| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(e) | The interconnected smoke detectors did not sound when tested on the second floor. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Smoke detectors were inspected and repaired and are in good working condition. The program associate are responsible to ensure the smoke detectors are inspected monthly using the health and safety checklist. The program specialist/manager or designee will ensure that all smoke detectors are in working order by checking them each month during fire drills. See attachment #10 |
06/10/2016
| Implemented |
| 6400.112(c) | The fire drill on 3/14/15 did not document what exit route was used. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | A performance improvement committee made up of management and direct care staff was created and reviewed the fire drill process. A new fire drill form was created that made it easier for staff to document. A staff training was done with all team members on 6/9/2016 to review fire drill process of date, time, exit route, meeting place, and any problems that occurred during the drill. See attachment
The program specialist/manager will ensure that the fire drills are routes are documented on the fire drill record forms. |
06/10/2016
| Implemented |
| 6400.112(d) | The fire drill on 10/15/15 had an evacuation time of 13 minutes and 59 seconds. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | A performance improvement committee made up of management and direct care staff was created and reviewed the fire drill process. A new fire drill form was created that made it easier for staff to document. A staff training was done with all team members on 6/8/16 review fire drill process of date, time, exit route, meeting place, and any problems that occurred during the drill. The program specialist/manager will ensure that the fire drills are conducted in under 2 ½ minutes or the evacuation plan will be discussed within their service plan.
See attachment #9 |
06/10/2016
| Implemented |
| 6400.112(h) | The fire drills on 12/5/15, 11/3/15, 10/15/15, 9/17/15, 8/5/15, 7/10/15, 5/15/15, and 4/14/15 did not document the designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | A performance improvement committee made up of management and direct care staff was created and reviewed the fire drill process. A new fire drill form was created that made it easier for staff to document. A staff training was done with all team members on 6/8/16 to review fire drill process of date, time, exit route, meeting place, and any problems that occurred during the drill. The program specialist/manager will ensure that the designated meeting place are documented on the fire drill record monthly. See attachment #9 |
06/10/2016
| Implemented |
| Article X.1007 | Bancroft is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including 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 person #1 date of hire 6/29/15 did not have a Pennsylvania criminal history check completed only a New Jersey FBI. REPEATED VIOLATION 9/12/14 | 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. | Bancroft is currently completing all new hire verifications prior to scheduling on-site orientation. Currently, all criminal background paperwork is completed upon hire and submitted for criminal background checks. The recruiter within the Human Resources department will review all criminal background documentation for completion prior to scheduling new staff orientation within the organization. The new hire will be unable to schedule orientation without the proper clearances completed. The Human Resources Compliance Manager will complete quarterly comparison audits to ensure the background checks are completed and data entered prior to orientation date. |
07/26/2016
| Implemented |