Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC 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.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 6/30/15 and a Pennsylvania criminal history check was completed on 8/12/15. 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 |