Identification Card issue date 05/08/19 with an expiration date of 05/08/23. 'Employment Application' record was reviewed. Previous employer section blank with no entries. No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 04/25/21-04/25/23.


An interview conducted with the agency Administrator on May 22, 2024 at approximately 12:45 p.m. confirmed the above findings.







Plan of Correction:

For EF# 1, 2, 6, 7 will be requested to obtain a Fingerprint record, Drivers License record showing 2 years immediately preceding hire residence, AND the issue date of the PA ID or Driver's License is less than 2 years of application/orientation, Fingerprints will be run prior to caregiver attending shift.
A full Internal audit will be conducted of the entire employee census to further up to-date any employee to verify 2 years of residency.
Will create/implement on the employment application under work history for the hire to supply the date (month/year) with full addresses, city, state provided to show 2 years immediately preceding hire date of residency in Pennsylvania. If any applicant does not have 2 years of employment immediately prior to the hiring date to verify residency then Fingerprint is requested, AND the issue date of the PA ID or Driver's License is less than 2 years of application/orientation, Fingerprints will be run prior to caregiver attending shift.
Comfort Keepers will monitor these files when submitted at the time of hire. Also, an internal audit of 10% of the personnel files will be audited every quarter by our Communication Supervisor to ensure that the deficient practice will not recur.
All employees (caregivers and administration) will receive TB Education, Risk Assessment, and TB Screening.
Will create/implement an updated TB Education, Tb Rish Assessment, and TB Screening to be distributed to all of our employees.
Our Communications Director will be in direct contact to obtain and monitor this process and correction prior to caregiver going on shift.



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 employee files and an interview with the agency Administrator, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for four (4) out of seven (7) employee files (EF) reviewed (EF#1, EF#4-EF#6).

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 screening annually. HCWs with a baseline positive or newly 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 EFs was conducted on May 22, 2024 at approximately 9:45 a.m. Employee date of hire (DOH) is listed below.

EF#1 DOH 12/14/23: No documentation provided of a TB test upon hire. Documentation provided of a TB test being conducted late on 04/12/24.
EF#4 DOH 10/05/23: No documentation provided of a TB test upon hire.

EF#5 DOH 01/12/24: No documentation provided of a TB test upon hire.

EF#6 DOH 03/10/23: No documentation provided of a TB test upon hire.


An interview conducted with the agency Administrator on May 22, 2024 at approximately 12:45 p.m. confirmed the above findings.









Plan of Correction:

EF #1,4,5,6 will be requested to complete complete QF.

Policy Statement:
It is the policy of Comfort Keepers to require all caregivers to undergo TB screening, either through a two-step TB test or QuantiFERON-TB Gold+, before going on shift with clients. The TB screening is to be completed and submitted at the time of orientation for Comfort Keepers employees. The screening will be conducted at Comfort Keepers' contracted labs, and Comfort Keepers will cover the cost of these screenings.
Purpose:
The purpose of this policy is to ensure the health and safety of both caregivers and clients by minimizing the risk of tuberculosis transmission. TB screening is an essential component of our commitment to providing a safe and healthy environment for our clients and staff.
Policy Details:
1. TB Screening Requirement:
a. All new caregivers must undergo TB screening before going on shift with clients.
b. Existing caregivers who have not previously undergone TB screening must complete the screening at the time of orientation.
2. Types of TB Screening:
a. Caregivers have the option to undergo either a two-step TB test or a QuantiFERON-TB Gold+ test.
b. The choice of screening method will be determined in consultation with Comfort Keepers' designated healthcare provider, preferred and expense covered is the QuantiFERON-TB Gold+ test.
3. Timing of Screening:
a. TB screening must be completed before the caregiver's first shift with a client.
b. The results of the TB screening will be provided directly to the Comfort Keepers compliance team from the contracted facility.
4. Conducting the TB Screening:
a. TB screenings will be conducted at labs contracted by Comfort Keepers.
b. Comfort Keepers will cover the cost of the TB screenings, and caregivers will not be responsible for any associated expenses.
5. Compliance and Consequences:
a. Failure to complete the TB screening as required may result in the caregiver being ineligible to work with clients until the screening is completed.
b. Non-compliance with this policy may also result in disciplinary action, up to and including termination.
6. Confidentiality:
a. All TB screening results will be kept confidential and will only be accessible to designated personnel in the HR and healthcare departments on a need-to-know basis.
b. Any information related to the TB screening will be handled in compliance with applicable privacy laws and regulations.
7. Updates and Renewal:
a. Caregivers will be required to undergo TB screening periodically as determined by Comfort Keepers' healthcare provider. QuantiFERON-TB Gold+ test. To be completed every two years.
b. Any changes to the TB screening policy will be communicated to all caregivers in a timely manner.
Implementation:
This policy will be effective immediately upon its issuance. All caregivers and relevant staff members will be informed of this policy, and the necessary steps will be taken to ensure compliance with the TB screening requirement.
Review and Revision:
This policy will be subject to periodic review to ensure its effectiveness and compliance with relevant regulations. Any necessary revisions will be made in consultation with appropriate stakeholders.
Conclusion:
By adhering to this policy, Comfort Keepers aims to uphold the highest standards of safety and care for both our clients and caregivers. We appreciate the cooperation of all caregivers in fulfilling this important health requirement.
Comfort Keepers will be completing this for all employees with the updated TB Education information. This will also continue annually Dec/Jan continuing for their employment file. Also, an internal audit of 10% of the personnel files will be audited every quarter by our Communication Supervisor to ensure that the deficient practice will not recur.



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 on a review of consumer files, the consumer admission packet, and an interview with the agency Administrator, the agency failed to provide the consumer, prior to the commencement of services, the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry for three (3) out of five (5) consumer files (CF) reviewed (CF#1, CF#2, CF#5).

Findings include:

A review of CFs was conducted on May 22, 2024 at approximately 10:00 a.m. Consumer start of service (SOS) is listed below.

CF#1 SOS 03/11/24: No documentation provided of the agency providing the consumer, prior to the commencement of services, the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.
CF#2 SOS 03/14/24: No documentation provided of the agency providing the consumer, prior to the commencement of services, the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.
CF#5 SOS 03/26/24: No documentation provided of the agency providing the consumer, prior to the commencement of services, the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.

An interview conducted with the agency Administrator on May 22, 2024 at approximately 12:45 p.m. confirmed the above findings.






Plan of Correction:

CF#1,#2, #5 did not have the updated documentation due to administrative error of policy that was updated in 2023. The External Client Care Coordinator used an outdated form. This has been audited and updated and the Client Conduct Rights and Responsibility correct documentation stating #20. Our Direct Care Workers have been trained according to Chapter 611.

We will maintain Internal audits quarterly and prior to 6 month POC updates so if updated paperwork is needed we can complete that as well to ensure correct documentation is being used when on-boarding clients.

We are having the External Client Care Coordinator go back to home to complete an POC Update, provide with updated and accurate documentation with signature to make up for this deficiency.

Our Communications Dept will be responsible to ensure these documents are correct.


Initial Comments:


Based on the findings of an unannounced onsite state re-licensure survey completed May 22, 2024, Comfort Keepers #488 was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: