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 onsite unannounced state re-licensure survey conducted on May 5, 2021, Comfort Keepers #488 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 state re-licensure survey conducted on May 5, 2021, 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:




611.2(a) LICENSURE
License required

Name - Component - 00
Each physical location of the home care agency or home care registry must be separately licensed.

Observations:


Based on a review of personnel files (PF) and an interview with the billing administrator, the agency did not keep complete PFs at its current location for review.

Findings include:

A review of PFs was conducted on May 5, 2021 at 10:08 -11:00 AM and 12:00-12:30 PM.

A total of fourteen (14) PFs were reviewed and found to contain incomplete documentation relevant for licensure review. The PFs contained mainly payroll information.

An interview with the billing administrator on May 5, 2021 at 10:30 AM stated that the parts of the PFs were kept at the Hazleton office (a separate agency, license number 15753601) and would have the remaining documentation scanned to the current location for review.











Plan of Correction:

All personnel files will be uploaded into Clear Care at the locations the DCW works from. The hard copy of the personnel file be in our Administrative office. The electronic file will be available to the surveyor upon any audit using Clear Care.
The files will be uploaded by the Staffing Coordinator within 48 hours of the completion of orientation.
Every Tuesday the following week, the Administrative Assistance will audit the file from the Monday to Sunday New Hires, to assure all paperwork has been completed and uploaded into Clear Care.


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 billing administrator, the agency did not obtain not less than two satisfactory references for the individual that is positive, verifiable form a former employer or other person not related to the individual for five (5) of fourteen (14) PFs. PF#6, 7, 8, 11, and 12.

Findings include:

A review of PFs was conducted on May 5, 2021 at 10:08-11:00 AM and 12:00-12:30 PM.

PF#6 Date of hire 11/11/20 contained two blank reference forms with reference contact information but no documented reference noted.

PF#7 Date of hire 10/27/20 contained only one reference.

PF#8 Date of hire 5/10/19 did not contain any references.

PF#11 Date of hire 3/18/19 did not contain any references.

PF#12 Date of hire 6/13/19 did not contain any references.

An interview with the billing administrator on May 5, 2020 at 12:45 PM confirmed the above findings.












Plan of Correction:

All personnel files will be uploaded into Clear Care at the locations the DCW works from. The hard copy of the personnel file be in our Administrative office. The electronic file will be available to the surveyor upon any audit using Clear Care.
The files will be uploaded by the Staffing Coordinator within 48 hours of the completion of orientation.
Every Tuesday the following week, the Administrative Assistance will audit the file from the Monday to Sunday New Hires, to assure all paperwork has been completed and uploaded into Clear Care.
The paperwork will be checked for completion. The Staffing Coordinator is responsible for completion of all on-boarding paperwork, especially interview forms and reference forms. The Staffing Coordinator did receive a discipline action due to this not being completed. We (Administrative Assistance, Operations Manager, and Payroll Admin) will begin auditing of every piece of paperwork moving forward.


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 billing administrator, the agency did not perform a competency review at least once per year after initial competency is established for eight (8) of fourteen (14) PFs. PF#1, 3, 4, 8, 9, 11, 12, and 14.

Findings include:

A review of PFs was conducted on May 5, 2021 at 10:08-11:00 AM and 12:00-12:30 PM.

PF#1 Date of hire 10/16/18 did not contain an annual competency review for 2019 and 2020.

PF#3 Date of hire 5/4/18 did not contain an annual competency review for 2019 and 2020.

PF#4 Date of hire 7/1/19 did not contain an annual competency review for 2020.

PF#8 Date of hire 5/10/19 did not contain an annual competency review for 2020.

PF#9 Date of hire 6/16/16 did not contain an annual competency review for 2019 and 2020.

PF#11 Date of hire 3/18/19 did not contain an annual competency review for 2020.

PF#12 Date of hire 6/13/19 did not contain an annual competency review for 2020.

PF#14 Date of hire 12/12/19 did not contain an annual competency review for 2020.

An interview with the billing administrator on May 5, 2020 at 12:45 PM confirmed the above findings.



















Plan of Correction:

All personnel files will be uploaded into Clear Care at the locations the DCW works from. The hard copy of the personnel file be in our Administrative office. The electronic file will be available to the surveyor upon any audit using Clear Care.
The files will be uploaded by the Staffing Coordinator within 48 hours of the completion of orientation.
Every Tuesday the following week, the Administrative Assistance will audit the file from the Monday to Sunday New Hires, to assure all paperwork has been completed and uploaded into Clear Care.
The paperwork will be checked for completion. The Staffing Coordinator is responsible for completion of all on-boarding paperwork and continued yearly and updated competency. The Staffing Coordinator did receive a discipline action due to this not being completed. We (Administrative Assistance, Operations Manager, and Payroll Admin) will begin auditing of every piece of paperwork moving forward.


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), recommendations from the Centers for Disease Control, and an interview with the billing administrator, the agency did not ensure that each direct care worker with direct consumer contact have documentation that the individual has been screened for and is free from active mycobacterium tuberculosis for eleven (11) of fourteen (14) PFs. PF# 1-4, 6, 8-10, 11-13.

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) of 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.

A review of PFs was conducted on May 5, 2021 at 10:08-11:00 AM and 12:00-12:30 PM.

PF#1 Date of hire 10/16/18 did not contain an initial two-step TST and did not contain an annual TB screening for 2019 and 2020.

PF#2 Date of hire 5/8/18 did not contain an annual TB screening for 2019 and 2020.

PF#3 Date of hire 5/4/18 did not contain an annual TB screening for 2019.

PF#4 Date of hire 7/1/19 did not contain a second TST on hire and did not contain an annual TB screening for 2020.

PF#6 Date of hire 11/11/20 did not contain an initial screening for TB.

PF#8 Date of hire 510/19 did not contain an initial two step TST and did not contain an annual screening for 2020.

PF#9 Date of hire 6/16/16 contained a one step TST on hire and did not contain an annual TB screening for 2017, 2018, 2019, 2020.

PF#10 Date of hire 10/3/17 did not contain an annual TB screening for 2018, 2019, 2020.

PF#11 Date of hire 3/18/19 contained a one step TST on hire and did not contain an annual TB screening for 2020.

PF#12 Date of hire 6/13/19 did not contain an initial two step TST on hire and did not contain an annual TB screening for 2020.

PF#13 Date of hire 1/19/21 did not contain an initial screening for TB.

An interview with the billing administrator on May 5, 2020 at 12:45 PM confirmed the above findings.












Plan of Correction:

Upon on boarding with Comfort Keepers for the orientation the 2 Step PPD process will have been started at the time of orientation. Within 21 days from the orientation the 2 step PPD must be completed and on file. Comfort Keepers will supply site for 2 step PPD to be completed. Annual the 1 step PPD and/or questionnaire will be completed by the caregiver. The monitoring system will be through ClearCare tasks for each caregiver. The Staffing Coordinator, will be monitoring these caregivers and tasks. Also, the responsible party for monitoring will be the Senior Staffing Coordinator.


Initial Comments:


Based on the findings of an onsite unannounced home care agency state re-licensure survey conducted on May 5, 2021, Comfort Keepers #488 was found to be in compliance with the requirements of 35 P.S. 448.809 (b).



Plan of Correction: