| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff member # 1 was hired on 03/14/2019 and their Pennsylvania criminal history check was completed on 03/18/2019.
Staff member # 2 was hired on 02/05/2019 and their Pennsylvania criminal history check was completed on 03/18/2019.
Staff member # 3 was hired on 02/05/2019 and their Pennsylvania criminal history check was completed on 08/09/2019. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees 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. | Binty Nurses, Inc will hire a Human Resource Specialist to make sure all Hiring process is done according to state law and 6400 regulations. Binty Nurses Inc Human Resource will ensure criminal records are done before a newly hired staff starts to work.
After Our HR has done all hiring process, Program Director will check all staff files before a new staff gains employment with Binty Nurses, Inc to make sure all criminal background is transparent with no records. |
09/17/2019
| Implemented |
| 6400.22(e)(3) | Individual #1's financial ledger dated 7/13/19 lists a Ross Store payment in the amount of $17.99 and there was no receipt presented for the expenditure. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Residential house managers will ensure that all individual petty cash receipts reflect the transaction on the reconciliation sheet. The residential House manager will bring the reconciliation sheet and receipts to the Residential Program Manager at the end of every week to make sure all receipts and transactions are reconciled. |
08/19/2019
| Implemented |
| 6400.66 | The entrance did not have an operable light. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Residential Program Manager has changed the bulb in front of the house. The residential Manager will make sure all light bulbs are checked every month. All house will have a box of electric spear bulbs for house supervisors t change anytime a bulb is fused. Program Specialist will make a walkthrough to all homes to avoid such errors not to happen again in the future. |
08/19/2019
| Implemented |
| 6400.71 | The kitchen telephone did not have emergency numbers on or near the phone. | 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.
| Residential Program Manager has created an emergency telephone number for the telephone in the house. residential program Manager will ensure all telephone in the homes has an emergency number that has the nearest Hospital, police department, ambulance, and poison control numbers by the side of the telephone. Program Specialist will do a walkthrough in all homes to make sure it is done every six months within the year. |
09/10/2019
| Implemented |
| 6400.82(e) | The basement bathroom shower did not have a mat or nonslip surface. | Bathtubs and showers shall have a nonslip surface or mat. | Program Manager of Binty Nurses Inc has bought a non-slip mat for the basement bathroom. Moving forward, The Program Manager will ensure all Residential house bathroom tub has a non-slip mat in all tubs in every home every month. Program Specialist will do a walkthrough in all homes every month to make sure it will not occur again. |
09/10/2019
| Implemented |
| 6400.112(a) | There was no documentation of a fire drill for the month of January 2019. | An unannounced fire drill shall be held at least once a month. | There was a record of a fire drill, but it was not filed in the house. Program Specialist will ensure all house manager do an unannounced awake and sleep drill every month. The program Specialists will keep a copy in the office and a copy in the house of all monthly fire drills to avoid reoccurrence. See attached emailed |
09/09/2019
| Implemented |
| 6400.141(c)(1) | Individual # 1 physical exam completed on 10/30/18 did not include a review of previous medical history. | The physical examination shall include: A review of previous medical history. | Binty Nurses In Nursing Coordinator will ensure Previous medical history is included in the current Annual physical exams every year to make the error do not happen again. Nursing will continue to make all appointments for all individual to make sure all the Individual are well screen and checked. Nursing Coordinator will accompany all Individual on all medical appointments to avoid reoccurrences. |
09/12/2019
| Implemented |
| 6400.141(c)(4) | individual # 1's physical exam completed on 10/30/18 did not include a vision and hearing screening and the physician recommended they be evaluated by a specialist, and there was no documentation of the specialist follow up for vision and hearing. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Binty Nurses Inc Nursing Coordinator will ensure all Vison, Hearing screening for all individuals are done and completed every year. Nursing Coordinator will take all individuals to all medical appointments recommended by PCP. Nursing Coordinator will set up all medical appointments to the specialist to make sure all referrals are done every year. |
09/17/2019
| Implemented |
| 6400.141(c)(9) | Individual #1's Physical exam completed on 10/30/18 did not include a prostate exam. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Binty Nurses Inc Nursing Coordinator will ensure to take the Individual two month before the Annual physical exams expiration, and all other medical appointments. Nursing Coordinator will ensure that Individual #1 sees his Primary Care Physician for all prostate exams to be completed every year. Nursing Coordinator will ensure to check all individuals record to make sure all individual do not miss their Medical appointment moving forward |
09/17/2019
| Implemented |
| 6400.181(c) | Individual #1's assessment completed on 12/19/18 did not document what the assessment was based on. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Binty Nurses Inc Will hire a new program Specialist. Ahmed Kamara will ensure he signs all annual assessment that will base on Interviews from staff, family Members, progress notes, and observation one month before the assessment due date. When the program specialist completes the yearly assessment, It shall be sent to all team members, including Support Coordination for verification and correction, and a signed copy kept on the individual's file at home. |
09/17/2019
| Implemented |
| 6400.181(d) | Individual #1's assessment completed on 12/19/18 was not signed and dated by the program specialist. | The program specialist shall sign and date the assessment. | Binty Will hire a new program Specialist Ahmed Kamara will ensure he signs all annual assessment. When the program specialist completes the yearly assessment, It shall be sent to all team members, including Support Coordination for verification and correction, and a signed copy kept on the individual's file at home. |
09/17/2019
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment completed on 12/19/18 did not document recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Moving forward in the future Binty Nurses, Inc Program Specialist Will Ensure All Individual Assessment is completed correctly by making certain specific areas of recommendation for training and program services are explained clearly. The Program Specialist will send a copy of the assessment to all team members to make any recommendation one month before the due date of the assessment |
09/17/2019
| Implemented |
| 6400.34(a) | Individual # 1's date of admission to the agency was on 10/21/18, and their rights wasn't completed until 1/18/19, which is 3 months after their admission to the agency. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Binty Nurses Inc has hired a new Program Specialist Ahmed Kamara to make all Individual Rights statement and Consent is signed before the moving date. EVery year May-June, Program Specialist will go through all individual records to make sure such an error do not occur in the future. Program Specialist will explain to the Individual #1 his rights and how to report any grievances each year a month before the assessment is due. |
09/17/2019
| Implemented |
| Article X.1007 | Binty Nurses 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 member #1's employee file did not document if they had been a Pennsylvania resident for the past 2 years.
Staff member #2's employee file did not document if they had been a Pennsylvania resident for the past 2 years.
Staff member #3's employee file did not document if they had been a Pennsylvania resident for the past 2 years. | 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. | Binty Nurses Inc has updated their job application with the question "Have you lived in the State of Pennsylvania for years"? Yes or No to correct this issue. Program Specialist will send you an email of a copy of the job application. Binty Nurses Inc will Hire a Human Resource Specialist to ensure all new and old employees to prove that they have lived in PA for more than two years. HR will ensure all Staff has a copy of their PA Drivers Licenses, and or PA ID cards. If they have not lived in PA for two years, they will do a Fingerprint FBI clearance and criminal history clearance.
Program Director will check all new and Old employees file to make sure all required documents are completed before they start work. |
09/09/2019
| Implemented |