| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | The agency did not request criminal hire checks for all new hires within five days of their hire date. Staff Member 1's criminal history background check was requested on 3/12/21, but they were hired on 3/1/21. Staff Member 2 (hired 7/13/20), Staff Member 3 (hired 11/1/20), Staff Member 4 (hired 1/8/21), Staff Member 5 (hired 1/4/21), Staff Member 6 (hired 5/3/20), Staff Member 7 (hired 8/5/20), and Staff Member 8 (hired 9/1/20) all have a criminal check request date of 3/14/21. Staff Member 9 (hired 5/3/21) and Staff Member 10 (hired 5/3/21) both have criminal check request dates of 5/20/21. Staff Member 11 was hired 6/19/21; their background check was requested 7/6/21. Staff Member 12 was hired 3/22/21 and their background check was requested 4/3/21. Staff Member 13 was hired 4/5/21; their background check was requested 4/12/21. Staff Member 14 was hired 6/14/21; their background check is dated 6/24/21. Staff Member 15 was hired 6/1/21, and their background check is dated 6/7/21. Staff Member 16 was hired 9/1/20; their background check is dated 11/20/20. Staff Member 17 was hired 6/1/21, and their background check request is dated 6/13/21. [Repeated Non-Compliance from 3/9/20] | 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.
| During Covid the administrative staff was working from home, employment documentation was no longer centralized. Therefore, employment files were not being examined frequently. Currently, employment files are uploaded to a drive shared by the administrative team. The agency is interviewing for a full-time human resource staff to maintain employment files. |
10/29/2021
| Not Accepted |
| 6400.151(a) | It could not be determined when Staff Member 1 received a staff physical due to physical documentation observed listing numerous dates: an exam date is listed as 8/21/20, a TB test read date as 1/22/21, and the form is signed by the doctor as of 2/11/21. [Repeated Non-Compliance from 3/9/20] | 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. | The CEO has reviewed the hire date of staff and scheduled physicals for all staff that aren't in compliance. The staff are scheduled to visit the PCP or an UrgentCare to update the physical. |
10/29/2021
| Not Implemented |
| 6400.46(a) | It could not be determined that Staff Member 1 received fire safety training prior to working with individuals. | 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. | Fire safety training is part of the new hire orientation. The trainer reviews general fire safety, smoking policy, and fire drills (procedures, locating smoke detectors, evacuation, meeting place and completion of the fire drill form). The details of this training will be added to the on-site training form. |
10/29/2021
| Not Implemented |
| 6400.51(a)(3) | It could not be determined that Staff Member 1 received orientation training prior to working with individuals. Trainings for Staff Member 1 observed in agency records that cover some, but not all, of the topics required of employee orientation under regulation 51b were completed June 17 -- June 18, 2021; their hire date was 3/1/21, and as such were not completed within 30 days of hire. The trainings observed were Recognizing and Reporting Incidents (completed 6/17/21); Addressing Day to Day Risks With the Team (6/17/21); Person Centered Practices (6/18/21); and Individual Rights (6/18/21). [Repeated Non-Compliance from 3/9/20] | 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. | In June, it was discovered that several staff members complete the ODP orientation trainings. Staff were instructed to complete them and submit the certificates. |
10/29/2021
| Not Accepted |
| 6400.169(a) | The agency did not retain documentation of staff completing medication administration training or practicum from 2020 - 2021. As it cannot be determined that staff has completed their practicum and agency training, all staff except for the agency's nurse are not permitted to administer medications until staff trainings are remediated. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Following the inspection, the agency engaged a licensed practical nurse (LPN) to administer medication. The LPN administered medication to all consumers until the staff completed the required observations. She continues to administer medication when staff hasn't completed the required training. |
11/30/2021
| Not Accepted |