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 June 18, 2024, 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 on the findings of an onsite unannounced state re-licensure survey conducted on June 18, 2024, Comfort Keepers, was found to not 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 review of personnel files (PF) and an interview with agency administrator, the agency failed to conduct face-to-face interview and/or obtain two (2) satisfactory references prior to hiring or rostering for six (6) of the seven (7) PF's reviewed. (PF#2-7)

Findings include:
Personnel file review conducted June 18, 2024 from approximately 12 p to 4 pm revealed the following:

PF #2 Date of hire (DOH), 10/5/23: Did not contain documentation of two (2) satisfactory references prior to the hire date.

PF#3 DOH 5/8/23: Did not contain documentation a face-to-face interview prior to hire date.

PF#4 DOH 6/26/23: Did not contain documentation a face-to-face interview prior to hire date.

PF#5 DOH 7/11/22: Did not contain documentation of two (2) satisfactory references prior to the hire date.

PF#6 DOH 4/19/22: Did not contain documentation of two (2) satisfactory references or a face to face interview prior to the hire date.

PF #7 DOH 2/21/23: Did not contain documentation of two (2) satisfactory references prior to the hire date.


An interview with the administrator on June 18,2024 at approximately 4:30pm confirmed the above findings.




Plan of Correction:

EF#2-7 will be reviewed and obtain valid satisfactory references to meet the requirements.

Will create/implement the employment verification of references to be two positive/satisfactory references of past employment and/or personal- non-relative for the applicant at hire. The Communication Director will decline any on-boarding of new employees if references are incomplete to meet the requirements.

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.


611.52(b) LICENSURE
State Police Criminal History Record

Name - Component - 00
If the individual required to submit or obtain a criminal history report has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.

Observations:

Based on a review of personnel files (PF), and an interview with the agency administrators, the agency failed to provide documentation of a Pennsylvania State Police Criminal Background Check (PATCH) at the time of application or within one (1) year immediately preceding the date of application for one (1) of seven (7) PF's reviewed. (PF#6)

Findings include:
Personnel file review conducted June 18, 2024 from approximately 12 p to 4pm revealed the following:

PF#6 DOH 4/19/22: Contained no documentation of a criminal background check performed upon hire or within one year preceding the hire date.

An interview with the administrator on June 18, 2024 at approximately 4:30pm confirmed the above findings.





Plan of Correction:

EF#6 file will be updated with PATCH document for updating the file.

Will create/implement that PATCH is ran for every new hire and on-boarding employee for Comfort Keepers. Communications Director will decline the on-boarding process is incomplete with the PATCH not being ran at the time of employment.

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.


611.52(d) LICENSURE
Proof of Residency

Name - Component - 00
The home care agency or home care registry may request an individual required to submit or obtain a criminal history record to furnish proof of residency through submission of any one of the following documents:
(1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation

Observations:

Based on a review of personnel files (PF) and an interview with the administrator, the agency did not provide documentation of proof of residency in order to obtain a criminal history record through submission of any of the following documents: (1) Motor vehicle records, such as a valid driver ' s license or a State-issued identification.
(2) Housing records, such as mortgage records or rent receipts.
(3) Public utility records and receipts, such as electric bills.
(4) Local tax records.
(5) A completed and signed, Federal, State or local income tax return with the applicant ' s name and address preprinted on it.
(6) Employment records, including records of unemployment compensation
for two (2) of seven (7) PFs. ( PF#5 and PF#7)


Findings include:
Personnel file review conducted June 18, 2024 from approximately 12 p to 4 pm revealed the following:

PF#5 DOH 7/11/22: Contained a Pennsylvania driver's license issued on 3/15/22, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency.

PF #7 DOH 2/21/23: Contained a Pennsylvania driver's license issued on 9/30/21, which fails to ascertain PA residence of two (2) or more years. No other documentation on file to establish proof of residency.


An interview with the administrator on June 18,2024 at approximately 4:30pm confirmed the above findings.





Plan of Correction:

For EF#5,7 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.


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 review of personnel files (PF), and an interview with the agency administrator, it was determined the agency failed to demonstrate, prior to assigning or referring the direct care worker to provide services to a consumer, competency by passing an initial competency examination for seven (7) of seven (7) PF reviewed. (PF#1-7)



Findings include:
Personnel file review conducted June 18, 2024 from approximately 12 p to 4 pm revealed the following:

PF#1 Date of hire (DOH) 11/3/23: Contained no documentation showing an initial competency exam was completed prior to assigning or referring the direct care worker to provide services to a consumer.

PF #2 DOH 10/5/23: Contained no documentation showing an initial competency exam was completed prior to assigning or referring the direct care worker to provide services to a consumer.

PF#3 DOH 5/8/23: Contained no documentation showing an initial competency exam was completed prior to assigning or referring the direct care worker to provide services to a consumer.

PF#4 DOH 6/26/23: Contained no documentation showing an initial competency exam was completed prior to assigning or referring the direct care worker to provide services to a consumer.

PF#5 DOH 7/11/22: Contained no documentation showing an initial competency exam was completed prior to assigning or referring the direct care worker to provide services to a consumer.

PF#6 DOH 4/19/22: Contained no documentation showing an initial competency exam was completed prior to assigning or referring the direct care worker to provide services to a consumer.

PF #7 DOH 2/21/23: Contained no documentation showing an initial competency exam was completed prior to assigning or referring the direct care worker to provide services to a consumer.


An interview with the administrator on June 18,2024 at approximately 4:30pm 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.

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 review of personnel files (PF), and an interview with the agency administrator, it was determined the agency failed to perform a competency review, which 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 for two (2) of seven (7) PF reviewed. (PF#5 and PF#6)


Findings include:
Personnel file review conducted June 18, 2024 from approximately 12p to 4 pm revealed the following:


PF#5 DOH 7/11/22: Contained no documentation for direct care worker competency to perform assigned duties through direct observation, testing, training, consumer feedback or other method approved by the Department.

PF#6 DOH 4/19/22: Contained no documentation for direct care worker competency to perform assigned duties through direct observation, testing, training, consumer feedback or other method approved by the Department.


An interview with the administrator on June 18,2024 at approximately 4:30pm confirmed the above findings.





Plan of Correction:

For EF#5,6 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 review of CDC guidelines, personnel files (PF) and staff interview it was determined the facility failed to ensure direct care workers were tested for and were free from active mycobacterium tuberculosis prior to assignment with clients for five (5) out of seven (7) PF's reviewed. (PF#1-4, PF#7)

Findings include:

The CDC guidelines state that all Health Care Workers (HCW) should received 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 screen 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;(RR-17)
http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.

Personnel file review conducted June 18, 2024 from approximately 12p to 4 pm revealed the following:

PF#1 Date of hire 11/3/23: Contained no documentation of a tuberculin test performed upon hire.

PF #2 DOH 10/5/23: Contained no documentation of a baseline tuberculin test upon hire. QuantiFERON Gold test dated 11/9/23 is after the hire date.

PF#3 DOH 5/8/23: Contained no documentation of a baseline tuberculin test upon hire. Quantiferon Gold test dated 2/23/24 is after the hire date.

PF#4 DOH 6/26/23: Contained no documentation of a completed baseline tuberculin test upon hire. One (1) step TST dated 6/5/23 documented. No documentation of a step two (2) in the file.

PF #7 DOH 2/21/23: Contained no documentation of a completed baseline tuberculin test upon hire. One (1) step TST dated 3/25/24 documented. No documentation of a step two (2) in the file.

An interview with the administrator on June 18,2024 at approximately 4:30pm confirmed the above findings.





Plan of Correction:

Will create/implement an updated TB Education, Tb Risk Assessment, and TB Screening to be distributed to all of our employees during orientation at the time of hire.
Our Communications Director will be in direct contact to obtain and monitor this process.
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+, at the time of hire. 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 at the time of hire.
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 personnel files (PF), and an interview with the administrator, the recommendations from the Centers for Disease Control (CDC), the agency did not provide documentation that the individual has completed annual tuberculosis (TB) education and screening for two (2) of the seven (7) PF's reviewed. (PF#5 and PF#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).

Personnel file review conducted June 18, 2024 from approximately 12 p to 4 pm revealed the following:

PF#5 Date of hire (DOH) 7/11/22: Contained no documentation of an annual TB screening or annual TB education for 2023.

PF#6 DOH 4/19/22: Contained no documentation of an annual TB screening or annual TB education for 2023.


An interview with the administrator on June 18,2024 at approximately 4:30pm confirmed the above findings.







Plan of Correction:

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 review of consumer files (CF) and an interview with the administrator, the agency failed to provide the following information to the consumer, the consumer's legal representative, or a responsible family member prior to the start of services: 1) the identity of the direct care worker (DCW) who would be providing the services, 2) the hours when the services would be provided, 3) the fees and total costs for those services on an hourly or weekly basis, and 4) the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry for five (5) of the five (5) CF's reviewed. (CF#1-5)

Findings include:
Consumer file review conducted June 18, 2024 from approximately 12 p to 4pm revealed the following:


CF#1 Start of care (SOC) 7/25/19: Did not contain evidence of the consumer, the consumer's legal representative, or a responsible family member receiving the following information prior to the start of services: 1) the identity of the DCW who would be providing the services, 2) the hours when the services would be provided, 3) the fees and total costs for those services on an hourly or weekly basis, and 4) 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 SOC 10/2/22: Did not contain evidence of the consumer, the consumer's legal representative, or a responsible family member receiving the following information prior to the start of services: 1) the identity of the DCW who would be providing the services, 2) the hours when the services would be provided, 3) the fees and total costs for those services on an hourly or weekly basis, and 4) the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.

CF#3 SOC 5/15/23: Did not contain evidence of the consumer, the consumer's legal representative, or a responsible family member receiving the following information prior to the start of services: 1) the identity of the DCW who would be providing the services, 2) the hours when the services would be provided, 3) the fees and total costs for those services on an hourly or weekly basis, and 4) the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.

CF#4 SOC 11/28/20: Did not contain evidence of the consumer, the consumer's legal representative, or a responsible family member receiving the following information prior to the start of services: 1) the identity of the DCW who would be providing the services, 2) the hours when the services would be provided, 3) the fees and total costs for those services on an hourly or weekly basis, and 4) 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 SOC 4/15/24: Did not contain evidence of the consumer, the consumer's legal representative, or a responsible family member receiving the following information prior to the start of services: 1) the identity of the DCW who would be providing the services, 2) the hours when the services would be provided, 3) the fees and total costs for those services on an hourly or weekly basis, and 4) 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 with the agency administrator on June 18, 2024 at approximately 4:30pm confirmed the above findings.






Plan of Correction:

This policy outlines the procedures for documenting communication with new clients regarding the initial caregiver attending the first shift and ongoing scheduling changes. The goal is to ensure transparency, accuracy, and accountability in all client communications and scheduling processes.
**Procedure:**
1. **New Client Communication:**
- When a new client is onboarded, a designated staff member will contact the client or their family to communicate details about the initial caregiver attending the first shift.
- The staff member must record the date, time, and details of the communication in the HHAexchange system.
- The HHAexchange file will include the name of the caregiver attending the first shift and the name of the staff member who communicated this information to the client or family.
2. **Initial Caregiver Assignment:**
- The initial caregiver assigned to the new client's first shift must be accurately documented in the HHAexchange system.
- Any changes to the initial caregiver assignment must be promptly updated in the system and communicated to the client or family.
3. **Ongoing Scheduling Changes:**
- Any scheduling changes for the client must be documented in the HHAexchange system.
- If a new caregiver is assigned to the client, the name of the new caregiver and the reason for the change must be recorded in the system.
- The client or family must be informed of any scheduling changes in advance, whenever possible.
4. **Audit Trail:**
- All communication records, including details of the initial caregiver assignment and scheduling changes, must be maintained in the HHAexchange system.
- The time and date of each recorded phone call must be included in the documentation for reference during audits.
5. **Compliance and Training:**
- All staff members involved in client communication and scheduling must be trained on this policy and understand the importance of accurate documentation.
- Compliance with this policy is mandatory for all staff members, and any deviations must be reported to the appropriate supervisor.
**Review and Update:**
This policy will be reviewed annually and updated as needed to ensure compliance with regulations and best practices in client communication and scheduling.
**Effective Date:**
This policy is effective immediately upon approval and dissemination to all relevant staff members.
By following this policy, Comfort Keepers aims to maintain clear communication with clients and ensure that scheduling changes are documented accurately and transparently.



Initial Comments:

Based on the findings of an unannounced, on-site, state re-licensure survey conducted on June 18, 2024, Comfort Keepers, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: