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 state re-licensure survey conducted on May 11 and 12, 2021, Comfort Keepers #488 was found to not to be in compliance with the following requirement of 28 Pa. Code, Health and Safety, Part IV, Health Facilities, Subpart A. Chapter 51.






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 review of agency policies/procedures, documentation and the Pennsylvania (PA) Department of Health (DOH) Event Reporting System manual and website reports, and based on interviews with the internal client care coordinator (employee #1), the staffing coordinator (employee #2) and the administrator, the agency failed to submit four (4) of four (4) event reports to the PA DOH Event Reporting System (ERS) website.

Findings included:

On May 12, 2021 at approximately 11:19 AM, review of the agency policy titled "Critical Incident Management Policy" revealed the following:
Policy...Comfort Keepers will report critical incidents to mandatory reporting agencies as directed...
Procedure: It is the responsibility of Comfort Keepers to report all critical incidents.

On May 11, 2021 at approximately 8:02 AM, review of the PA DOH Event Reporting System Manual revealed "Health Department Reportable Diseases" are included under the reportable events included on page 7.

On May 11, 2021 at approximately 8:05 AM, review of the PA DOH website (https://www.health.pa.gov/topics/Reporting-Registries/Pages/Reportable-Diseases.aspx) revealed that COVID-19 is a PA DOH reportable disease.

On May 11, 2021 at approximately 11:03 AM, review of the agency forms titled "COVID-19 Evaluation Form for all prospective/current clients and caregivers" revealed the following:
On 01/13/2021, consumer #1 was documented as having been hospitalized with COVID-19.
On 01/13/2021, the direct care worker (employee #4) was documented as having developed symptoms of COVID-19 on 01/10/2021 and that the employee #4 had been evaluated/treated by a physician. During interview conducted on May 11, 2021 at approximately 3:50 PM, the internal client care coordinator confirmed that employee #4 had tested positive for COVID-19.
On 03/31/2021, the staffing coordinator (employee #2) was documented as having developed symptoms of COVID-19 on 03/29/2021 and that the employee #2 had been evaluated/treated by a physician. During interview conducted on May 11, 2021 at approximately 2:29 PM, the staffing coordinator confirmed that employee #2 had tested positive for COVID-19.
On 04/01/2021, the direct care worker (employee #5) was documented as having developed symptoms of COVID-19 on 04/01/2021 and that the employee #5 had been evaluated/treated by a physician. During interview conducted on May 11, 2021 at approximately 3:50 PM, the internal client care coordinator confirmed that employee #5 had tested positive for COVID-19.

On May 11, 2021 at approximately 8:12 AM, review of the PA DOH ERS website failed to reveal that the agency had submitted reports of COVID-19 positive results between 01/13/2021 and 05/11/2021 to the PA DOH ERS website.

During telephone interview conducted on May 11, 2021 at approximately 3:50 PM, the administrator reported that the agency had been informed that the agency did not have to continue to report COVID-19 positive cases but the administrator was unable to provide evidence regarding the source that informed the agency of same. The administrator confirmed the agency failed to submit the above referenced reports to the PA DOH ERS website prior to May 11, 2021.










Plan of Correction:

Comfort Keepers will maintain reporting directly based upon their DCW and Consumers with any and all critical incidents regarding COVID-19 diagnosis positive results. We will maintain our in-house documentation and tracking with evaluation forms and communication with clients and caregivers who are in the period of days. Location Admin (Internal and Staffing) will report to Operations Manager, who will then report to ERS.


Initial Comments:

Based on the findings of an onsite state licensure survey conducted on May 11 and May 12, 2021, Comfort Keepers #488 was found not to be in compliance with the following requirements of Title 28 Health and Safety Part IV, Health Facilities, Subpart H. Chapter 611 Home Care Agencies and Home Care Registries.






Plan of Correction:




611.4(c) LICENSURE
Requirements for HCA and HCR

Name - Component - 00
Home care agencies and home care registries licensed under this Chapter shall comply with applicable environmental, health, sanitation and professional licensure standards which are required by Federal, State, and local authorities.

Observations:

Based on review of agency policies/procedures, documentation and personnel files, observational tour and interview with the staffing director (employee #2) and the administrator, the agency failed to ensure three (3) of three (3) office staff followed the May 3, 2021 Pennsylvania Department of Health COVID-19 universal face covering guidelines. (Employees #1, #2 and #3)

Findings:

On May 11, 2021 at approximately 4:10 PM, review of the agency's COVID-19 procedures revealed the following:
Sample of signage in the office...Attention Please Wear A Face Covering Before Entering.

On May 12, 2021 at approximately 12:33 PM, review of the May 3, 2021 "Updated Order of the Secretary of the Pennsylvania Department of Health Requiring Universal Face Coverings" revealed the following under "Frequently Asked Questions":
Do I have to wear a mask if alone in my workplace or office? Everyone must wear a face covering when indoors, irrespective of physical distance, however, if a person is working alone, and has no expectation of being around other persons, they do not need to do so.

On May 11, 2021 at approximately 2:13 PM, review of personnel files revealed the following:
Employee #1: The date of hire of the internal client care coordinator was 07/10/2019.
Employee #2: The date of hire of the staffing coordinator was 03/07/2016.
Employee #3: The date of hire of the field director was 06/15/2012.

On May 11, 2021 at approximately 11:03 AM, review of the agency forms titled "COVID-19 Evaluation Form for all prospective/current clients and caregivers" revealed the following:
On 03/31/2021, the staffing coordinator (employee #2) was documented as having developed symptoms of COVID-19 on 03/29/2021 and that the employee #2 had been evaluated/treated by a physician. During interview conducted on May 11, 2021 at approximately 2:29 PM, the staffing coordinator confirmed that employee #2 had tested positive for COVID-19.

Onsite observational findings on May 11, 2021 between the approximate times of 9:59 AM and 3:50 PM revealed three (3) staff members were present in the office (employees #1, #2 and #3). Employees #1, #2 and #3 were not wearing face coverings at 9:59 AM and failed to apply face coverings after 09:59 AM.

During telephone interview conducted on May 11, 2021 at approximately 3:50 PM, the administrator reported that agency staff socially distance while working in the office and that face coverings are only worn when staff orientation is being conducted. The administrator confirmed the agency failed to ensure that face coverings were utilized by employees #1, #2 and #3 on May 11, 2021.









Plan of Correction:

Comfort Keepers will maintain the most current guidelines for COVID-19 for wearing of PPE equipment. As of 5.26.21 update face coverings will be worn indoors. Monitoring will be completed throughout the week due to webcalls and/or in-person visits once a week by Operations Manager. Comfort Keepers always has PPE equipment available to Administration, DCW, and Consumers.


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 agency policies/procedures, consumer (agency) and personnel files and based on an interview with the administrator, the agency failed ensure a pre-employment interview was conducted prior to the date of hire/assignment to provide home care services for four (4) of seven (7) direct care workers (caregivers) who were hired/assigned after August 29, 2017. (Employees #4, #7, #8 and #10)

Findings include:

On May 11, 2021 at approximately 4:10 PM, review of the agency's COVID-19 procedures revealed the following:
Caregiver Interviewing...Conduct interviews by phone and video. Suspend in person interviews until further notice if needed.

Consumer #1: On May 11, 2021 at approximately 11:18 AM, review of the consumer list/consumer file revealed home care services were initiated on 11/26/2019. Direct care worker (DCW) electronic note documentation revealed employee #4 provided home care services in April and May 2021.

Consumer #4: On May 11, 2021 at approximately 12:50 PM, review of the consumer list/consumer file revealed home care services were initiated on 02/14/2020. DCW electronic note documentation revealed employee #7 provided home care services in April and May 2021.

Consumer #5: On May 11, 2021 at approximately 12:55 PM, review of the consumer list/consumer file revealed home care services were initiated on 03/11/2020. DCW electronic note documentation revealed employee #8 provided home care services in April and May 2021.

Consumer #7: On May 11, 2021 at approximately 1:24 PM, review of the consumer list/consumer file revealed home care services were initiated on 04/19/2021. DCW electronic note documentation revealed employee #10 provided home care services in May 2021.

On May 11, 2021 at approximately 2:13 PM, review of personnel files revealed the following:
Employee #4: The date of hire/assignment of the DCW was 01/29/2020. Review of the initial interview form revealed there were no interview findings entered on the form.
Employee #7: The date of hire/assignment of the DCW was 02/17/2020. There was no documentation in the personnel file which provided evidence that an initial interview was conducted prior to the DCW's date of hire/assignment.
Employee #8: The date of hire/assignment of the DCW was 01/30/2020. There was no documentation in the personnel file which provided evidence that an initial interview was conducted prior to the DCW's date of hire/assignment.
Employee #10: The date of hire/assignment of the DCW was 12/02/2020. There was no documentation in the personnel file which provided evidence that an initial interview was conducted prior to the DCW's date of hire/assignment.

During telephone interview conducted on May 11, 2021 at approximately 3:50 PM, the administrator confirmed the personnel file did not include documentation which provided evidence that an initial interview was conducted prior the date of hire/assignment for the above referenced DCW's.






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.



Initial Comments:

Based on the findings of an onsite state re-licensure survey conducted on May 11 and May 12, 2021, Comfort Keepers #488 was found to be in compliance with the requirements of 35 P.S. 448.809 (b).







Plan of Correction: