QA Investigation Results

Pennsylvania Department of Health
COZY CAREGIVERS HOMECARE AGENCY, LLC
Health Inspection Results
COZY CAREGIVERS HOMECARE AGENCY, LLC
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an unannounced on-site state re-licensure survey conducted on March 11, 2020, Cozy Caregivers Homecare Agency, 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 unannounced state licensure survey conducted on March 11, 2020, Cozycaregivers Homecare Agency, LLC was found not to be in compliance with the following requirements of Pa. Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart H, Chapter 611, Home Care Agencies and Home Care Registries.





Plan of Correction:




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 review of personnel files (PFs) and interview with the agency's administrator, the agency failed to ensure that a criminal background check was completed prior to employment for three (3) of ten (10) PFs reviewed. (PF #1, 2 and 10).

Findings include:

Act 169 of 1996 as amended by Act 13 of 1997 states: "If the applicant/employee has been a resident of the Commonwealth of Pennsylvania for 2 or more years prior to application for employment, the applicant will need to obtain a clearance from the Pennsylvania State Police. This clearance is obtained by doing the following: Request for Criminal Record Check Form (SP4-164)." "When the applicant/employee has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out of state, in addition to the Pennsylvania State Police Criminal History Check, the applicant/employee will also need to obtain an FBI Criminal History Check. Facilities are defined by the act to include: Domiciliary Care Homes, Home Health Care Agency, Nursing Facility (licensed by the Department of Aging), and Personal Care Home (licensed by the Department of Public Welfare). A Home Health Care Agency is further defined to include those agencies licensed by the Department of Health and any public or private organization which provides care to a care-dependent individual in their place of residence." "If entities run into special circumstances where they need to hire an employee before the results of their record checks are returned, there is a provision in CPSL that allows for a provisional hiring period. The period is to not exceed 30 days for in state residents and 90 for out of state residents."

Findings:

A review of the PFs was conducted on March 11, 2020 between approximately 11:30 AM- 1:00 PM revealed the following:


PF #1 Date of Hire (DOH): 2/24/2019 - There was documentation that a Watch Dog Criminal Screen was obtained on 3/1/2019. A Pennsylvania State Police Criminal Background Check was conducted on 1/14/2020, which was eleven (11) months after date of hire.

PF #2 (DOH): 2/24/2019 - There was documentation that a Watch Dog Criminal Screen was obtained on 3/1/2019. A Pennsylvania State Police Criminal Background Check was conducted on 1/14/2020, which was eleven (11) months after date of hire.

PF #10 (DOH): 8/9/2019 - File did not contain a Pennsylvania State Police Criminal Background Check.


Interview with the adminstrator on March 11, 2020 at approximately 1:30 PM confirmed the above findings.




Plan of Correction:

0310
PLAN OF CORRECTION:

1. In order to correct this deficiency A Pennsylvania state criminal background was conducted on 1/14/2020 for PF #1 and PF #2.
A Pennsylvania state background check was conducted on 3/31/2020 for PF #10.

2.To ensure the safety of our clients. The administrator will ensure that A Pennsylvania State Police Criminal Background Check is conducted prior to first day of employment.
3.To ensure that this problem does that reoccur, our agency added a second review step to our hiring process, and as of 03/01/2019 we stopped using Criminal Watch Dogs for background checks.
The agency's Administrator1 will review the PF file prior to employee's start date and confirm that PA state criminal background was completed. Then, Administrator2 will review the PF file a second time and confirm that the Pennsylvania state background check was completed prior to employee's start date.
4. Administrator1 and Adminstrator2 will review PF files every 30 days to ensure that all required documents are present, and all backgrounds are completed.
5. Corrective Action was completed on 1/14/2020 for PF #1 and PF #2. Corrective Action was completed for PF #10 on 3/31/2020.




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 personnel files (PF), Centers for Disease Control guidelines, and Administrator interview, it was determined the agency failed to ensure that direct care workers were screened for and were free from active mycobacterium tuberculosis prior to assignment with clients. Review of personnel files revealed that eight (8) of ten (10) direct care workers were not screened for mycobacterium tuberculosis per CDC guidelines. (PF #1, 2, 3, 5, 6, 7, 8 and 9).

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 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.

A review of PFs was conducted on March 11, 2020 from approximately 11:30 AM - 1:00 PM revealed the following:

PF #1 Date of Hire (DOH): 2/24/2019 - There was no documentation of annual TB screening for 2019.

PF #2 (DOH): 2/24/2019: There was no documentation of annual TB screening for 2019.

PF #3 (DOH): 8/5/2019: There was no documentation of a second step TST for 2019.

PF #5 (DOH): 1/24/2020: There was no documentation of a second step TST for 2020.

PF #6 (DOH): 9/9/2019: There was no documentation of a second step TST for 2019.

PF #7 (DOH): 5/13/2019: There was no documentation of a second step TST for 2019.

PF #8 (DOH): 1/13/2020: There was no documentation of a second step TST for 2020.

PF #9 (DOH): 1/15/2020: There was no documentation of an annual TB screening for 2018 and 2019.


An interview with the Administrator on March 11, 2020 at approximately 1:30 PM confirmed the above findings.





Plan of Correction:

0700
PLAN OF CORRECTION:

1.The Agency corrected this deficiency by immediately having PF # 1, 2, 3, 4, 5, 6, 7, 8, and 9 complete a two-step tuberculin skin test.

2.To ensure the safety of our clients. The administrators will ensure that PF # 1, 2, 3, 4, 5, 6, 7, 8, and 9 are screed for mycobacterium tuberculosis per CDC guidelines and are free from active mycobacterium tuberculosis. An annual TB screen questionnaire will be completed for each employee for each year after date of hire, signed by the employee, Administrator 1 and Administrator 2 and placed into employee's file.

3.To ensure that this problem does that reoccur, our agency added a second review step to our hiring process.
The agency's Administrator1 will review the PF file prior to employee's start date and confirm that the employee was screened for mycobacterium tuberculosis per CDC guidelines and is free from active mycobacterium tuberculosis. Then, Administrator2 will review the PF file a second time and confirm that the employee was screened for mycobacterium tuberculosis per CDC guidelines and are free from active mycobacterium tuberculosis, prior to start date. An annual TB screen questionnaire will be completed for all employees for each year after date of hire, signed by the employee, Administrator 1 and Administrator 2 and placed into employee's file.



4. Administrator1 and Adminstrator2 will review PF files every 30 days to ensure that all required documents are present, all screening results have been completed, and are up to date.

5. Corrective Action was completed on 3/27/2020 for ,PF # 1, 2, 3, 4, 5, 6, 7, 8, and 9.





611.57(b) LICENSURE
Prohibitions

Name - Component - 00
(b) No individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The home care agency or home care registry may not require a consumer to endorse checks over to the home care agency or home care registry.

Observations:


Based on review of the agency's consumer information packet, consumer records (CR) and interview with the administrator, the agency failed to provide documentation that no individual as a result of the individual's affiliation with a home care agency or home care registry may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency for ten (10) of ten (10) CR reviewed. (CR #1 - 10).

Findings include:

Review of CR conducted on March 11, 2020, from approximately 10:00 AM - 11:30 AM revealed the following:

CR #1 - Start of Service (SOS): 1/13/2020 - Did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry, may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry.

CR #2 - (SOS): 9/11/2019 - Did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry, may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry.

CR #3 - (SOS): 2/21/2019 - Did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry, may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry.

CR #4 - (SOS): 12/10/2019 - Did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry, may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry.

CR #5 - (SOS): 1/13/2020 - Did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry, may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry.

CR #6 - (SOS): 9/9/2019 - Did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry, may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry.

CR #7 - (SOS): 1/13/2020 - Did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry, may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry.

CR #8 - (SOS): 1/13/2020 - Did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry, may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry.

CR #9 - (SOS): 2/24/2019 - Did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry, may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry.

CR #10 - (SOS): 8/2/2019 - Did not contain documentation that the consumer was informed that no individual as a result of the individual's affiliation with a home care agency or home care registry, may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry.


Interview with the administrator on March 11, 2020, at approximately 1:30 PM confirmed the above findings.






Plan of Correction:

0810
PLAN OF CORRECTION:

1.The Agency Administrator1 corrected this deficiency by informing CR # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 that no individual as a result of the individual's affiliation with a home care agency or home care registry, may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. The consumer information packet was updated to include the above statement and all consumers signed that they received and understand the information that was given.

2.To ensure the safety of our clients the Administrator1 updated the Agency's consumer information packet to include the following statement: No individual as a result of the individual's affiliation with a home care agency or home care registry, may assume power of attorney or guardianship over a consumer utilizing the services of that home care agency or home care registry. All New consumer will receive the updated Consumer Information packet prior to start date.

3.To ensure that this problem does that reoccur, Our Admintrator1 updated our consumer information packet with all required information.

4. To make sure that solutions are sustained, Administrator1 and Adminstrator2 will review our Consumer Information Packet every 30 days and compare it to the state regulations to ensure that all required information is present.

5. Corrective Action was completed on 3/13/2020 for, CR # 1, 2, 3, 4, 5, 6, 7, 8,9 and 10.





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 the consumer records (CR) and interview with the administrator, the agency failed to provide documentation to the consumer, the consumer's legal representative or responsible family member an information packet stating, 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: 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) for ten (10) of ten (10) CRs reviewed. (CR #1 - 10).


Findings include:

Consumer records (CR) reviewed on March 11, 2020 between approximately 10:15 AM - 11:30 AM revealed the following:


CR #1: Start of Service (SOS): 1/13/2020 - There was no documentation to confirm that prior to the commencement of services, the home care agency or home care registry provided 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: 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).

CR #2: (SOS): 9/11/2019 - There was no documentation to confirm that prior to the commencement of services, the home care agency or home care registry provided 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: 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).

CR #3: (SOS): 2/21/2019 - There was no documentation to confirm that prior to the commencement of services, the home care agency or home care registry provided 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: 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).

CR #4: (SOS): 12/10/2019 - There was no documentation to confirm that prior to the commencement of services, the home care agency or home care registry provided 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: 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).

CR #5: (SOS): 1/13/2020 - There was no documentation to confirm that prior to the commencement of services, the home care agency or home care registry provided 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: 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).

CR #6: (SOS): 9/9/2019 - There was no documentation to confirm that prior to the commencement of services, the home care agency or home care registry provided 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: 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).

CR #7: (SOS): 1/13/2020 - There was no documentation to confirm that prior to the commencement of services, the home care agency or home care registry provided 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: 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).

CR #8: (SOS): 1/13/2020 - There was no documentation to confirm that prior to the commencement of services, the home care agency or home care registry provided 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: 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).

CR #9: (SOS): 2/24/2019 - There was no documentation to confirm that prior to the commencement of services, the home care agency or home care registry provided 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: 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).

CR #10: (SOS): 8/2/2019 - There was no documentation to confirm that prior to the commencement of services, the home care agency or home care registry provided 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: 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).



An interview with the Administrator was conducted on March 11, 2020 at approximately 1:30 PM confirmed the above findings.




Plan of Correction:

0820
PLAN OF CORRECTION:

1.Administrator1 corrected this deficiency by informing CR # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 the Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program for Bucks(213-348-0510) , Chester (610-344-6350), Delaware (610-490-1300), Montgomery (610-278-3601), and Philadelphia(215-545-5728). The consumer information packet was updated to include the above statement and all consumers signed that they received and understand the information that was given.

2.To ensure the safety of our clients the Administrator1 updated the Agency's consumer information packet to include the following information: Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program for Bucks(213-348-0510) , Chester (610-344-6350), Delaware (610-490-1300), Montgomery (610-278-3601), and Philadelphia(215-545-5728). New consumers will receive the updated Consumer Information Packet prior to start date.

3.To ensure that this problem does that reoccur, Our Admintrator1 updated our consumer information packet with all required information.

4. To make sure that solutions are sustained, Administrator1 and Adminstrator2 will review our Consumer Information Packet every 30 days and compare it to the state regulations to ensure that all required information is present.

5. Corrective Action was completed on 3/13/2020 for, CR # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.





Initial Comments:


Based on the findings of an onsite unannounced state licensure survey completed on March 11, 2020, Cozy Caregivers Homecare Agency, LLC was found to be in compliance with the requirements of 35 P.S. 448.809 (b).






Plan of Correction: