QA Investigation Results

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


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Initial Comments:

Based on the findings of an on-site unannounced state re-licensure survey conducted on December 17, 2024 and concluded off-site on December 23, 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 on-site unannounced home care agency state re-licensure survey conducted on December 17, 2024, and concluded off-site on December 23, 2024, Comfort Keepers 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 upon a review of direct care worker personnel files (PF) and interview with the agency Vice President of Operations, the agency failed to document two (2) satisfactory references prior to employment for five (5) of seven (7) PF reviewed. (PF #1, 2, 4, 5, and 6).

Findings Include:

A review of PF's conducted on December 17, 2024, from approximately 10:15 A.M. to 11:15 A.M. and December 23, 2024, from approximately 8:30 A.M. to 9:00 A.M. revealed the following:

PF #1, date of hire March 11, 2024, contained no documentation of two (2) satisfactory references obtained prior to hire.

PF #2, date of hire September 23, 2024, contained no documentation two (2) satisfactory references obtained prior to hire.

PF #4, date of hire March 27, 2024, contained no documentation of two (2) satisfactory references obtained prior to employment.

PF #5, date of hire March 11, 2024, contained no documentation of two (2) satisfactory references obtained prior to employment.

PF #6, date of hire September 19, 2024, contained no documentation of two (2) satisfactory references obtained prior to employment.

An interview with the agency Vice President of Operations on December 17, 2024, at approximately 11:15 A.M. and a follow-up email on December 23, 2024, confirmed the above findings.














































































Plan of Correction:

1. How you will correct the deficiency for the files cited? We will locate original references for all personnel files in our digital filing system and correctly assign them to each caregivers file. In addition, with the help of our new HRIS system that went into effect on 12/23/2024, employee will no longer be able to move through the hiring process until references are added to their file.

2. How you will identify and correct any additional files that may have the same deficiency? We will be conducting an internal audit of all current employees and identifying any that are missing proper documentation of references and either uploading from digital filing system or making contacts with references to complete the file.

3. Steps you will implement to prevent recurrence. This would be the new system that is being put in place today. We have moved to a new HRIS system and have benchmarks in place that will prevent an applicant from being hired until references are entered into their profile page.

4. How you will ensure your remedies are sustained. We will continue to conduct quarterly internal audits.

5. The title (NO NAMES) of the person responsible for monitoring the implementation of the POC. CEO / VP of Operations / Caregiver Coordinator.

6. The date for completion, February 21, 2025.



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 review of direct care worker personnel files (PF) and interview with the agency Vice President of Operations, the agency failed to document proof of residency for the two (2) years immediately preceding the date of hire for two (2) of seven (7) PF reviewed. (PF # 4 and 6).

Findings include:

Review of PF's on December 17, 2024, from approximately 10:15 A.M. to 11:15 A.M. and December 23, 2024, from approximately 8:30 A.M. to 9:00 A.M. revealed the following:

PF #4, date of hire March 27, 2024, contained a Pennsylvania driver's license issued December 5, 2024. There was no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date of hire.

PF #6, date of hire September 19, 2024, contained a Pennsylvania driver's license issued February 15, 2024. There was no documentation that the applicant resided in Pennsylvania for the two (2) years immediately preceding the date of hire.

An interview with the Vice President of Operations on December 17, 2024, at approximately 11:15 A.M. and a follow-up email on December 23, 2024, confirmed that above findings.



























Plan of Correction:

1. How you will correct the deficiency for the files cited? We will continue to work with the employee's in reference to obtain proof of residency in PA for a time greater than 2 years at time of hirs. In addition, with the help of our new HRIS system that went into effect on 12/23/2024, employees will no longer be able to move through the hiring process with ID that does not prove residnecy in PA for 2+ years. They will be required to submit additional documentation to confirm residency in PA for over 2 years before moving along in the hiring process.

2. How you will identify and correct any additional files that may have the same deficiency? We will be conducting an internal audit of all current employees and identifying any that are missing proper documentation of residency in PA of greater than 2 years from hire date and either uploading from digital filing system if we already have that documentation or making contacts with caregivers to get updated documentation to complete the file.

3. Steps you will implement to prevent recurrence. This would be the new system that is being put in place today. We have moved to a new HRIS system and have benchmarks in place that will prevent an applicant from being hired until proof of residency in PA of 2 years+ is entered into their profile page.

4. How you will ensure your remedies are sustained. We will continue to conduct quarterly internal audits.

5. The title (NO NAMES) of the person responsible for monitoring the implementation of the POC. CEO / VP of Operations / Caregiver Coordinator.

6. The date for completion, February 21, 2025.



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 upon review of direct care worker personnel files (PF) and an interview with the Vice President of Operations, the agency failed to ensure baseline testing was completed for four (4) of seven (7) PF reviewed (PF #1, 3, 4, and 5)

Findings Include:

The CDC (Centers for Disease and Control and Prevention) guidelines state baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or tuberculin skin test (TST), shall include a symptom screen questionnaire and an individual tuberculosis (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 PF's conducted on December 17, 2024, from approximately 10:15 A.M. to 11:15 A.M. and December 23, 2024, from approximately 8:30 A.M. to 9:00 A.M. revealed the following:

PF #1, date of hire March 11, 2024, contained documentation of a single TST conducted on April 18, 2024, which was one (1) month after the date of hire. There was no documentation of a second-step TST completed.

PF #3, date of hire June 1, 2022, contained documentation of a single TST conducted on September 7, 2021. There was no documentation of a second-step TST completed.

PF #4, date of hire March 27, 2024, contained no documentation of baseline testing completed upon hire.

PF #5, date of hire March 11, 2024, contained documentation of a single TST conducted on April 17, 2024, which was one (1) month after the date of hire. There was no documentation of a second-step TST completed.

An interview with the Vice President of Operations on December 17, 2024, at approximately 11:15 A.M. and a follow-up email on December 23, 2024, confirmed the above findings.











































Plan of Correction:

1. How you will correct the deficiency for the files cited? We will locate original PPD results for all personnel files in our digital filing system and correctly assign them to each caregivers file. In addition, with the help of our new HRIS system that went into effect on 12/23/2024, employee will no longer be able to move through the hiring process until current, 2 Step PPD, results are added to their file.

2. How you will identify and correct any additional files that may have the same deficiency? We will be conducting an internal audit of all current employees and identifying any that are missing proper documentation of 2 step PPD and either uploading from digital filing system or making contacts with caregivers to have testing completed by 2/14/25 to complete the file.

3. Steps you will implement to prevent recurrence. This would be the new system that is being put in place today. We have moved to a new HRIS system and have benchmarks in place that will prevent an applicant from being hired until their 2 step PPD results are entered into their profile page.

4. How you will ensure your remedies are sustained. We will continue to conduct quarterly internal audits.

5. The title (NO NAMES) of the person responsible for monitoring the implementation of the POC. CEO / VP of Operations / Caregiver Coordinator.

6. The date for completion, February 21, 2025.



Initial Comments:

Based on the findings of an on-site unannounced home care agency state re-licensure survey conducted on December 17, 2024, and concluded off-site on December 23, 2024, Comfort Keepers was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: