Initial Comments:
Based on the findings of an onsite State Re-Licensure Survey conducted on May 7, 2025, Comfort Living Home Care LLC 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 State Re-Licensure Survey conducted on May 7, 2025,, Comfort Living Home Care LLC 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 on a review of personnel files (PF) and an interview with the administrator, the home care agency (HCA) failed to provide evidence that prior to hiring or rostering a direct care worker (DCW), the HCA obtained not less than two satisfactory, non-family member references for the individual. Seven (7) of seven (7) PF's did not meet the requirement: PF#1, PF#2 PF#3, PF#4, PF#5 PF#6, and PF#7.
Findings include:
A review of PF's was conducted on May 7, 2025 starting at 10:25 AM. The date of hire (DOH) and start of service (SS) are indicated below.
PF#1 DOH 07/22/2024, SS 07/23/2024 contained no evidence that reference checks were obtained prior to hiring or rostering the DCW.
PF#2 DOH 10/12/2023, SS 10/20/2023 contained no evidence that reference checks were obtained prior to hiring or rostering the DCW. Two blank reference check forms were present in the PF.
PF#3 DOH 12/16/2024, SS 01/12/2025 contained no evidence that reference checks were obtained prior to hiring or rostering the DCW.
PF#4 DOH 01/27/2024, SS 01/27/2024 contained no evidence that reference checks were obtained prior to hiring or rostering the DCW.
PF#5 DOH 10/14/2024, SS 10/14/2024 contained no evidence that reference checks were obtained prior to hiring or rostering the DCW. Two blank reference check forms were present in the PF.
PF#6 DOH 02/12/2025, SS 02/13/2025 contained no evidence that reference checks were obtained prior to hiring or rostering the DCW.
PF#7 DOH 03/08/2025, SS 03/10/2025 contained no evidence that reference checks were obtained prior to hiring or rostering the DCW.
An interview held with the administrator on May 7, 2025 starting at 11:50 AM confirmed the above findings.
Plan of Correction:Agency will obtain at least two reference checks prior to the date of hire for all new employees. No new employee will be hired until reference checks are completed.
Administrator will check all current files to make sure all reference checks are completed. Administrator will inspect all files on a quarterly basis.
Agency will update the hiring process checklist to make sure that this requirement is met by the employee before hiring. Agency will create an excel spreadsheet to keep track of all requirements needed for employees.
Administrator will conduct reference checks for PF's 1 through 7 by 06/09/2025.
611.52(a) LICENSURE
Criminal Background Checks
Name - Component - 00
The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.
Observations:
Based on a review of personnel files (PF) and an interview with the administrator, the home care agency (HCA) failed to provide evidence that a criminal history report was obtained for the applicant at the time of application or within one (1) year immediately preceding the date of application for three (3) of seven (7) PF's reviewed: PF#1, PF#2, and PF#4.
Findings include:
A review of PF's was conducted on May 7, 2025 starting at 10:25 AM. The date of hire (DOH) and start of service (SS) are indicated below.
PF#1 DOH 07/22/2024, SS 07/23/2024 contained no evidence that a Pennsylvania Access to Criminal History (PATCH) report was obtained at the time of application or within one (1) year immediately preceding the date of application. The PATCH report contained in the PF, dated 07/26/2024, was obtained after the DOH and SS.
PF#2 DOH 10/12/2023, SS 10/20/2023 contained no evidence that a Pennsylvania Access to Criminal History (PATCH) report was obtained at the time of application or within one (1) year immediately preceding the date of application. The PATCH report contained in the PF, dated 10/23/2023, was obtained after the DOH and SS.
PF#4 DOH 01/27/2024, SS 01/27/2024 contained no evidence that a Pennsylvania Access to Criminal History (PATCH) report was obtained at the time of application or within one (1) year immediately preceding the date of application. The PATCH report contained in the PF, dated 02/08/2024, was obtained after the DOH and SS.
An interview held with the administrator on May 7, 2025 starting at 11:50 AM confirmed the above findings.
Plan of Correction:Agency will conduct/run all background checks prior to the date of hire for all of new employee's.
Administrator will make sure that no Direct Care Worker will start servicing the client before their Criminal Background Check is run.
Agency will update the hiring process checklist to make sure that this requirement is met by the employee before hiring. Agency will create an excel spreadsheet to keep track of all requirements needed for employees.
Administrator will conduct quarterly audits to make sure that all Criminal Background Checks are up to date.
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 personnel files (PF), and an interview with the administrator, the home care agency (HCA) did not provide evidence that a Federal criminal history record and a letter of determination from the Department of Aging were obtained for an employee who was not a resident of the Commonwealth of Pennsylvania (PA) for two (2) consecutive years immediately preceding the date of the request for one (1) of seven (7) PF's: PF#5.
Findings include:
A review of PF's was conducted on May 7, 2025 starting at 10:25 AM. The date of hire (DOH) and start of service (SS) are indicated below.
PF#5 DOH 10/14/2024, SS 10/14/2024 contained a New Jersey Identification Card and no evidence of PA residency for the two (2) consecutive years immediately preceding the DOH. The PF also contained a receipt from IdentoGO, dated 10/14/2024, indicating that payment had been made for a finger printing appointment so that a federal criminal history check could be conducted. However, there was no evidence that the federal criminal history check was completed, nor was a letter of determination from the Department of Aging present in the PF.
An interview held with the administrator on May 7, 2025 starting at 11:50 AM confirmed the above findings.
Plan of Correction:Agency will make sure that if a Direct Care Worker provides an out of state ID or if they have not been a resident of the commonwealth of PA for the past 2 years to obtain FBI Fingerprinting through Identego, before they start servicing the client.
Administrator will conduct quarterly audits for all files to make sure that proof of residency document is obtained/matches the criteria required.
Agency will update the hiring process checklist to make sure that this requirement is met by the employee before hiring. Agency will create an excel spreadsheet to keep track of all requirements needed for employees.
PF5 is the only file we have that has an out of state ID, all other other files contain the correct document for proof of residency.
Administrator will obtain the results for PF5 by 06/09/2025.
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 personnel files (PF) and an interview with the administrator, the home care agency (HCA) failed to document proof of Pennsylvania (PA) residency for two (2) consecutive years immediately preceding date of hire 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 for two (2) of seven (7) PF's reviewed: PF#1 and PF#6.
Findings include:
A review of PF's was conducted on May 7, 2025 starting at 10:25 AM. The date of hire (DOH) and start of service (SS) are indicated below.
PF#1 DOH 07/22/2024, SS 07/23/2024 contained a Pennsylvania (PA) Driver's License (DL) issued 06/13/2023. There was no verifiable documentation contained in the PF of PA residency for the two (2) consecutive years immediately preceding the DOH from 07/22/2022 to 07/22/2024.
PF#6 DOH 02/12/2025, SS 02/13/2025 contained a PA Identification Card (ID) issued 01/23/2025. There was no verifiable documentation contained in the PF of PA residency for the two (2) consecutive years immediately preceding the DOH from 02/12/2023 to 02/12/2025.
An interview held with the administrator on May 7, 2025 starting at 11:50 AM confirmed the above findings.
Plan of Correction:Agency will obtain proof of residency for all employee's for the last two years by gathering one of the following documents:
Motor vehicle records, such as a valid driver's license or a State-issued identification; Housing records, such as mortgage records or rent receipts; Public utility records and receipts, such as electric bills; Local tax records; A completed and signed, Federal, State or local income tax return with the applicant's name and address preprinted on it; Employment records, including records of unemployment compensation.
Administrator will make sure that before the hire of caregiver, proof of residency document is in their file.
Administrator will conduct quarterly audits of all files to make sure this requirement is met.
Agency will update the hiring process checklist to make sure that this requirement is met by the employee before hiring. Agency will create an excel spreadsheet to keep track of all requirements needed for employees.
Administrator will obtain 2 year proof of residency for PF's 1 and 6 by 06/09/2025.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
The screening shall be conducted in accordance with CDC guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings. The documentation must indicate the date of the screening which may not be more than 1 year prior to the individual's start date.
Observations:
Based on a review of personnel files (PF), the Centers for Disease Control and Prevention (CDC) Guidelines, and an interview with the administrator, the home care agency (HCA) did not provide evidence that a direct care worker (DCW), upon hire, completed a TB test (e.g., a TB single blood assay test or a two-step tuberculin skin test (TST) for three (3) of seven (7) PF's reviewed: PF#3, PF#4, and PF#6.
Findings include:
The Centers for Disease Control and Prevention (CDC) and the National TB Controllers Association released updated recommendations for Tuberculosis (TB) screening, testing, and treatment of health care personnel on May 17, 2019. These recommendations update the health care personnel screening and testing section of the 2005 CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings. All health care personnel should be screened for TB upon hire (i.e., preplacement). TB screening is a process that includes: a baseline individual TB risk assessment, a TB symptom evaluation, and a TB test (e.g., a TB single blood assay test or a two-step tuberculin skin test (TST), and additional evaluation for TB disease as needed. Health care personnel with a positive TB test result should receive a symptom evaluation and a chest x-ray to rule out TB disease. Additional workup may be needed based on those results. All health care personnel should receive TB education annually. TB education should include information on TB risk factors, the signs and symptoms of TB disease, and TB infection control policies and procedures. (CDC/MMWR/May 17, 2019/Vol.68/No.19).
