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 April 11, 2024, Comfort Keepers #488 was found to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.





Plan of Correction:




Initial Comments:


Based on the findings of an unannounced onsite state re-licensure survey completed April 11, 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:




611.52(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, the agency failed to obtain a federal criminal history record and a letter of determination from the Department of Aging for three (3) out of seven (7) employee files (EF) reviewed (EF#2, EF#5, EF#6).

Findings include:

A review of EFs was conducted on April 11, 2024 at approximately 11:15 a.m. Employee date of hire (DOH) is listed below.

EF#2 DOH 08/30/23: 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 issued 08/09/23 with an expiration date of 09/11/26. 'Employment Application' form was reviewed. Employer listed with incomplete address. 'Employment Dates:' "2/10/22 To 4/15/22." No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 08/30/21-08/09/23.

EF#5 DOH 11/03/23: 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. Identification Card issued 05/02/23 with an expiration date of 09/16/26. 'Employment Application' form was reviewed. Employer listed with incomplete address. 'Employment Dates:' "9/22 To 10/23." No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 11/03/21-05/02/23.

EF#6 DOH 02/10/23: 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 issued 04/02/21 with an expiration date of 06/30/25. 'Employment Application' form was reviewed. 'Previous Employer' section blank with no entries. No other Pa. proof of residency documentation provided.
No proof of Pa. residency from 02/10/21-04/02/21.


An interview conducted with the agency Administrator on April 11, 2024 at approximately 2:15 p.m. confirmed the above findings.






Plan of Correction:

For EF# 2,5,6 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.



611.55(a) LICENSURE
Competency Requirements

Name - Component - 00
Prior to assigning or referring a direct care worker to provide services to a consumer, the home care agency or home care registry shall ensure that the direct care worker has done one of the following: (1) Obtained a valid nurse ' s license in this Commonwealth;
(2) Demonstrated competency by passing a competency examination developed by the home care agency or home care registry which meets the requirements of subsection (b)and (c).
(3) Has successfully completed one of the following:
(i) A training program developed by a home care agency, home care registry, or other entity which meets the requirements of subsection (b) and (c).
(ii) A home health aide training program meeting the requirements of 42 C.F.R. 484.36 (relating to the Conditions of Participation; Home Health Aide Services).
(iii) The nurse aid certification and training program sponsored by the Department of Education and located at www.pde.state.pa.us.
(iv) A training program meeting the training standards imposed on the agency or registry by virtue of the agency ' s or registry ' s participation as a provider in a Medicaid waiver or other publicly funded program providing home and community based services to qualifying consumers.
(v) Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department ' s website.

Observations:


Based on a review of employee files and an interview with the agency Administrator, the agency failed to ensure documentation showing direct care workers, prior to providing services to consumers, completed/demonstrated an initial competency training covering all required sixteen (16) subject areas, for seven (7) of seven (7) employee files (EF) reviewed (EF#1 - EF#7).

Findings include:

A review of EFs was conducted on April 11, 2024 at approximately 11:15 a.m. Employee date of hire (DOH) is listed below.

EF#1 DOH 07/04/23: No documentation provided of initial competency training containing all sixteen (16) required elements.

EF#2 DOH 08/30/23: No documentation provided of initial competency training containing all sixteen (16) required elements.

EF#3 DOH 05/09/23: No documentation provided of initial competency training containing all sixteen (16) required elements.

EF#4 DOH 12/05/23: No documentation provided of initial competency training containing all sixteen (16) required elements.

EF#5 DOH 11/03/23: No documentation provided of initial competency training containing all sixteen (16) required elements.

EF#6 DOH 02/10/23: No documentation provided of initial competency training containing all sixteen (16) required elements.

EF#7 DOH 02/13/24: No documentation provided of initial competency training containing all sixteen (16) required elements.


An interview conducted with the agency Administrator on April 11, 2024 at approximately 2:15 p.m. confirmed the above findings.









Plan of Correction:

For EF#1-EF#7 will be requested to complete the new competency that shows the examples and actions of competency.
All employees (caregivers and administration) will conduct an updated competency with the updated competency form that provides examples of competency.
Will create/implement a competency form that include all 16 required areas (confidentiality, Consumer control and the independent living philosophy, Instrumental activities of daily living, Recognizing changes in the consumer that need to be addressed, Basic infection control, Universal precautions, Handling of emergencies, Documentation,
Recognizing and reporting abuse or neglect, Dealing with difficult behaviors, Bathing, shaving, grooming and dressing, Hair, skin and mouth care, Assistance with ambulation and transferring, Meal preparation and feeding, Toileting,and Assistance with self-administered medications) that tests and displays the true competency of the employee without explanation.
Comfort Keepers will be completing this for all employees with new competency forms to be up to date with corrections and changes. 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.



