| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment was not completed 3-6 months prior to license expiration date which is 12/29/15. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| WHO: Douglas Jones, CEO/Administrator
WHAT WILL BE CORRECTED: The self-assessment was not completed 3-6 months prior to license expiration date which is 12/29/15.
WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 04/29/16
HOW: Fix the Violation, an immediate self-assessment for 3320 Mary Street, Apartment 1 Drexel Hill, PA 19026 was conducted on 4/30/2016. A copy of the assessment was placed in a centralize folder hosting all of Acute¿s assessments.
PLAN TO PREVENT FUTURE OCCURRENCE: The responsible staff will ensure that Acute completes a self-assessment of each home it operates within 3 to 6 months prior to the expiration date of the certificate of compliance, to measure and record compliance with this chapter.
An outlook calendar will be set to alert the CEO 4 months prior to the Certificate of Compliance expiration date. Once the assessment is completed, a copy of the assessment will be stored in the home and in the head office.
ATTACHMENT AND SUPPORTING DOCUMENTS
Self-Assessment
WHO: Douglas Jones, CEO/Administrator
WHAT WILL BE CORRECTED: The self-assessment was not completed 3-6 months prior to license expiration date which is 12/29/15.
WHEN: Target Date of completion was 05/04/16. Specific Date of Completion was 05/04/16
HOW: Fix the Violation, an immediate self-assessment for 3320 Mary Street, Apartment 1 Drexel Hill, PA 19026 was conducted on 4/30/2016. A copy of the assessment was placed in a centralize folder hosting all of Acute¿s assessments.
PLAN TO PREVENT FUTURE OCCURRENCE: The responsible staff will ensure that Acute completes a self-assessment of each home it operates within 3 to 6 months prior to the expiration date of the certificate of compliance, to measure and record compliance with this chapter.
An outlook calendar will be set to alert the CEO 4 months prior to the Certificate of Compliance expiration date. Once the assessment is completed, a copy of the assessment will be stored in the home and in the head office.
ATTACHMENT AND SUPPORTING DOCUMENTS
Self-Assessment
WHO: Douglas Jones, CEO/Administrator
WHAT WILL BE CORRECTED: The self-assessment was not completed 3-6 months prior to license expiration date which is 12/29/15.
WHEN: Target Date of completion was 05/07/16. Specific Date of Completion was 05/07/16
HOW: Fix the Violation, an immediate self-assessment for 3320 Mary Street, Apartment 1 Drexel Hill, PA 19026 was conducted on 4/30/2016. A copy of the assessment was placed in a centralize folder hosting all of Acute¿s assessments.
PLAN TO PREVENT FUTURE OCCURRENCE: The responsible staff will ensure that Acute completes a self-assessment of each home it operates within 3 to 6 months prior to the expiration date of the certificate of compliance, to measure and record compliance with this chapter.
An outlook calendar will be set to alert the CEO 4 months prior to the Certificate of Compliance expiration date. Once the assessment is completed, a copy of the assessment will be stored in the home and in the head office.
ATTACHMENT AND SUPPORTING DOCUMENTS
Self-Assessment
|
05/07/2016
| Implemented |
| 6400.32 | The water in the bath tub and sink in the bathroom located at the end of the hallway was turned off by staff to prevent Individual #2 from having access to the water. | An individual may not be deprived of rights.
| WHO: Gifty Quashigah, Program Specialist and Michael Addo, Director will be responsible for fixing violation.
WHAT WILL BE CORRECTED: The water in the bath tub and sink in the bathroom located at the end of the hallway was turned off by staff to prevent Individual #2 from having access to the water.
WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 04/29/16
HOW: ACUTE immediately obtained a written order from Individual #2 PCP to have the water turned off and turned on as needed to prevent Individual #2 from reapplying water to her wound which delays healing. The order is to shut the water does this frequently after regular shower in the mornings. TJ goes to the bathroom often and applies water from the shower, toilet or sink. TJ¿s obsession of this behavior causes delay to the wound which TJ sustained from skin graft.
PLAN TO PREVENT FUTURE OCCURRENCE: ACUTE will obtain an active doctor¿s order prior to shutting main water supply line and present for viewing to proper authority for justification so as to not appear as a deprivation of rights but instead a medical necessity.
ATTACHMENT AND SUPPORTING DOCUMENTS
Attachment DRs Order |
04/29/2016
| Implemented |
| 6400.67(a) | There was a round crack, the size of regular grapefruit on the lower right wall next to the window in Individual #2¿s bedroom. There was also a round crack, the shape of a tennis ball on the right of the wall leading to the living room. A circular crack, the size of a grapefruit. There was no upper drawer door on Individual # 2¿s chess located in the individual¿s bedroom. | Floors, walls, ceilings and other surfaces shall be in good repair. | WHO: Douglas Jones, CEO/Administrator, Acute, will be responsible for correcting the problem
WHAT WILL BE CORRECTED: There was a round crack, the size of regular grapefruit on the lower right wall next to the window in Individual #2¿s bedroom. There was also a round crack, the shape of a tennis ball on the right of the wall leading to the living room. A circular crack, the size of a grapefruit. There was no upper drawer door on Individual # 2¿s chess located in the individual¿s bedroom.
WHEN: Target date of completion was 5/20/16. Specific Date of Completion was 05/25/16
HOW: The walls were immediately repaired and painted to match the remaining of the home and a new chess was purchased to replace the old one.
PLAN TO PREVENT FUTURE OCCURRENCE:
Property damage policy was put in place to ensure damages to the homes are quickly identify and reported to the supervisors. In addition, a bi-weekly inspection of the homes will be conducted by the Program Specialist to identify damages. All repairs/replacements will be completed within two weeks of the initial damaged date.
ATTACHMENT AND SUPPORTING DOCUMENTS
Attachment Property replace policy
Attachment Images of walls
Attachment Image of chess |
05/25/2016
| Implemented |
| 6400.112(f) | Fire Drill records reviewed for the period 11/15/15- 4/18/16 all indicated the front door as exit rout. There were two other exits through the basement which were not used for exits during the drills. | Alternate exit routes shall be used during fire drills. | WHO: Douglas Jones, CEO/Administrator, Acute, will be responsible for correcting the problem
WHAT WILL BE CORRECTED: Fire Drill records reviewed for the period 11/15/15- 8/18/16 all indicated the front door as exit route. There were two other exits through the basement which were not used for exits during the drills.
WHEN: Target date of competition was set for 05/31/16. Specific Date of Completion was 05/22/16
HOW: Because Mary St location is an apartment complex, the basement was commercially restricted. Arrangement were made with the landlord to allow not only laundry access in the basement but also exist access. Acute¿s fire drill form was modified to include the additional two basement exits. 5/25/16, an unannounced fire drill was conducted and the basement front door was utilized. Staff was immediately trained to utilize alternate exits while conducting fire drill.
PLAN TO PREVENT FUTURE OCCURRENCE:
Staff will use an alternate exit route each time fire drill is conducted. Staff will also document the route used for each fire drill. Acute will continue to inform the landlord of ODP regulation and the importance of using alternate exits throughout the building.
ATTACHMENT AND SUPPORTING DOCUMENTS
Attachment Fire Drill Documents
Attachment In-House Training Attendance Sheet 1 |
05/22/2016
| Implemented |
| 6400.144 | Individual #2 is prescribed Glycolax 255mg Powder, Miralax and Vitamin A&D ointment and it was not in the home. | 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.
| WHO: Gifty Quashigah, Program Specialist, Acute, will be responsible for correcting the problem
WHAT WILL NE CORRECTED: Individual #2 is prescribed Glycolax 255mg Powder Miralax and Vitamin A&D ointment that were not in the home but listed on MAR
WHEN: The target date of completion was 4/29/16. Specific Date of Completion was 5/01/16
HOW: To fix the violation, the Program Specialist called Individual #2¿s Doctor, obtained a discontinued script for the Glycolax 255mg that was discontinued, took it to the pharmacy and got it removed from the MAR. Program Specialist searched for the Vitamin A&D cream, that was located in Individual #2 shower box and placed it in the medication lock box.
PLAN TO PREVENT FUTURE OCCURRENCE: To prevent future violation, Acute will ensure that a discontinuation script is obtained for all discontinued medications and also inform the Pharmacy to remove the discontinued medication from the MAR. In addition, Acute implemented a nightly check by staff to ensure all medications are present in the medication lock box.
ATTACHMENT AND SUPPORTING DOCUMENTS
Attachment Mary Street MAR
Attachment Med Overnight check |
05/01/2016
| Implemented |
| 6400.151(a) | Staff person #3 was hired on 9/9/14 and the physical examination was completed on 11/3/15
Staff person #4 was hired on 10/31/15 and the physical examination was completed on 11/3/15
Staff person #5 was hired on 1/30/16 and the physical examination was completed on 10/16/14
| 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. | WHO: Fortune Quashigah, Associate Director, Acute, will be responsible for correcting the problem
WHAT WILL BE CORRECTED: Staff person #1was hired on 1/30/16 and the physical exam was completed on 2/12/16.
WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 05/01/16. This includes reviewing all employees¿ records.
HOW: To fix the violation, Acute Community Home Aid, implemented a mandatory requirement to obtain physical examination completed within a year prior to orientation or employment, from all newly hired staff who will come into direct contact with individuals or who will prepare or serve food. Thereafter, active staff will complete physical examination every 2 years.
All current staff members whose physical examinations were conducted after their hire dates were identified and documented for corrective action.
Management staff completed In-House Training on Staff¿s physical exam requirement¿ Section 151 under DHS Chapter 6400.
PLAN TO PREVENT FUTURE OCCURRENCE: Acute will ensure that all newly hired staff will have their physical examination completed within 12 months prior to participating in orientation and being offered employment. The physical examination will be according to the guidelines of the program. To inforce this concept, a FingerCheck¿ system was purchased, including a Human Resource module.
Once the physical exam document is submitted, this information will be uploaded into Acute new Human Resource Management system and attached to the appropriate employee profile. The system will be set to email Fortune Quashigah, Douglas Jones, Michael Addo, and the employee in question one month prior to the expiration date of the physical exam. The employee will be contacted directly by Fortune Quashigah to ensure a new physical form is being processed. The email will include specifics such as employee name, expiration date, and the document that will be expiring.
The system includes a pre-screening component that allows for checklist to be attached to potential employees. Only employees who have passed a full check will be invited to orientation. If one of the check items is missing for any given employee, he/she will not be shortlisted for orientation.
Management will continue to keep abreast with program bulletin for updates to the regulations and adhere to them in order to avoid violations in the future.
Staff who fail to renew their physical exam will be removed from providing services or having any direct contact with individuals in the program.
ATTACHMENT AND SUPPORTING DOCUMENTS:
www.fingercheck.com
Attachment III 6400151 (Signature In-House Training for Management)
WHO: Fortune Quashigah, Associate Director, Acute, will be responsible for correcting the problem
WHAT WILL BE CORRECTED: Staff person #3 was hired on 9/9/14 and the physical examination was completed on 11/3/15
WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 05/01/16
HOW: Staff #3 had completed a physical examination prior to hire date according to the guidelines of the program. However, during the inspection Staff #3 physical was not in the folder. The responsible staff located and placed it in the appropriate folder. Please see supporting document.
Management staff completed In-House training on Staff Health ¿ Section 151 under DHS Chapter 6400.
PLAN TO PREVENT FUTURE OCCURRENCE: Acute purchased a `Finger-Check¿ system, including the HR module that allows the company to enter employee documents and records. This system sends an automatic email to staff, 30 days or any day of choice prior to expiration of all documents. (www.fingercheck.com)
ATTACHMENT AND SUPPORTING DOCUMENTS:
Attachment In-House Training Attendance Sheet 1
Attachment III 6400151
Attachment VI GQ151 |
05/01/2016
| Implemented |
| 6400.151(c)(2) | Staff person #3 was hired on 9/9/14 and the Tuberculin test was completed on 1/28/15
Staff person #4 was hired on 10/31/15 and the Tuberculin test was completed on 11/5/15.
Staff person #5 was hired on 1/30/16 and the Tuberculin test was completed on 8/28/14.
| 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. | WHO: Fortune Quashigah, Associate Director, Acute, will be responsible for correcting the problem
WHAT WILL BE CORRECTED: Staff person #3 was hired on 9/9/14 and the Tuberculin test was completed on 1/28/15
WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 05/01/16
HOW: Staff #3 had completed a physical examination with Tuberculin test with a negative result prior to hire date according to the guidelines of the program. However, during the inspection Staff #3 Tuberculin test was not in the folder. The responsible staff located and placed it in the appropriate folder. Please see supporting document.
Acute Community Home Aid also implemented a mandatory requirement to obtain from all newly hired staff, physical examination inclusive of tuberculin skin test by Mantoux method completed in 2 years with a negative results or chest x-ray for positive test result, prior to orientation and hire date. Thereafter, active staff will complete physical examination very 2 years.
All current staff members whose Tuberculin test were completed after their hire dates were identified for corrective action by Acute.
Management staff completed In-House training on Staff Health ¿ Section 151 under DHS Chapter 6400.
PLAN TO PREVENT FUTURE OCCURRENCE:
Acute purchased a `Finger-Check¿ system, including the HR module that allows the company to enter employee documents and training records. This system sends an automatic email to staff, 30 days or any day of choice prior to expiration of all documents. (www.fingercheck.com)
Staff who fail to renew their Tuberculin test will be removed from providing services or having any direct contact with individuals in the program.
Acute will ensure that all newly hired staff complete their Tuberculin test with negative results or chest x-ray if positive. This will be completed within 2 years prior to orientation and/or employment with Acute. This will be the requirement for employment in order to remain compliant with the program regulation.
The responsible staff will check all employee folders on a monthly basis to ensure that all documents are filled appropriately. All documents will be and checked for expiration dates. Staff will be notified and must renew his/her physical and PPD test prior to expiration every two years after the initial exam.
Management will continue to keep abreast with program¿s bulletin for updates to the regulations and adhere to them in order to avoid violations in the future.
ATTACHMENT AND SUPPORTING DOCUMENTS
Attachment III 6400151
Attachment VI GQ151
WHO: Fortune Quashigah, Associate Director, Acute, will be responsible for correcting the problem
WHAT WILL BE CORRECTED: Staff person #4 was hired on 10/31/15 and the Tuberculin test was completed on 11/5/15.
WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 05/01/16
HOW: To fix the violation, Acute Community Home Aid, immediately implemented a mandatory requirement to obtain from all newly hired staff, physical examination inclusive of tuberculin skin test by Mantoux method completed in 2 years with a negative results or chest x-ray for positive test result, prior to orientation and hire date. Thereafter, active staff will complete physical examination very 2 years.
All current staff members whose Tuberculin test were completed after their hire dates were identified for corrective action by Acute.
Management staff completed In-House training on Staff Health ¿ Section 151 under DHS Chapter 6400.
PLAN TO PREVENT FUTURE OCCURRENCE:
Acute will ensure that all newly hired staff complete their Tuberculin test with negative results or chest x-ray if positive. This will be completed within 2 years prior to orientation and/or employment with Acute. This will be the requirement for employment in order to remain compliant with the program regulation.
Attachment III 6400151 |
05/01/2016
| Implemented |
| 6400.181(a) | Individual #1 date of admission was11/13/15 and the initial assessment was completed on 2/13/16.
Individual #2 date of admission was 11/16/15 and the initial assessment was completed on 2/16/15.
| 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. | WHO: Program Specialist, Gifty Quashigah and Associate Director, Fortune Quashigah
WHAT WILL BE CORRECTED: Individual #1 date of admission was11/13/15 and the initial assessment was completed on 2/13/16.
WHEN Target Date of completion was 04/29/16. Specific Date of Completion was 04/29/16
HOW: An in-house training was conducted for the Program Specialist together with three administrative staff on 4/29/16 covering the entire Assessment Section: 55 PA Code Chapter 6400.181(a-f) ¿ The training highlighted guidelines for completing initial assessment of all new residents 60 calendar days after admission into ACUTE. This assessment will include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission.
PLAN TO PREVENT FUTURE OCCURRENCE:
ACUTE will ensure that all initial assessments will be completed 60 calendar days after admission. The Program Specialist will document the calendar day that an assessment of an individual is due. The Program Specialist is to put an entry into Outlook calendar reminding her five business days before the actual due date and another entry reminding her one day before the actual due date.
ATTACHMENT AND SUPPORTING DOCUMENTS:
In-house training signature sheet
WHO: Program Specialist, Gifty Quashigah and Associate Director, Fortune Quashigah
WHAT WILL BE CORRECTED: Individual #2 date of admission was 11/16/15 and the initial assessment was completed on 2/16/15.
WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 04/29/16
HOW: An in-house training was conducted for the Program Specialist together with three administrative staff on 4/29/16 covering the entire Assessment Section: 55 PA Code Chapter 6400.181(a-f) ¿ The training highlighted guidelines for completing initial assessment of all new residents 60 calendar days after admission into ACUTE. This assessment will include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission.
PLAN TO PREVENT FUTURE OCCURRENCE:
ACUTE will ensure that all initial assessments will be completed 60 calendar days after admission. The Program Specialist will document the calendar day that an assessment of an individual is due. The Program Specialist is to put an entry into Outlook calendar reminding her five business days before the actual due date and another entry reminding her one day before the actual due date.
ATTACHMENT AND SUPPORTING DOCUMENTS:
Attachment In-House Training Attendance Sheet 1 |
04/29/2016
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment dated 2/13/16 did not document the Individual¿s ability to swim | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | WHO: Gifty Quashigah, Program
WHAT WILL BE CORRECTED: Individual #1's assessment dated 2/13/16 did not document the Individual¿s ability to swim
WHEN Target Date of completion was 04/29/16. Specific Date of Completion was 04/29/16
HOW: Immediately following the inspection, on 4/25/2016, Individual #1 assessment was update to include the individual¿s knowledge of water safety and ability to swim. In addition, the assessment was compared to 6400.181 regulation to ensure all contents were present. For those missing contents, they were immediately added.
PLAN TO PREVENT FUTURE OCCURRENCE: Before creating an assessment of each individual, the Program Specialist must/will create a checklist using the content from 6400.181 regulation. The Program Specialist will follow the checklist while creating the assessment. Once a content is represented in the assessment, the Program Specialist will put a check mark next to the content in the checklist indicating a completion of that specific content.
ATTACHMENT AND SUPPORTING DOCUMENTS:
Attachment In-House Training Attendance Sheet 1 |
08/31/2016
| Implemented |
| 6400.181(f) | There was no documentation to show that Individual #1's assessment dated 2/13/16 was sent to the support coordinator at least 30 calendar days prior to the Individual Support Plan meeting held on 11/19/15. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| WHO: Gifty Quashigah, Program
WHAT WILL BE CORRECTED: There was no documentation to show that Individual #1's assessment dated 2/13/16 was sent to the support coordinator at least 30 calendar days prior to the Individual Support Plan meeting held on.
WHEN Target Date of completion was 05/02/16. Specific Date of Completion was 04/28/16
HOW: The assessment for Individual #1 was delivered to the SC following the inspection. The original assessment was revisited and modified using data collected during the individual first sixty days in Acute¿ s program, this includes progress notes. The Program Specialist ensured that the SC signed a recipient document upon receiving the assessment.
PLAN TO PREVENT FUTURE OCCURRENCE: When an assessment is completed 60 days after an individual moves in Acute¿s program, the Program Specialist must emailed a pdf version of the assessment to the SC within a week of completion. The email will include verbiages that informs the SC of it been a receipt. In instances where emailing servers are unavailable, the Program Specialist will ensure that the SC receives a hard copy of the assessment in person and provide a signature. The Program Specialist must cced/copy the entire team on the email.
ATTACHMENT AND SUPPORTING DOCUMENTS:
SC Receipt of Assessment
Attachment In-House Training Attendance Sheet 1 |
04/28/2016
| Implemented |
| 6400.185(a) | Individual #1¿s three months ISP review documentation dated 11/13/15-2/13/16 was not implemented by the ISP start date of 2/7/16. | The ISP shall be implemented by the ISP's start date. | WHO: Gifty Quashigah, Program
WHAT WILL BE CORRECTED: Individual #1¿s three months ISP review documentation dated 11/13/15-2/13/16 was not implemented by the ISP start date of 2/7/16.
WHEN Target Date of completion was 04/29/16. Specific Date of Completion was 05/02/16
HOW: The Program Specialist together with three administrative staff were trained on 55 PA Code Chapter 6400. 185(a) to identify implementation of ISP¿s start date in relations to completing quarterly reports.
A tracking sheet was created for quick and easy reference of all individual¿s quarterly dates and when their quarterly reports are to be completed within any given service period.
PLAN TO PREVENT FUTURE OCCURRENCE:
The Program Specialist will be mindful of all individual¿s ISP start date when completing the quarterly reports so that there are no overlapping dates.
The tracking sheet will be implemented to ensure that all quarterly reports are completed within the reporting period according to program regulation.
ATTACHMENT AND SUPPORTING DOCUMENTS:
Attachment In-House Training Attendance Sheet 1
Individual Quarterly Tracking Sheet |
05/02/2016
| Implemented |
| 6400.186(b) | Individual #2¿s Three months ISP review for the period 11/16/15-2/16/16 was signed on 2/13/16 prior to the end of the review period. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | WHO: Gifty Quashigah, Program Specialist
WHAT WILL BE CORRECTED: Individual #2¿s Three months ISP review for the period 11/16/15-2/16/16 was signed on 2/13/16 prior to the end of the review period.
WHEN Target Date of completion was 04/29/16. Specific Date of Completion was 05/02/16
HOW: The Program Specialist and all administrative staff completed an in-house training covering the entire section of 55 PA Code Chapter 6400.186(b) highlighting the role of the PS to ensure that all individuals in our program sign and date the ISP review signature sheet upon review of the ISP.
PLAN TO PREVENT FUTURE OCCURRENCE:
The Program Specialist will ensure that all ISP plans are reviewed and signed, every three months, by the Individual and the Program Specialist on the reviewed date.
A tracking sheet is developed to show dates that ISP reviews will be conducted. The dates established will be entered into Outlook¿s calendar and a reminder message will be sent to the Program Specialist one week prior to the ISP review due date and one day before the ISP review due date.
ATTACHMENT AND SUPPORTING DOCUMENTS:
Attachment ISP reviewed Signature sheet
Attachment In-House Training Attendance Sheet 1
Attachment Tracking sheet |
05/02/2016
| Implemented |
| Article X.1007 | Staff #1 was hired on 10/31/15 and the criminal history check was completed on 8/15/14.
Staff #2 was hired on 2/1/15 and the criminal history check was done on 2/15/15
| 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. | WHO: Fortune Quashigah, Associate Director, Acute, will be responsible for correcting the problem
WHAT WILL BE CORRECTED: Staff #2 was hired on 1/30/16 and the criminal history record was completed on 2/7/16
WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 04/29/16
HOW: Acute Community Home Aid Employment Background Check and Qualification Policy was immediately updated to include mandatory completion of criminal history record check of all newly hired staff within one-week prior to orientation or date of hire.
All current staff members whose criminal history record checks were conducted after their hire dates were identified and documented for corrective action
Management staff were oriented on Criminal History Record Check ¿ Section 21 under DHS Chapter 6400. The training highlighted the importance of conducting a timely background check and also provided insights on the safety of the individuals we support.
PLAN TO PREVENT FUTURE OCCURRENCE:
Acute will run criminal history record checks within a week prior to potential staff orientation to ensure compliance to the program¿s regulation. Utilizing our new Human Resource System, ¿FingerCheck¿, all potential employees will be associated with a checklist that Fortune Quashigah will follow. All items on the list must be completed before a potential employee can be invited to orientation. The shortlisted employees will be submitted to Michael Addo and Michael Addo will verify that every item on the checklist is provided before an individual is officially invited to orientation.
ATTACHMENT AND SUPPORTING DOCUMENTS:
www.fingercheck.com
Attachment II 640021 Mgmt In-House Training
Attachment VII Background Check Policy
WHO: Fortune Quashigah, Associate Director, Acute, will be responsible for correcting the problem
WHAT WILL BE CORRECTED: Staff #2 was hired on 2/1/15 and the criminal history record check was done on 2/15/15
WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 04/29/16
HOW: Staff #2 had completed a background check prior to hire date according to the guidelines of the program. However, during the inspection Staff #2 clearance was not in the folder. The responsible staff located and placed criminal background check clearance appropriate folder. Please see supporting document.
To fix the violation in general, Acute Community Home Aid Employment Background Check and Qualification Policy was immediately updated to include mandatory completion of criminal history record check of all newly hired staff within one-week prior to orientation or date of hire. All current staff members whose criminal history record checks were conducted after their hire dates were identified for corrective action by Acute.
Management staff completed In-House training on Criminal History Record Check ¿ Section 21 under DHS Chapter 6400. The training highlighted the importance of conducting a timely background check and also provided insights on the safety of the individuals we support.
PLAN TO PREVENT FUTURE OCCURRENCE:
Acute purchased a `Finger-Check¿ system, including the HR module, which allows the company to enter employee documents and training records. This system sends an automatic email to staff, 30 days or any day of choice prior to expiration of all documents. (www.fingercheck.com)
Staff who fail to renew their Tuberculin test will be removed from providing services or having any direct contact with individuals in the program.
To prevent future violations, Acute will run criminal history record checks of all newly hired staff prior to orientation to ensure compliance to the program¿s regulation.
Staff who fail to renew their Tuberculin test will be removed from providing services or having any direct contact with individuals in the program.
ATTACHMENT AND SUPPORTING DOCUMENTS
Attachment II 640021
Attachment VII Background Check Policy
Attachment IV DW21 |
04/29/2016
| Implemented |