| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(d) | Staff person #3 date of hire 4/10/11 did not complete 24 hours of training for the training year of 2014, they only had 19.5 hours completed. | Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. | Going forward, the staff training specialist, will ensure that all staff completes 24 hours of training each year. Coursework has been selected and currently being implemented. Staff person #3 date of hire 4/10/11 did not complete 24 hours of training in the 2014, however, going forward program associates will have 24 hours of training in the training year. |
02/01/2016
| Implemented |
| 6400.67(b) | Several wood planks, and other materials were hanging and leaning on the cabinet inside of the kitchen closet. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The maintenance technician removed the wood planks and other materials that were hanging and leaning on the inside of a cabinet in the kitchen . A lock was added to the closet in the kitchen to secure these items. The program associates or designee will ensure that the items in the home are safe and secure. The program specialist/manager will ensure that the floors, walls, ceilings and other surfaces are hazard free. |
06/01/2016
| Implemented |
| 6400.111(f) | The inspection tag on the fire extinguisher on the kitchen wall was expired with the date of 10/2014. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | All fire extinguishers in all homes are being inspected on 6/27/16 and retagged. Annually Bancroft's Facilities Department will inspect the fire extinguishers and provide documentation. The Program associates are trained as fire experts by the Program Specialist/Manager. The Program Associates are responsible to check the fire extinguishers monthly and ensure the date of the inspection are documented using the electronic health and safety checklist. See attachment #8 inspection doc |
06/27/2016
| Implemented |
| 6400.112(c) | The fire drills on 12/15/15 and 8/20/15 did not document the exit route 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 6/3/16 to review fire drill process of date, time, exit route, meeting place, and any problems that occurred during the drill. Program specialist/manager will be responsible for ensuring an exit route is documented on the fire drill record. See attachment #6, #7 |
06/03/2016
| Implemented |
| 6400.112(d) | The fire drills on 12/15/15 had an evacuation time of 5 minutes and 10 seconds, and on 11/18/15 an evacuation time of 3 minutes 45 seconds, and on 7/12/15 an evacuation time of 2 minutes 35 seconds, and on 5/28/15 an evacuation time of 3 minutes 30 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 6/3/16 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 fire drills are conducted in under 2 ½ minutes or the evacuation plan will be discussed within their service plan. See attachment #6, #7 |
06/03/2016
| Implemented |
| 6400.141(c)(14) | Individual #1's physical dated 7/15/15 did not include medical information pertinent to diagnoses and treatment in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program Nurse liaison with the primary care doctor to ensure that Individual #1's annual physical includes medical information pertinent to diagnosis and treatment in case of emergency. |
07/30/2016
| Implemented |
| 6400.151(a) | Staff person #3 date of hire 4/10/11 did not have documentation of a physical completed.
Staff person #4 date of hire 7/13/15 did not have documentation of a physical completed. REPEATED VIOLATION 9/12/14
| 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. | Staff person #3's whose date of hire is 4/10/11 and staff person #4 whose date of hire 7/13/2015, will have a physical examination in their file within 30 days. The Human Resources Recruiter will ensure that all staff have a physical completed upon hire and a copy of the physical will be placed in their personnel file. |
06/10/2016
| Implemented |
| 6400.164(b) | Individual #1's medication log for Naproxen 500mg at 8:00am on 12/1 and 12/2/15 had a line through the space without an explanation. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | Pill book was purchased for each home to be used as reference. Medication and MAR retraining was done with the team on 6/3/16. M.A.R.s will be reviewed and audited monthly by nurse, nursing team, or program manager. See attachment #5 |
06/03/2016
| Implemented |
| 6400.181(d) | Individual #1's assessment dated 9/1/15 did not have the program specialist sign and date it. | The program specialist shall sign and date the assessment. | ISP process was reviewed with the program managers on 6/9/16. Program Directorsmanagers or designee are acting program specialist while position is hired responsible for ensuring the Program Specialist/Managers have signed and dated the ISP. Information will be forwarded to the SC in a timely manner. See attachment #3 |
06/09/2016
| Implemented |
| 6400.181(f) | Individual #1's assessment dated 9/1/15 was not sent to the supports coordinator. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| Going forward, the program specialist/manager or designee will ensure that assessments are provided to the supports coordinator as needed. The program director or designee will ensure that all assessments are completed, signed and dated and submitted as needed. |
06/10/2016
| Implemented |
| 6400.183(5) | Individual #1's social emotional and environmental plan was not updated. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | SEP plan wasfor Individual #1 was updated on 6/7/156. Process going forward will be that Program Specialist/ Managers will ensure assess the individuals for a plan of social, emotional and environmental plan are updated for individuals if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. . Program managers were trained on this process on 6/9/16. See attachment #3 , # 4 |
06/09/2016
| Implemented |
| 6400.186(b) | Individual #1's 3 month ISP review dated 10/1/15 was not signed and dated by the program specialist. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Individual #1 current ISP review is signed by the program speicalist/manager. The ISP process was reviewed with the program specialist/ managers on 6/9/16. Program managers or designee are responsible for ensuring the ISP acting program specialist while position is hired signature sheets are signed. Program directors are currently interviewing for program specialist position. See attachment #3 |
06/09/2016
| 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 7/27/15 did not have a Pennsylvania criminal history check completed only a New Jersey FBI. Staff person #2 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 |