| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Inventory sheet for individual #1 was dated 5-12-19. Inventories should be current and kept up to date. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | It is important for individuals to have a property record/inventory list for personal items. It was discovered that individual #1s list was not up to date. It is the responsibility of the program specialist to ensure a property/inventory list is completed and maintained in each individual record. The program specialist will be retrained on this regulation by 6/30/2022. |
06/30/2022
| Implemented |
| 6400.51(a)(1) | Staff #1 did not have all of the mandatory orientation training within 30 days of hire. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | Staff #1 had all of the mandatory orientation training within 30 days of hire. Her ODP training was completed at Bethel Care Homes & Services; however, it was not in her file. It is the responsibility of the compliance manager to ensure all Program Specialists are properly trained and it is the responsibility of the program assistant to ensure all new hires have the proper documentation in each employee file. The program assistant and compliance manager will be retrained on this regulation by 6/30/2022 |
06/30/2022
| Implemented |
| 6400.51(b)(1) | Staff #1 did not have documentation of the proper number of hours of orientation training on Person Centered Practices. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff #1 did have documentation of the proper number of hours of orientation training on Person Centered Practices Her ODP training was completed at Bethel Care Homes & Services; however, it was not in her file at the time of inspection. It is the responsibility of the compliance manager to ensure all Program Specialists are properly trained and it is the responsibility of the program assistant to ensure all new hires have the proper documentation in each employee file. The program assistant and compliance manager will be retrained on this regulation by 6/30/2022 |
06/30/2022
| Implemented |
| 6400.51(b)(2) | Staff #1 did not have documentation of orientation training on Prevention, Detection and Reporting of Abuse. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. | Staff #1 did have documentation of orientation training on Prevention, Detection and Reporting of Abuse. Her ODP training was completed at Bethel Care Homes & Services; however, it was not in her file at the time of inspection. It is the responsibility of the compliance manager to ensure all Program Specialists are properly trained and it is the responsibility of the program assistant to ensure all new hires have the proper documentation in each employee file. The program assistant and compliance manager will be retrained on this regulation by 6/30/2022 |
06/30/2022
| Implemented |
| 6400.51(b)(3) | Staff #1 did not have documentation of orientation training on Individual Rights. | The orientation must encompass the following areas: Individual rights. | Staff #1 did have documentation of orientation training on Individual Rights. Her ODP training was completed at Bethel Care Homes & Services; however, it was not in her file at the time of inspection. It is the responsibility of the compliance manager to ensure all Program Specialists are properly trained and it is the responsibility of the program assistant to ensure all new hires have the proper documentation in each employee file. The program assistant and compliance manager will be retrained on this regulation by 6/30/2022 |
06/30/2022
| Implemented |
| 6400.51(b)(4) | Staff #1 did not have documentation of orientation training on Recognizing and Reporting Incidents. | The orientation must encompass the following areas: recognizing and reporting incidents. | Staff #1 did have documentation of orientation training on Recognizing and Reporting Incidents. Her ODP training was completed at Bethel Care Homes & Services; however, it was not in her file at the time of inspection. It is the responsibility of the compliance manager to ensure all Program Specialists are properly trained and it is the responsibility of the program assistant to ensure all new hires have the proper documentation in each employee file. The program assistant and compliance manager will be retrained on this regulation by 6/30/2022 |
06/30/2022
| Implemented |
| 6400.51(b)(5) | Staff #1 did not have documentation of orientation training on Job-related knowledge and skills, specifically training on implementation of individual plans. | The orientation must encompass the following areas: Job-related knowledge and skills. | Staff #1 did not have documentation of orientation training on Job-related knowledge and skills but the training on implementation of individual plans was in her file. Her ODP training was completed at Bethel Care Homes & Services; however, it was not in her file at the time of inspection. It is the responsibility of the compliance manager to ensure all Program Specialists are properly trained and it is the responsibility of the program assistant to ensure all new hires have the proper documentation in each employee file. The program assistant and compliance manager will be retrained on this regulation by 6/30/2022 |
06/30/2022
| Implemented |
| 6400.182(c) | ISP dated 4/18/22 under Stranger Awareness section states that there is concern that Individual #1 would open the door to a stranger and that she could be easily victimized. The assessment dated 3/22/22 on a chart titled "Need for Supervision" indicates (by marking "yes") that she understands the dangers associated with strangers and also marks "yes" for answers door safely. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | It is important that the ISP and assessment are in perfect alignment. It is the responsibility of the program specialist to ensure congruity between ISPs and assessments. Although the program specialist at the time of the inspection was not the program specialist who completed the 3/22/22 assessment, the current program specialist will be retrained on this regulation by 6/30/22. The assessment was corrected and sent to the individual¿s team on 5/20/2022 |
06/30/2022
| Implemented |
| 6400.182(c) | ISP dated 4/18/22 under Cooking/Appliance section states that Individual #1 needs assistance to dial the telephone and encouragement to talk when on the phone. The assessment dated 3/2222 under Communication Skills lists "I" on the chart for use of telephone. The document key states "I" means Independent. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | It is important that the ISP and assessment are in perfect alignment. It is the responsibility of the program specialist to ensure congruity between ISPs and assessments. Although the program specialist at the time of the inspection was not the program specialist who completed the 3/22/22 assessment, the current program specialist will be retrained on this regulation by 6/30/22. The assessment was corrected and sent to the individuals team on 5/20/2022. |
06/30/2022
| Implemented |