A review of PF's was conducted on May 7, 2025 starting at 10:25 AM. The date of hire (DOH) and start of service (SS) are indicated below.
PF#3 DOH 12/16/2024, SS 01/12/2025 contained no evidence that TB testing was completed upon hire. The PF contained documentation of a one-step TST completed on 10/08/2024. A second-step TST was not present in the PF, nor was there any other evidence that TB testing was completed upon hire.
PF#4 DOH 01/27/2024, SS 01/27/2024 contained no evidence that TB testing was completed upon hire. The PF contained documentation of a chest x-ray completed on 01/31/2024, after the DOH and SS.
PF#6 DOH 02/12/2025, SS 02/13/2025 contained no evidence that TB testing was completed upon hire. The PF contained documentation of a one-step TST completed on 02/10/2025. A second-step TST was not present in the PF, nor was there any other evidence that TB testing was completed upon hire.
An interview held with the administrator on May 7, 2025 starting at 11:50 AM confirmed the above findings.
Plan of Correction:Agency will not hire any Direct Care Worker without obtaining the full 2-Step process for the skin test, QuantiFERON Blood Test and or chest x ray to rule out Tuberculosis.
Administrator will make sure that if skin test is completed as a form of TB test for an employee, the full two step process is completed within the year.
Administrator will review all files in a quarterly basis and a excel spreadsheet will be created to keep track of all TB tests for all employees.
Administrator will obtain new TB Test Results for PF's 3 and 6 by 06/09/2025.
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 (CF) and an interview with the administrator, the home care agency (HCA) failed to ensure that prior to the start of services, the consumer, consumer's legal representative or a responsible family member received a list of home care services that would be provided to the consumer by the direct care worker (DCW) for nine (9) of nine (9) CF's reviewed: CF#1, CF#2, CF#3, CF#4, CF#5, CF#6, CF#7, CF#8, and CF#9.
Findings include:
A review of CF's was conducted on May 7, 2025 starting at 9:35 AM. The start of care (SOC) is indicated below.
CF#1 SOC 07/23/2024 contained no evidence that prior to the start of services, the consumer received a list of the available home care services that would be provided to the consumer by the DCW.
CF#2 SOC 01/15/2025 contained no evidence that prior to the start of services, the consumer received a list of the available home care services that would be provided to the consumer by the DCW.
CF#3 SOC 02/09/2025 contained no evidence that prior to the start of services, the consumer received a list of the available home care services that would be provided to the consumer by the DCW.
CF#4 SOC 04/06/2025 contained no evidence that prior to the start of services, the consumer received a list of the available home care services that would be provided to the consumer by the DCW.
CF#5 SOC 05/24/2024 contained no evidence that prior to the start of services, the consumer received a list of the available home care services that would be provided to the consumer by the DCW.
CF#6 SOC 02/20/2025 contained no evidence that prior to the start of services, the consumer received a list of the available home care services that would be provided to the consumer by the DCW.
CF#7 SOC 12/08/2024 contained no evidence that prior to the start of services, the consumer received a list of the available home care services that would be provided to the consumer by the DCW.
CF#8 SOC 09/10/2024 contained no evidence that prior to the start of services, the consumer received a list of the available home care services that would be provided to the consumer by the DCW.
CF#9 SOC 08/13/2024 contained no evidence that prior to the start of services, the consumer received a list of the available home care services that would be provided to the consumer by the DCW.
An interview held with the administrator on May 7, 2025 starting at 11:50 AM confirmed the above findings.
Plan of Correction:Agency will make sure that once the Plan of Care for the consumer is completed, two copies of the Plan of Care will be printed out, one will be signed by the consumer and left in their file, the other copy will be left with the consumer before the start of care date.
Administrator will make sure that all Plan of Cares are completed, printed out and provided to the client at the initial home visit.
Administrator will make sure that all current files have a completed plan of care signed by the client in their file. Quarterly reviews will be conducted for all current and new files.
Agency will create an excel spreadsheet to keep track of all requirements needed for the clients file.
Admin will obtain signed copies of Plan of Care's for CF's 1 through 9 by 06/09/2025.
Initial Comments:
Based on the findings of an onsite State Re-Licensure Survey conducted on May 7, 2025, Comfort Living Home Care LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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