| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | An application for a Pennsylvania criminal history record check was not submitted to the State Police for staff numbers 2,3,4,5, and 6. Checks were subsequently not submitted prior to date of hire. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes 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.
| The Jami's Residence CEO will perform all criminal history checks. The administrative assistant will enter document into the employee's file timely. The Administrative assistant will have employees sign a statement that they lived in PA for more than 2 years- resolved with an affidavit and attach statement) |
04/01/2020
| Implemented |
| 6400.77(b) | The First Aid Kit did not contain assortment of adhesive bandages. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A checklist will be created. The Administrative Assistant will check all first aid kits monthly. If items are missing the administrative assistant will compile a list and forward to the facilities coordinator, for ordering. |
04/01/2020
| Implemented |
| 6400.80(a) | Outside of the building, in the rear of the home the electric box was not good repair and not free from unsafe conditions. The wires were exposed. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Jami Residences environmental team will ensure that all property material inside and outside of the homes will be upkept weekly. Jami employee's submit timely maintenance request for items that need be repaired or replaced to ensure compliance and safety |
04/01/2020
| Implemented |
| 6400.151(a) | Staff #1's record did not have documentation of a physical exam, Tuberculin test, statement the staff is free from communicable disease and physical readiness. | 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. | Jami Residences Administrative Assistant will ensure that all physical examinations are current, and entered into the employee's file timely and track to ensure compliance |
04/01/2020
| Implemented |
| 6400.46(a) | Staff #1's Initial fire safety training was not completed prior to working with individuals. Staff #1's hire date on 7/25/19 and fire safety training completed on 11/20/19. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | The agency has hired a training consultant, who will be responsible for providing all of Jami Residence staff training in accordance with OPD trainings requirements and will work to bring all of the organization employees training hours and requirements into compliance with ODP training regulatory requirements Person Centered and Incident Management |
06/30/2020
| Implemented |
| 6400.51(a)(3) | There was no documentation of Orientation prior to working with individuals prior to 7/25/19 date of hire for staff 1. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | The agency has hired a training consultant, who will be responsible for providing all of Jami Residence staff training in accordance with OPD trainings requirements and will work to bring all of the organization employees training hours and requirements into compliance with ODP training regulatory requirements.
In addition, the consultant will be reviewing all of Jami Residence training records to identify additional non compliances staff training. Retrain staff on required trainings if the Jami Residence staff is discovered to be out of compliance. |
06/30/2020
| Implemented |
| Article X.1007 | Jami Residences 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 persons 7,8,9,10, and 11 did not have an FBI check completed when it was unknown if they lived in Pennsylvania 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. | The Jami's Residence CEO will perform all criminal history checks. The administrative assistant will enter document into the employee's file timely. The Administrative assistant will have employees sign a statement that they lived in PA for more than 2 years- resolved with an affidavit and attach statement) |
04/01/2020
| Implemented |