| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(c) | Staff person #1 started working 2/13/19 and the FBI was requested on3/27/19.
Staff person #2 was hired on 12/13/18 and the FBI check was requested on 3/27/19. | The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire.
| Non-compliance of 6400.21c was stated in error by the licensing team as evidenced by the criminal record check. Staff person #1 criminal record check was ordered 2/13/19 and began work 3/27/19. See exhibit-11. Staff person #2 criminal record was requested 12/13/18 and began work 3/27/19. please see exhibit-12. Both staff criminal record check and employment dates were reversed. |
04/20/2019
| Implemented |
| 6400.46(a) | Staff person #3 the Program Specialist, did not have documentation of orientation training. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | Program Specialist scheduled to participate in routine Orientation Training planned for third quarter of training year. Regular and routine training schedule developed to address training needs and requirements(see exhibit 13 attached). Also CDS training package procured and topics included in regular routine training. Please see training scheduled attached as exhibit-10. Word of Life International has finalized training plan with the College of Direct Support, CDS, for our staff to use their platform for year round online training. This training will be in addition to our internal annual training as evidence by the attached training schedule. |
04/20/2019
| Implemented |
| 6400.46(c) | Staff person #4 the CEO, had only completed 5.5 hours of Human Services training for the current full year of training. | The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. | Staff person #4, the CEO has provided record of training that exceeded the 24 hours of human services training requirement that should be completed during the training and program year. His training hours are in excess of the 24 hours minimum required. |
04/20/2019
| Implemented |
| 6400.46(d) | There was no documentation of 24 hours of training for the current full year for all direct care staff reviewed. | 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. | Records of annual trainings conducted to include medication administration, fire safety, fire drill, recognizing and preventing abuse and neglect, ISP goals, orientation, working with individuals with intellectual disablility, individual rights, were provided to office by contractor and respective personnel files updated. An annual routine and regular training schedule has been developed as attached as exhibit-9. Also, Word of Life International has finalized training plan with the College of Direct Support, CDS, for our staff to use their platform for year round online training. This training will be in addition to our internal annual training as evidence by the attached training schedule. Administration also developed matrix to track staff training to avoid repetition of non-compliance. |
04/15/2019
| Implemented |
| 6400.46(d) | Staff person #3 the Program Specilist did not have documentation of 24 hours of training for the period 1/1/18 -- 12/31/18. | 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. | Program Specialist, staff person #3, completed 24 hours of training for training year January 01, 2018 through December 31, 2018. as required by 6400.46. Copy of training record provided to office and is attached as exhibit-8. Regular training at office to include orientation and working with individuals with disabilities is ongoing. Training scheduled has been developed and is being implemented. Copy is attached as exhibit-7. Also, Word of Life International has finalized training plan with the College of Direct Support, CDS, for our staff to use their platform for year round online training. This training will be in addition to our internal annual training as evidence by the attached training schedule. |
04/20/2019
| Implemented |
| 6400.64(a) | The overhead exhaust vent had dust. | Clean and sanitary conditions shall be maintained in the home. | The overhead exhaust vent had been clean of all dust particles. Photo of outcome is attached as exhibit-7. Physical assessment of all homes shall be done quarterly to as early warning alert for corrective actions. |
04/15/2019
| Implemented |
| 6400.66 | Individual #1's bedroom had no lighting available. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The bedroom for individual #1 has lights fixtures replaced and they are functional. A photo of the lights have been attached as exhibit-6. Going forward, all homes have been checked, broken and unsafe furniture removed and replace. A quarterly assessment of physical homes has been mandated as a standing policy going forward. The quarterly home physical assessment will alert administration of early warning actions required at home. |
04/15/2019
| Implemented |
| 6400.67(a) | The bathroom had a broken door, a broken vanity top, and a broken bath tub shower head. | Floors, walls, ceilings and other surfaces shall be in good repair. | The bathroom door was damaged the week of licensing by the consumer during a crisis and outburst episode. The bathroom door broken vynil top and bath tub shower head have been replaced. There is no hazardous condition to posed risk. A photo of the replaced door and bathtub shower head and vynil top are attached as exhibit-5. Going forward, all homes have been checked, broken and unsafe furniture removed and replace. A quarterly assessment of physical homes has been mandated as a standing policy going forward. The quarterly home physical assessment will alert administration of early warning actions required at home. |
04/15/2019
| Implemented |
| 6400.76(a) | Individual #1's bedroom had a detached drawer from the dresser, also a nail was sticking out on the dresser. The bedroom closet door was found mission and broken, and the bedroom closet rack was bent significantly. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The bedroom furniture and equipment were damaged the week of licensing by the consumer during a crisis and outburst episode. The damaged furniture and equipment to include the dresser, closet and closet rack have been replaced or repaired. There is no hazardous condition to posed risk. A photo of the replaced dresser and repaired equipment is attached as exhibit-4. Going forward, all homes have been checked, broken and unsafe furniture removed and replace. A quarterly assessment of physical homes has been mandated as a standing policy going forward. The quarterly home physical assessment will alert administration of early warning actions required at home. |
04/15/2019
| Implemented |
| 6400.76(a) | The edge of the dining room table was damaged. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Dining room table was damaged the week of licensing by the consumer during a crisis and outburst episode. The dining room table was replaced and no hazardous condition is posed or exist. A photo of the replaced dining room table is attached as exhibit-3. All homes have been checked, broken and unsafe furniture removed and replace. A quarterly assessment of physical homes has been mandated as a standing policy going forward. The quarterly home physical assessment will alert administration of early warning actions required at home. |
04/15/2019
| Implemented |
| 6400.82(f) | The bathroom wall was missing a mirror. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | A mirror has been replaced in the bathroom. Also toilet paper holder has been repaired. A quarterly assessment of physical homes has been mandated as a standing policy going forward. A copy of recent physical assessment conducted at home following licensing inspection is attached as exhibit-2. The quarterly home physical assessment will alert administration of early warning actions required at home. |
04/15/2019
| Implemented |
| 6400.151(a) | Staff person #3 the Program Specialist's most current physical exam is dated 10/8/16. | 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. | Program Specialist, staff person #3, completed physical exam with chest x-ray on 2/13/19. The record of the Physical Exam for Staff Person #3 has been submitted to office and placed in personnel file. The copy of the record is herewith attached as exhibit 1. The human resource office also developed a matrix to indicate required hiring doucuments. Henceforth, all required hiring documents shall be provided prior to hiring. |
04/10/2019
| Implemented |
| 6400.151(c)(2) | Staff person #3 the Program Specialist physical exam did not include a current Mantoux. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The Program Specialist, staff #3, on 2/13/19 completed physical examination with chest x-ray. The record of the exam was submitted to the office and the personnel file has been updated. The copy of the record has been attached as exhibit-1. The human resource sectioin has update the file of all staff to reflect current hiring documents. The human resource office also developed a matrix to indicate required hiring doucuments. Henceforth, all required hiring documents shall be provided prior to hiring. |
04/10/2019
| Implemented |