| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #1 made the following purchases that should have been covered by the provider agency:
· 7/25/22 -- Walmart -- 2 mattress covers that totaled $24.89
· 7/25/22 -- Walmart -- 2 packs of disposable bed pads that totaled $33.72 | Individual funds and property shall be used for the individual's benefit. | Individual's funds were returned to them from the agency
Retraining of all staff on what items fall under Chapter 6100 regulations regarding room and board |
10/10/2022
| Implemented |
| 6400.110(a) | At the time of the 9/21/22 inspection, the smoke detector in the attic was not operable. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Retraining of staff and increased oversight from the DOS and HR Director. |
10/06/2022
| Implemented |
| 6400.144 | Individual #1 has a blood pressure protocol that requires their blood pressure to be checked by staff on Monday and Thursday mornings. If the top number is higher than 170 or lower than 90 and the bottom number is higher than 90 or lower than 70, blood pressure is to be rechecked in 30 minutes. If the blood pressure numbers do not improve, Individual #1's doctor is to be contacted immediately. On the following dates, Individual #1's bottom number was below 70, but Individual #1's blood pressure was not rechecked in 30 minutes: 11/11/21, 11/22/21, 11/29/21, 8/18/22, 8/22/22, and 9/5/22. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Retraining of all staff within the program and modification to the MAR to assist staff with ensuring the parameters are followed. |
10/10/2022
| Implemented |
| 6400.46(a) | Staff person #1 was hired on 10/8/21. This staff person did not complete fire safety training until 2/22/22. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Training in the regulations and the expectations and checked remaining records to ensure compliance |
10/10/2022
| Implemented |
| 6400.51(a)(3) | Staff person #1 was hired on 10/8/21. This staff person did not complete the orientation training required in 6400.51(b) until 11/17/21. Staff person #1 completed the prevention, detection, and reporting of abuse training, person centered practices training, and reporting and recognizing incidents training on 11/15/21, and job-related knowledge and skills training on 11/17/21. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | Training in the regulations and the expectations and checked remaining records to ensure compliance |
10/10/2022
| Implemented |
| 6400.166(b) | Individual #1's 8am medications on 8/30/22 and 8pm medications on 8/31/22 were not documented as administered at the time of administration. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | All staff in the program were retrained on the regulation and the process of ensuring all required information is clearly documented on the MAR.
Updated the internal cheat sheet that was created to ensure that staff have an example of proper documentation. |
10/10/2022
| Implemented |
| Article X.1007 | Bell Socialization Services is required to maintain 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 #2 was hired on 6/15/22, resided outside the state of Pennsylvania within 2 years of their date of hire, and at the time of the 9/19/22 inspection the agency did not complete and process a Federal Bureau of Investigation (FBI) background check. | 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. | 1. For all new hires, this is the process that must be followed:
a. the Assistant Program Coordinator will ensure that the question is answered correctly, and that the applicant signs the form during the interview.
i. Remember to inform the applicant that Bell Socialization may ask for proof of residency in the Commonwealth of Pennsylvania for the previous 2 years. In the event that the applicant cannot prove 2 years of residency, Bell Socialization Services, Inc. will automatically require an FBI check, as licensing representative can ask for proof.
ii. During this year¿s annual licensing, the proof that was provided was a copy of a PennDOT driver¿s license check with the date the employee received their driver¿s license and a diploma form a local high school was provided.
b. the Assistant Program Coordinator will ensure that a PA State Police Check is also completed by giving the completed form to the Human Resource Employment Specialist to run the check.
c. the Human Resource Employment Specialist will input the information into the computerized system and print off all applicable paperwork to prove that the PA State Police background was completed.
d. If an FBI clearance is also required, the Assistant Program Coordinator will provide the information to the applicant to register for the appointment.
i. The Human Resource Employment Specialist will ensure that the applicant submits the receipt for the FBI clearance proving that he/she/they have had their clearance completed PRIOR to their sign on date.
e. Once all of the internal paperwork is completed, the Assistant Program Coordinator must submit the packet of paperwork to the Director or Assistant Director of IDD Services for approval BEFORE the applicant is offered the position.
i. The Director or Assistant Director of IDD Services will be the 3rd check to ensure that the applicant either requires or does not require a FBI Clearance.
2. You are being retrained on all regulations regarding criminal histories. I have listed the regulations and the information from ODP¿s regulatory compliance guide below. |
10/06/2022
| Implemented |