611.55(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 employee files and an interview with the agency Administrator, the agency failed to provide documentation showing annual competency review covering all required sixteen (16) subject areas for one (1) of one (1) employee files (EF) annual documentation reviewed (EF#6).

Findings include:

A review of EFs was conducted on April 11, 2024 at approximately 11:15 a.m. Employee date of hire (DOH) is listed below.

EF#6 DOH 02/10/23: No documentation provided of a 2024 annual competency review containing all sixteen (16) required elements.


An interview conducted with the agency Administrator on April 11, 2024 at approximately 2:15 p.m. confirmed the above findings.









Plan of Correction:

For EF#6 will be requested to complete the new competency that shows the examples and actions of competency.
All employees (caregivers and administration) will conduct an updated competency with the updated competency form that provides examples of competency.
Will create/implement a competency form that include all 16 required areas (confidentiality, Consumer control and the independent living philosophy, Instrumental activities of daily living, Recognizing changes in the consumer that need to be addressed, Basic infection control, Universal precautions, Handling of emergencies, Documentation,
Recognizing and reporting abuse or neglect, Dealing with difficult behaviors, Bathing, shaving, grooming and dressing, Hair, skin and mouth care, Assistance with ambulation and transferring, Meal preparation and feeding, Toileting,and Assistance with self-administered medications) that tests and displays the true competency of the employee without explanation.
Comfort Keepers will be completing this for all employees with new competency forms to be up to date with corrections and changes. 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.



611.56(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 seven (7) out of seven (7) employee files (EF) reviewed (EF#1-EF#7).

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 April 11, 2024 at approximately 11:15 a.m. Employee date of hire (DOH) is listed below.

EF#1 DOH 07/04/23: No documentation provided of an individual TB risk assessment (containing all three required questions) nor a TB symptom screen upon hire.

EF#2 DOH 08/30/23: No documentation provided of an individual TB risk assessment (containing all three required questions) upon hire.

EF#4 DOH 12/05/23: No documentation provided of a TB symptom screen upon hire.

EF#5 DOH 11/03/23: No documentation provided of a TB test nor a TB symptom screen upon hire.

EF#6 DOH 02/10/23: No documentation provided of a TB test, an individual TB risk assessment (containing all three required questions), nor a TB symptom screen upon hire.

EF#7 DOH 02/13/24: No documentation provided of a TB symptom screen upon hire.


An interview conducted with the agency Administrator on April 11, 2024 at approximately 2:15 p.m. confirmed the above findings.









Plan of Correction:

EF#1-EF#7

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.
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.



611.56(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 a review of employee files and an interview with the agency Administrator, 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 one (1) of one (1) employee files (EF) annual documentation reviewed (EF#6).

Findings Include:

The CDC (Center for Disease and Control) 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. ........ 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 April 11, 2024 at approximately 11:15 a.m. Employee date of hire (DOH) is listed below.
EF#6 DOH 02/10/23: No documentation provided of 2024 annual TB education.

An interview conducted with the agency Administrator on April 11, 2024 at approximately 2:15 p.m. confirmed the above findings.







Plan of Correction:

EF# 6 will obtain TB Education to bring their file up to date.
All employees (caregivers and administration) will receive TB Education.
Will create/implement an updated TB Education to be distributed to all of our employees.
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 fees and total costs for services provided on an hourly or weekly basis, for one (1) out of one (1) consumer files (CF) private payor sources reviewed (CF#1).

Findings include:

A review of CFs was conducted on April 11, 2024 at approximately 11:15 a.m. Consumer start of service (SOS) is listed below.

CF#1 SOS 04/28/23: No documentation provided of the agency providing the consumer with the fees and total costs for services provided on an hourly or weekly basis


An interview conducted with the agency Administrator on April 11, 2024 at approximately 2:15 p.m. confirmed the above findings.






Plan of Correction:

Consumer File # 1 will be updated with updated information hourly rate or weekly rate.
Will create/implement that the consumers will receive and sign documentation that they are aware of Comfort Keepers hourly or weekly rate.
Comfort Keepers will be completing this for all new consumers and working on updating on-gong consumers with the updated documentation. 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.




Initial Comments:


Based on the findings of an unannounced onsite state re-licensure survey completed April 11, 2024, Comfort Keepers #488 was found to be in compliance with the requirements of 35 P.S. 448.809 (b).















Plan of Correction: