Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00216821 Renewal 12/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The exterior backdoor light (just off the enclosed porch) was not functioningRooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Maintenance ticket was put in for light bulb replacement. 01/31/2023 Implemented
6400.112(e)Greater than 6 months between sleep drills: The 6 month period was from at least the start of December 2021 to June 1, 2022A fire drill shall be held during sleeping hours at least every 6 months. Last overnight drill held September 2022. Next overnight drill to be held by March 2023. Overnight drills will be conducted at least every six months. 01/31/2023 Implemented
SIN-00180930 Renewal 12/21/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The blinds in the main bathroom were broken.Floors, walls, ceilings and other surfaces shall be in good repair. The blinds were replaced. Staff complete a facilities request when items found that are not in good repair. The facilities department then goes to the home to repair or replace the item. In addition, staff will complete a monthly health and safety checklist which includes ensuring that floors, walls, ceilings and other surfaces are in good repair. A facilities request can be submitted with the form should staff find an item that is not in good repair. See attachment #1 01/28/2021 Implemented
6400.71There was no emergency contact list near phone in the living room.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. An individual in the home removed the paper list of telephone numbers by the phone in the living room. Program has reprinted and placed the telephone number list into a picture frame and hung it on the wall where the individual is unlikely to want to remove it. 12/22/2020 Implemented
6400.76(a)There was a knob missing from a cabinet in the dining room. Furniture and equipment shall be nonhazardous, clean and sturdy. A facilities request was placed and a new knob was installed. Staff will complete a monthly health and safety checklist (see attachment #1) which includes ensuring that furniture is non hazardous, clean and sturdy. A facilities request can be submitted with the form should staff find an item that is not in good repair. 12/23/2020 Implemented
6400.141(b)Individual #5 annual physical dated 7/21/2020 was not dated by the physician.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. The sending facility was contacted and they were asked to add the date to the annual physical form. Going forward, prior to admission all medical records will be reviewed by admissions and medical department and all missing information will be obtained or corrected prior to admit. See attachment #3. 12/29/2020 Implemented
6400.141(c)(4)Individual #5 eye screening at the time of his annual physical dated 7/21/2020 recommended follow up eye evaluation by a specialist. There was no indication in the record that tis was completed.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. A vision appointment is scheduled for Individual #5 on 2/22/21. Going forward, prior to admission all medical records will be reviewed by admissions and medical department and all missing information will be obtained or corrected prior to admit. 12/23/2020 Implemented
6400.181(e)(6)Individual #5 is new to Bancroft. The assessment eludes to the individual never attempting to ingest inedible products, but no real sense of their ability to recognize the item as dangerous.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. The assessment has been updated to reflect individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. Assessments will be completed by the individual's program specialist. The assessment will then be reviewed by another program specialist who will proofread, advise if corrections should be made, and provide the feedback to the individual's program specialist. The individual's program specialist will then correct the assessment if needed and file the form. See attachment #4 12/29/2020 Implemented
6400.50(a)Orientation records for staff #1 were not available at the time of inspection.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.Orientation records for staff #1 are now available on file in program. Program will conduct an annual review of their staff records to ensure that records are on site. See Attachment #5 02/01/2021 Implemented
6400.181(b)Individual #5's annual assessment dated 9/11/2020 had at one point in the assessment, the name of the individual and then changed to another name without any understanding of which person is being assessed.If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section.This assessment has been corrected to reflect individual #5's name. Assessments will be completed by the individual's program specialist. The assessment will then be reviewed by another program specialist who will proofread, advise if corrections should be made, and provide the feedback to the individual's program specialist. The individual's program specialist will then correct the assessment if needed and file the form. See attachment #4 12/29/2020 Implemented
SIN-00130381 Renewal 02/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature of the home was tested and found to be 124.3. Hot water temperatures in bathtubs and showers may not exceed 120°F. The hot water tank was adjusted and the temperature was reduced to be in compliance. 02/22/2018 Implemented
SIN-00095191 Renewal 12/22/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff person #1's Pennsylvania criminal history check on 8/12/15 was completed more than 5 days after the date of hire 6/30/15. 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. Going forward, the Human Resources compliance specialist will ensure that Pennsylvania criminal history check is completed within 5 days of the date of hire.The Program Director will conduct periodic audits of all new hires criminal history checks to ensure they are completed as required. 06/10/2016 Implemented
6400.62(a)Image deodorizing neutral cleaner, Concentrate 117 cleaning, critical core by Envirox, and professional brand Sani-wipes were found unlocked in the basement. REPEATED VIOLATION 9/3/15 Poisonous materials shall be kept locked or made inaccessible to individuals.Facilities management department came out on 12/22/16 and installed a lock for the basement door. Staff were trained on the policy of keeping poisonous materials locked at all times.The program associates and program specialist/manager will be responsible to ensure all poisonous materials are locked and secure. See attachment #17 barren staff training 12/22/2016 Implemented
6400.64(a)There was about 30 dead bugs found on the ceiling of the shower stall in the bathroom.Clean and sanitary conditions shall be maintained in the home. Facilities management department came out on 12/22/15 and clean the shower ceiling. The program associates and program specialist/manager are responsible to ensure that areas of the home are clean and that maintenance is notified as needed following monthly inspections of all showers. 12/22/2015 Implemented
6400.76(a)The dryer lint trap was covered in lint approximately 1/2 inch thick. Furniture and equipment shall be nonhazardous, clean and sturdy. The emptying of the lint trap was reviewed with the staff on 5/25/16 by the Program Specialist/Manager. Staff are currently is checking the lint trap at least every day. See attachment #15 barren staff training. The Program Specialist will check the lint in the dryer during monthly checks of the home. 05/27/2016 Implemented
6400.112(e)The fire drills from 4/24/15 through 11/5/15 did not have a sleep drill.A fire drill shall be held during sleeping hours at least every 6 months. Sleep drill was done April 2016. 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, frequency, and any problems that occurred during the drill. To ensure that there is an overnight fire drill done at least every 6 months. See attachment #15 #16 Barren's fire training 04/11/2016 Implemented
6400.181(a) Individual #1 did not have an assessment completed 60 days after admission on 4/23/15. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Assessment was completed 12/15/15. ISP review process was reviewed with the program managers on 6/9/16. Program managers shall complete an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. This will be monitored by the Program Directors or designee. See attachment #3 ,#14 GW assessment 06/09/2016 Implemented
6400.183(6)(i)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 eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: An assessment to determine the causes or antecedents of the behavior. Individual #1 SEP plan was updated on 6/7/15. Process going forward will be that Program 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.access the individual for a plan of medication reduction , review quarterly, and update the plan annually. This will be monitored by program directors or designee. Program managers were trained on this process on 6/9/16. See attachment #3 , # 13 Individual #1's plan 06/09/2016 Implemented
6400.213(9)Individual #1's record did not have a current ISP. Each individual's record must include the following information: A copy of the current ISP. Individual #1Ccurrent ISP is currently in program book dated 4/4/16. The Program Manager/Specialist is responsible for ensuring the current ISP is in the program and the Program Directors or designee will audit to ensure the current ISP's are maintained in the programs. 04/04/2016 Implemented
Article X.1007Bancroft 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 6/30/15 and a Pennsylvania criminal history check was completed on 8/12/15. REPEATED VIOLATION 9/12/14When, 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
SIN-00109596 Renewal 02/09/2017 Compliant - Finalized