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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(b) | There was a hose strewn across the door way outside the garage door. There was several inches of water puddled in front of the basement door. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | 1. Hose strewn found across the door way outside the garage door was removed and thrown away. (Need date they went to the house). Moving forward, during monthly Quality Assurance (QA) checks, Administrators will conduct an internal and external sweeping to ensure the site is free from hazardous objects or materials.
2. The maintenance department has installed concrete blocks to raise the elevation in front of the outside basement door to create a dry area to prevent future water retention.
(The home supervisor will complete weekly physical site inspections to ensure the home is free from hazardous objects. During the inspection, if a hazardous situation is present, the home supervisor will immediately remove the hazard or contact management of the home and the maintenance department to remove/fix the issue. The program specialist will complete monthly physical site inspections and follow the same plan should a hazardous situation be found. AH 10.26.2015) |
09/23/2015
| Implemented |
| 6400.168(d) | Staff #1 received medication administration training on 3/29/14. The practicum observer, Staff #3, did not pass the Department's practicum observer course as required.
| A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | The Employee Development Coordinator will create a tracking list of all agency practicum observers and their certification date. The Employee Development Coordinator will track all relevant compliancy requirements and will send out monthly reports to the Assistant Residential Directors to assure compliancy.
(Staff #3 will be re-trained in the practicum observer initial testing within 30 days of receipt of this plan. The initial practicum observer test will be sent to BHSL within 5 days of completion. Any staff that were observed by Staff #3 will be re-trained within 30 days of receipt of this plan. medication practicums for those staff trained initially trained by staff #3 will be sent to BHSL within 5 days of completion. Upon completion of the medication administration test and the practicum observer test, the training packet will be sent to the Director for review to ensure all requirements of the training have been met. The director is responsible to ensure all observers, trainers, and med passers are properly trained and have passed all aspects of the training. AH 10.26.2015) |
09/23/2015
| Implemented |
| Article X.1007 | Community Interactions is required to maintain criminal history checks and hiring policies for the hiring, retention, and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA)(35 P.S. 10225.101-10225.5102) and its regulations (6 Pa. Code Ch.15) Staff #1 and #5 were hired on 4/14/14 but a criminal history check was not requested unil 4/18/14. Staff #6 was hired on 3/17/14. A criminal history check was not requested until 3/18/14. Staff #7 was hired on 3/17/14. A criminal history check was not requested until 11/3/14. Staff #8 was hired on 12/1/14 and did not reside in the state of Pennsylvania during the two years previous to her employment. There was no documentation that an FBI clearance was requested. Staff #9 was hired on 2/9/15 but did not live in the state of Pennsylvania two years prior to employment. An FBI check was not requested until 2/25/15. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Human Resources Coordinator was retrained on proper procedures.
Hiring practices updated to state:
Community Interactions, Inc. conducts all hiring in accordance with the applicable rules and regulations set forth by the regulatory bodies of the state in which the employee works.
As such, all hiring for staff employed in the state of Pennsylvania is conducted in the following manner:
In accordance 6 Pa. Code Chapter 15 ¿ Protective Services for Older Adults, all staff hired after May 17, 2002 must have background checks from the Pennsylvania State Police. If the applicant has not lived in Pennsylvania for the previous two years immediately preceding the date of application or does not currently live in Pennsylvania, an FBI background check will also be completed. Both Pennsylvania State Police background checks and FBI background checks are conducted at the expense of the Agency, and are conducted for the current period of employment. Community Interactions will not accept background checks conducted for other employment relationships, and any person seeking to be rehired by the Agency more than 1 year after their initial background checks were run, must have new background checks performed.
Based on the results of these background checks, employment determinations are made by either Agency staff (as defined in 6 Pa. Code §15.2) or the Pennsylvania Department of Aging (PDA). All employment determinations made by the Agency staff are compliant with OAPSA and the prohibited offenses list. However, employment determinations for FBI background checks are made by PDA.
If a background check comes back with a prohibitive offense, the hiring policies shall be in accordance with the Child Protective Services Law and the Department of Aging¿s Older Adult Protective Services Act policy as posted on the Department of Aging¿s website. The Human Resources Coordinator will receive a sign off from ELT and/or the Agency¿s appointed counsel before making offers of employment to any persons with a prohibitive offense on their background. Community Interactions, Inc. will no longer provide provisional employment pending the completion of background checks.
(The human resource coordinator is responsible to ensure all potential staff have background checks and FBI clearances (if required) prior to the date of hire. The human resource coordinator will utlize a tracking system to ensure all staff have received their required clearances prior to the date of hire. This information will also be contained on the new staff orientation training sheet. AH 10.26.2015) |
09/09/2015
| Implemented |
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