| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | 2 of the new hire files had background checks dated over five (5) days after the hire date. | 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.
| Complete Comfort ID Residential staffing policy has been updated with the following:
· The program will apply background checks for staff prior to hiring including criminal history, child abuse, FBI (if applicable) clearances.
· A report of criminal history record information from the Pennsylvania State Police or a statement from the Pennsylvania State Police that the State Police Central Repository does not contain information relating to that person under 18 Pa.C.S. § § 9101---9183 (relating to Criminal History Record Information Act) if staff has been a resident of this Commonwealth for at least 2 years.
· A report of Federal criminal history record information under the Federal Bureau of Investigation (FBI) if staff has been a resident of this Commonwealth for less than 2 years or is currently a client of another state.
· Criminal history checks will be in accordance with the Older Adults Protective Services.
· A copy of the final reports received from the Pennsylvania State Police and the FBI, if applicable, shall be kept in staff person's confidential record.
· All backgrounds checks shall be ran prior to hire/ no later than within 5 working days after the persons date of hire. |
10/02/2024
| Implemented |
| 6400.21(b) | Staff #3 had a date of hire of 3/1/24, however the FBI criminal background check occurred on 3/11/24 | 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.
| Complete Comfort ID Residential has updated the staffing policy to include the following:
All employees will submit Proof of ability to work in the United States
· The program will apply background checks for staff prior to hiring including criminal history, child abuse, FBI (if applicable) clearances.
· A report of criminal history record information from the Pennsylvania State Police or a statement from the Pennsylvania State Police that the State Police Central Repository does not contain information relating to that person under 18 Pa.C.S. § § 9101---9183 (relating to Criminal History Record Information Act) if staff has been a resident of this Commonwealth for at least 2 years.
· A report of Federal criminal history record information under the Federal Bureau of Investigation (FBI) if staff has been a resident of this Commonwealth for less than 2 years or is currently a client of another state.
· Criminal history checks will be in accordance with the Older Adults Protective Services.
· A copy of the final reports received from the Pennsylvania State Police and the FBI, if applicable, shall be kept in staff person's confidential record. |
10/02/2024
| Implemented |
| 6400.34(a) | Individual #1 - The individual rights statement signed by the Individual on 4/19/24 did not contain all of the required individual rights documentation. Individual #2 - (admission date 7/1/22) has no updated individual rights documentation since 5/25/22. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Complete Comfort iD Residential has updated its Individual Rights statement effective 10/02/2024. All internal staff including Program Specialist and Site supervisor have been retrained on the Individual Rights policy effective 10/02/2024. |
10/02/2024
| Implemented |