| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency does not have a completed self-assessment on file. | 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.
| In response to the violation of 6400.15(a), effective immediately, the executive director will be trained to utilize and keep an update on each section of the self-assessment tool as a part of the ODP 6400 Regulatory Compliance Guide. The executive director will be responsible for completing these self-assessments, including marking ¿NA¿ for any areas that do not apply to We Care For All and highlighting areas that need ¿ improvement.¿ |
07/22/2022
| Implemented |
| 6400.21(a) | The agency did not complete Pennsylvania criminal background checks within a year prior or 5 working days after the dates of hire for any of the hired staff. | 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.
| In response to the violation of 6400.21(a) discovered during the licensing inspection of We Care For All will ensure that all background checks are adequately performed within the stated guidelines of 5 working days after the person's date of hire. To ensure We Care for all remains complained during the hiring process, the pram specialist will perform all background checks upon hiring and keep a paper and digital copy. The Executive director will audit these records monthly and update the ODP Staff Qualification Record google sheet with all New Hire info ( DOB, DOH, residency, etc.). Currently, We Care For All has no participants and has completed provisional hiring for licensing purposes. In the next hiring stage, the Executive Director for We Care For All will ensure that all background checks are done immediately upon hiring. |
07/22/2022
| Implemented |
| 6400.21(b) | Staff Member #1's resume indicates they live in Delaware; they were hired on 2/16/22. The agency does not have an FBI criminal history background check on file for the staff member. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| In response to the violation of 6400.21(b) discovered during the licensing inspection, We Care For All will ensure that all background checks are adequately performed within the stated guidelines of 5 working days after the person's hire date. Prospective employees who reside outside of Pennsylvania shall submit an FBI background check no more than one year prior to the person's date of hire. If a prospective employee does not have an FBI background check, the We Care For All program specialist will ensure the FBI criminal history record check and Pennsylvania criminal history record check will be performed within five working days after the person's date of hire. To ensure We Care for all remains complained during the hiring process, the program specialist will perform all background checks upon hiring and keep a paper and digital copy. The Executive director will be in charge of running an audit of these records monthly and updating the ODP Staff Qualification Record google sheet with all New Hire info ( DOB, DOH, residency, etc.). We Care For All has notified the Behavior Specialist as of 07/16/22 that an FBI Background check is needed before working directly with any individuals. The Behavior Specialist will provide documentation that their FBI BackGround check is under review after submission during the week of 07/18/22 -08/01/22. |
08/01/2022
| Implemented |
| 6400.43(b)(1) | The agency's Individual Rights policy does not address all rights listed under 6400.32. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | In response to violation 6400.43(b)(1), We Care For All has updated its individual rights policy for 2022 to include all rights listed under 6400.32. The updated policy will be implemented immediately by the CEO and have all participants sign the New Individual Rights Policy. |
07/22/2022
| Implemented |
| 6400.67(b) | The basement has substantial flooding anytime it rains. During the time of inspection, the basement floor was completely wet from the previous day's rain. This is a hazard since the basement serves as a route to the emergency exit of the home. | Floors, walls, ceilings and other surfaces shall be free of hazards. | In response to the violation of 6400.67(b), We Care For All CEO and Maintenance Man will be responsible for correcting any problem with the structure of the home. As of July 20, 2022, We Care for All hired a contractor ( Hand Contracting LLC) to clean out the drainage system in the basement to improve the flow of water out to the sewer. We Care For All Maintenance Man, along with the contractor, will monitor the basement for proper drainage in the future. |
08/01/2022
| Implemented |
| 6400.71 | The emergency contact list is missing the following information: information for the nearest hospital and poison control. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| In response to violation 6400.71, We Care For All has updated the emergency contact list effective immediately to include the following:
Nearest Hospital
Police Department
Fire Department
Ambulance and Poison control center
We Care For All keeps an emergency list posted on a bulletin board in the living area as well as next to the house phone. The program specialist will ensure that this list stays updated if any of the contacts change. |
07/22/2022
| Implemented |
| 6400.77(b) | The first aid kit is missing a thermometer and scissors. | 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. | In response to violation 6400.77(b), We Care For All has updated the First Aid Kit in the home to include a thermometer and scissors. The program specialist will ensure that the first Aid Kit contains antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors, and syrup of Ipecac. |
07/22/2022
| Implemented |
| 6400.111(f) | The fire extinguisher on the main level and basement has not been inspected by a fire safety expert. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | In response to violation 6400.111(f), We Care For All has gotten both Fire extinguishers (2A-10BC) for the kitchen and basement inspected by a fire safety expert as of 07/15/2022. |
07/22/2022
| Implemented |
| 6400.44(c)(3) | Staff Member #2 does not have the qualifications to be a program specialist, but is serving in that role. Their resume indicates a 2001 diploma from Simon Gratz High School, but no college degree work. | A program specialist shall have one of the following groups of qualifications: An associate's degree or 60 credit hours from an accredited college or university and 4 years of work experience working directly with individuals with an intellectual disability or autism. | In response to violation 6400.44(c)(3), the CEO will rearrange the organization Chart to ensure that all staff members meet the requirements of 55 PA Code Chapter 6400.44(c)(3). As of July 22, 2022, the new program specialist has a bachelor¿s degree from an accredited college or university and two years of work experience working directly with individuals with an intellectual disability or autism. |
07/22/2022
| Implemented |