| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | Sunset Support Services has an agency policy regarding Transporting Individuals in Personal Vehicles (Agency Policy 438-a). This policy states that if an agency vehicle is not available at their current home, that it is the responsibility of the employee to contact other agency homes to see if there is another agency vehicle for use. If after doing this, a vehicle is still not available, then staff are permitted to use their personal vehicle to transport an individual. There is no documentation that staff #6 contacted other homes on 11/6/2023 to see if any agency vehicles were available prior to transporting Individual #1 in their personal vehicle. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | The CEO will update the Transporting Individuals in Personal Vehicles policy:
Sunset Support Services provides vehicles for our individuals to be transported to doctor's appointments and various outings. However, there may be times when a company vehicle is not available. It is the responsibility of the employee to call around to the other houses to see if another vehicle is available. Any employee who fails to call to find another vehicle is subject to disciplinary action up to and including termination. If after doing this, one is still not available, they are permitted to use their personal vehicle and the employee can be eligible for mileage reimbursement (Gas Mileage Reimbursement Policy).
An employee can also request a waiver in writing to the CEO to use their personal vehicle instead of using our company-owned vehicle. The waiver is good for 6 months. However, an employee is not eligible for mileage reimbursement while on the waiver.
When using their personal vehicle, it is up to the employee to ensure that their vehicle is up to date on registration, insurance, and annual safety inspection to ensure that it is safe to transport our individuals. It should go without saying that to drive the individuals around, employees should have a valid license.
Staff are to be familiar with the individual's ISP and BSP to ensure that there will be nothing in your personal vehicle that could violate the individual's ISP or BSP. For example, if the individual cannot have sharps, please ensure that all sharps are removed from the vehicle.
If an employee does not follow this policy, the employee is subject to disciplinary action up to and including termination. |
12/12/2023
| Implemented |
| 6400.67(a) | Upon physical site inspection on 11/8/2023, the following items were noted as not being in good repair: Stains found on Individual #1's bedroom carpet, stains and cut in the living room carpet, as well as multiple marks on the living room walls. | Floors, walls, ceilings and other surfaces shall be in good repair. | Carpet was replaced in the bedroom by maintenance department. The walls will be painted, and carpet replaced next week by Sunset's maintenance department. |
12/15/2023
| Implemented |
| 6400.18(a)(5) | Prior to the incident that occurred on 11/6/2023, Staff #3 reported that Individual #1 reported to them that Staff #6 has taken them to a marijuana dispensary and smoked marijuana in front of them. Staff #3 did not report these prior alleged incidents of neglect within 24 hours of discovery. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| Staff #3 was retrained on Incident Management on 11/28/2023 and disciplinary action was taken on staff #3. According to the disciplinary action notice, if this occurs again that staff # 3 will be terminated. |
01/31/2024
| Implemented |
| 6400.24 | OAPSA -- Staff #7 was hired on 9/5/2023 and has the following prohibited offenses specified in OAPSA: Robbery (felony), (2) thefts (misdemeanor), (2) manufacture of controlled substance (felony). Provider is responsible for completing a case-by-case decision about whether to hire the person and keep documentation of the review. Provider did not include documentation of the facts surrounding the conviction or the nature and requirements of the job in relation to their criminal record.
OAPSA: Staff #3 was hired on 5/9/2022 and has the following prohibited offenses specified in OAPSA: Receiving stolen property (misdemeanor) and retail theft (misdemeanor). Provider is responsible for completing a case-by-case decision about whether to hire the person and keep documentation of the review. Provider did not include documentation of the facts surrounding the conviction or the nature and requirements of the job in relation to their criminal record. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Sunset updated our policy and procedures to clarify the process of hiring potential hires with a criminal record.
Sunset Criminal History Record Checks Policy was updated to:
To be considered for employment at Sunset Support Services, all potential employees (including part time and casual staff) must apply for a Pennsylvania criminal history record check thru the State Police prior to working with an individual at Sunset Support Services. This service will be run by Sunset Support Services. The cost of the application is the responsibility of the employee. It can be taken out of their first paycheck, or they can pay for it separately with cash or money order. If the employee quits or is terminated before their orientation period ends, the employee is still responsible for the cost of the application.
If at any point in the employment term, an employee commits a crime and the charges fall into the following categories, Sunset Support Services reserves the right to discipline said employee up to and including termination no matter where the crime(s) were committed.
One (1) felony OR two (2) misdemeanors within the 3900 series (CC3901-CC3934) One felony conviction for CC3901 = PROBIHITED OFFENSE
Two misdemeanor convictions for CC3921 = PROHIBITED OFFENSE One misdemeanor conviction for CC3924 in 1999 AND one misdemeanor conviction for CC3931 in 2004 = PROHIBITED OFFENSE
(Information pulled from Regulatory Compliance Guide- Appendix B: Prohibitive Offenses in OAPSA.)
NEW CHANGE*Sunset Support Services will perform a risk assessment on all employees and potential employees that have any offenses that show on the criminal record check. It consists of a one-on-one meeting with the CEO and Administrative Director where the nature of the crime(s), facts surrounding the conviction, the employee¿s description of the crime(s), evidence of the employee¿s rehabilitation, and how the crime(s) will affect their job duties will be discussed.
Following this meeting, a decision will be made whether to continue with employment or not. If employment is continued, stipulations may be made such as drug testing regularly, continued follow-up with physicians, etc.* |
12/08/2023
| Implemented |