|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's self-assessment, completed between 1/27/23 and 1/28/23, the agency certificate of compliance expires 8/27/2023. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| LIIs are scheduled to be completed beginning on the week of 3/20/23. |
03/20/2023
| Implemented |
| 6400.104 | The home's Local Fire Department Notification Letter did not include the exact location of the individuals' bedrooms. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Letters to the local Fire Department were updated to include bedroom locations and mailed on 3/20/23. All supervisors were instructed to review their letters and confirm that they include the location of bedrooms and are accurate with the needs of the individuals no later than 3/17/23. |
03/20/2023
| Implemented |
| 6400.111(a) | On 3/1/23, the home's upper floor was observed at 10:34 AM without the presence of a fire extinguisher. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | A fire extinguisher was placed on the upper floor on 3/8/23. |
03/08/2023
| Implemented |
| 6400.18(i) | EIM Incident # 9101077 for Abuse has a discovery date of 10/5/22. Its final report was submitted on 2/1/23. No extensions had been requested. EIM Incident #'s 9143242, 9143256, and 9143264 for Abuse have a discovery date of 12/28/22 with a final report due date of 1/27/23. No extensions have been requested, and no final reports have been submitted. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | All open incidents that were near or over 30 days were reviewed and had an extension filed or were finalized on 3/17/23. On Monday mornings, the Director of Risk Management will provide a report of all open incidents to Residential Management. The incidents will be discussed every Friday morning with the Risk Dir and Residential Management. |
03/17/2023
| Implemented |
| 6400.32(r) | Individual #1 signed a form on 6/30/20 requesting a bedroom door lock. On 3/1/23, Individual #1's bedroom door was discovered without a door lock at 10:10 AM. | An individual has the right to lock the individual's bedroom door. | The individiauls choice regarding a bedroom lock was discussed on 3/17/23 and she stated she is still interested in a lock. A locking mechanism that meets her physical needs was purchased on 3/20/23 and will be installed when it is delivered. |
03/20/2023
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not complete a self-assessment of the home. The expiration of the agency's certificate of compliance was 8/27/17. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The Assistant Director who did not complete the self-assessments was terminated and the Residential Dept. was restructured in October 2017 to have 1 Asst. Director overseeing all of the sites. Effective 2018, the Asst. Director will complete all of the self-assessments. The self-assessments will be turned in to the Residential Director no later than 4 months prior to the expiration on the license to be checked for accuracy and completion. The Residential Director will maintain all documentation of self-assessments.[Upon receipt of the current Certificate of Compliance the Assistant Director and the Residential Director shall develop and implement at tracking system to ensure timely completion of all self-assessments. Documentation of aforementioned audits by the Residential Director shall be kept. (AS 12/21/17)] |
12/05/2017
| Implemented |
| 6400.31(b) | Individual #1 had a signed statement acknowledging receipt of the information on rights completed 1/1/16 then again 1/19/17. (Repeated Violation-12/6/16, et al) | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | This error occurred prior to either of the current Program Specialists starting their position. The current Program Specialists were trained on their duties 4/12/17. Ongoing, the Program Specialists and/or Asst. Director will complete quarterly audits of all program documentation to ensure that the signature sheet is completed accurately and within time frames. Documentation of all audits will be maintained in the Residential office. [Immediately, the CEO or designated management staff person shall develop and implement a tracking system to ensure timely competition of receipt of information of individual rights. (AS 12/21/17)] |
12/22/2017
| Implemented |
| 6400.186(b) | The program specialist signed and dated Individual #1's ISP review for review period 11/10/16 to 2/10/17 on 2/6/17. Individual #1 signed and dated the same ISP review on 1/13/17. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | This error occurred prior to either of the current Program Specialists starting their position. The current Program Specialists were trained on their duties 4/12/17. Ongoing, the Program Specialists and/or Asst. Director will complete quarterly audits of all program documentation to ensure that the signature sheet is completed accurately and within time frames. Documentation of all audits will be maintained in the Residential office. |
12/05/2017
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Service Worker #1, who was scheduled to work on 8/4/16 from 10:00 PM to 9:00 AM, 8/6/16 from 8:00 AM to 11:00 PM, and 8/7/16 from 8:00 AM to 11:00 PM had another person who is not an employee of the facility report to the home in his/her place. The person who provided supervision to the individuals during the aforementioned dates and shifts did not have a Pennsylvania criminal background check completed. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Our contract with Capital HealthCare Solutions Staffing Company (attached) states, in #2 ¿Statement of Services¿, that the staff they provide to Milestone will meet criteria as required by our regulations and that they will ensure that, among other things, the staff have a valid pre-employment physical and criminal background check. The contract also states that Capital HealthCare will provide us with these documents upon request. Attached is the physical and the criminal history for ¿Direct Service Worker #1¿ who was scheduled by Capital HealthCare Solutions to work at Penhurst and Howell on 8/4, 8/6 and 8/7. Capital HealthCare provides information to their staff upon assignment to orient them to the site (subsequent to meeting with each Site Supervisor to gather pertinent and necessary information).
The violations occurred because the employee of Capital HealthCare Solutions, Direct Service Worker #1, did not work at Howell and Penhurst as scheduled and expected. Rather the individual who worked these shifts at these sites fraudulently impersonated Direct Service Worker #1. To ensure that, in the future, any Capital HealthCare Solutions staff (or any staff from any contracted staffing agency) who appears on site to work a scheduled shift, is who he/she is supposed to be and therefore does meet all regulatory requirements ¿ Milestone established the attached Procedure with Capital HealthCare Solutions. All Residential Site Supervisors were informed of this procedure at their department meeting on 9/14/16 and it was implemented immediately there-after.[Addition to POC on 11/21/16 All of the temp staff vendors that we work with have been notified that there are new training binders at each site with information specific to the individuals that the temp staff are to read and sign prior to beginning direct care at the site on their initial shift. The temp staff will leave the training records for the Site Supervisor to review. The Site Supervisor will then bring the training records to the Administrative Assistant, who maintains the required Qualification documentation for temp staff (physicals, clearances, etc). The training information will be kept in the employee¿s file. The Residential Program Specialist will maintain the binders and update information as needed. Attached is the email sent to the Temp Staff vendors, the meeting minutes from the Supervisor¿s meeting to discuss the protocol, the training record for the Adminstrative Assistant, and the table of contents from the training binder.] (AS 11/23/16) |
11/06/2016
| Implemented |
| 6400.46(a) | Direct Service Worker #1, who was scheduled to work on 8/4/16, from 10:00 PM to 9:00 AM, 8/6/16 from 8:00 AM to 11:00 PM, and 8/7/16 from 8:00 AM to 11:00 PM had another person who is not an employee of the facility report to the home in his/her place. The person who provided supervision to the individuals during the aforementioned dates and shifts did not have orientation training relevant to the responsibilities, the daily operations of the home and policies and procedures of the home prior to working with the individuals. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | Our contract with Capital HealthCare Solutions Staffing Company (attached) states, in #2 ¿Statement of Services¿, that the staff they provide to Milestone will meet criteria as required by our regulations and that they will ensure that, among other things, the staff have a valid pre-employment physical and criminal background check. The contract also states that Capital HealthCare will provide us with these documents upon request. Attached is the physical and the criminal history for ¿Direct Service Worker #1¿ who was scheduled by Capital HealthCare Solutions to work at Penhurst and Howell on 8/4, 8/6 and 8/7. Capital HealthCare provides information to their staff upon assignment to orient them to the site (subsequent to meeting with each Site Supervisor to gather pertinent and necessary information).
The violations occurred because the employee of Capital HealthCare Solutions, Direct Service Worker #1, did not work at Howell and Penhurst as scheduled and expected. Rather the individual who worked these shifts at these sites fraudulently impersonated Direct Service Worker #1. To ensure that, in the future, any Capital HealthCare Solutions staff (or any staff from any contracted staffing agency) who appears on site to work a scheduled shift, is who he/she is supposed to be and therefore does meet all regulatory requirements ¿ Milestone established the attached Procedure with Capital HealthCare Solutions. All Residential Site Supervisors were informed of this procedure at their department meeting on 9/14/16 and it was implemented immediately there-after.[Addition to POC on 11/21/16 All of the temp staff vendors that we work with have been notified that there are new training binders at each site with information specific to the individuals that the temp staff are to read and sign prior to beginning direct care at the site on their initial shift. The temp staff will leave the training records for the Site Supervisor to review. The Site Supervisor will then bring the training records to the Administrative Assistant, who maintains the required Qualification documentation for temp staff (physicals, clearances, etc). The training information will be kept in the employee¿s file. The Residential Program Specialist will maintain the binders and update information as needed. Attached is the email sent to the Temp Staff vendors, the meeting minutes from the Supervisor¿s meeting to discuss the protocol, the training record for the Adminstrative Assistant, and the table of contents from the training binder.] (AS 11/23/16) |
11/06/2016
| Implemented |
| 6400.151(a) | Direct Service Worker #1, who was scheduled to work on 8/4/16, from 10:00 PM to 9:00 AM, 8/6/16 from 8:00 AM to 11:00 PM, and 8/7/16 from 8:00 AM to 11:00 PM had another person who is not an employee of the facility report to the home in his/her place. The person who provided supervision to the individuals during the aforementioned dates and shifts did not have a physical examination. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Our contract with Capital HealthCare Solutions Staffing Company (attached) states, in #2 ¿Statement of Services¿, that the staff they provide to Milestone will meet criteria as required by our regulations and that they will ensure that, among other things, the staff have a valid pre-employment physical and criminal background check. The contract also states that Capital HealthCare will provide us with these documents upon request. Attached is the physical and the criminal history for ¿Direct Service Worker #1¿ who was scheduled by Capital HealthCare Solutions to work at Penhurst and Howell on 8/4, 8/6 and 8/7. Capital HealthCare provides information to their staff upon assignment to orient them to the site (subsequent to meeting with each Site Supervisor to gather pertinent and necessary information).
The violations occurred because the employee of Capital HealthCare Solutions, Direct Service Worker #1, did not work at Howell and Penhurst as scheduled and expected. Rather the individual who worked these shifts at these sites fraudulently impersonated Direct Service Worker #1. To ensure that, in the future, any Capital HealthCare Solutions staff (or any staff from any contracted staffing agency) who appears on site to work a scheduled shift, is who he/she is supposed to be and therefore does meet all regulatory requirements ¿ Milestone established the attached Procedure with Capital HealthCare Solutions. All Residential Site Supervisors were informed of this procedure at their department meeting on 9/14/16 and it was implemented immediately there-after.[Addition to POC on 11/21/16 All of the temp staff vendors that we work with have been notified that there are new training binders at each site with information specific to the individuals that the temp staff are to read and sign prior to beginning direct care at the site on their initial shift. The temp staff will leave the training records for the Site Supervisor to review. The Site Supervisor will then bring the training records to the Administrative Assistant, who maintains the required Qualification documentation for temp staff (physicals, clearances, etc). The training information will be kept in the employee¿s file. The Residential Program Specialist will maintain the binders and update information as needed. Attached is the email sent to the Temp Staff vendors, the meeting minutes from the Supervisor¿s meeting to discuss the protocol, the training record for the Adminstrative Assistant, and the table of contents from the training binder.] (AS 11/23/16) |
11/06/2016
| Implemented |
|
|