Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00257267 Renewal 12/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There were several knobs missing from dressers in one of the individual's bedroomsFloors, walls, ceilings and other surfaces shall be in good repair. The individual went through his clothing and decided to remove any clothing that he did not like or did not fit. This dresser was empty after the individual went through all of his clothes.The individual decided to have the dresser removed from his room as it was empty and removing it would allow him more space in his bedroom. 01/08/2025 Implemented
6400.104Letter starts off stating that the letter is to notify the department of location of bedrooms of clients, but never references where the bedrooms are.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The letter was updated to include the information as to where the bedrooms are in the home. The letter was submitted to the fire department on 1/14/25 and confirmation of receipt of the letter was received from the fire department on 1/15/25. 01/14/2025 Implemented
6400.110(a)The basement in the home did not have a functional smoke detector. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. A ticket was placed for evaluation/repair of the smoke detector. Facilities visited the home on 1/8/25 to assess the smoke detector. 01/31/2025 Implemented
SIN-00198374 Renewal 12/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)There is no vision screening for Individual #1. On physical dated 12/20, screening indicates 'not done'.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual' #1's annual vision screening was completed on 1/25/22. 01/25/2022 Implemented
6400.142(e)On 10.21.21 there was a dentist visit for Individual #1 that required follow up with an oral surgeon. There is no verification of a follow-up appointment.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.Individual #1's oral surgery was completed on 1/11/22. 01/11/2022 Implemented
6400.144individual #1's quarterly injection of Depo Provera for Menorrhagia was missed 9/2021.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Individual #1 received her Depo shot 1/6/2022. 01/06/2022 Implemented
6400.181(e)(14)Individual #1's assessment completed 7.20.21 does not speak to her understanding of water safety. It discusses her ability to temper water when showering, but not her ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Individual assessment was updated to reflect individual knowledge of water safety on 2/10/2022 02/10/2022 Implemented
6400.165(g)Psychotropic medication reviews for Individual #1 were not completed timely. The dates they were completed are: 4.14.21; 8.9.21; 10.6.21.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Individual #1 completed a psychotropic medication review on 1/19/22. 01/19/2022 Implemented
SIN-00155703 Renewal 04/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(b)This home's self-assessment did not complete pages 2, 4, and 6.The agency shall use the Department's licensing inspection instrument for the community homes for people with intellectual disability regulations to measure and record compliance. All Management staff of the appropriate departments have been retrained on the 6400 Self Assessment tool. This was completed on 5/6/2019. Going forward, all new management staff will also be trained on the Self Assessment Tool. 05/06/2019 Implemented
6400.112(d)The Fire Drill dated 9/9/18 had an evacuation time of 2 minutes, 48 seconds. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Fire drills for all homes will be audited by PA Audit Specialist from the Risk Management department. Any errors will be addressed before the close of the month. Staff of the Edgevale location will be retrained on the procedure of running a fire drill. All new staff will complete/run one supervised fire drill within their first 90 days of employment. This protocol was put into place beginning with the June 2019 new hire orientation. 06/26/2019 Implemented
6400.181(e)(8)Individual # 1's assessment did not document their ability to evacuate in case of a fire.The assessment must include the following information: The individual's ability to evacuate in the event of a fire. Individual #1's assessment has been updated to include his ability to evacuate in the event of a fire. This individual's assessments are reviewed annually by the program manager prior to ISP. Bancroft also has an individual Fire evacuation plan that is updated annually by the Program Specialist. 06/18/2019 Implemented
SIN-00109585 Renewal 02/09/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(b)Staff #3's FBI check was completed on 10/21/16 and the date of hire was 4/18/16. 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. As of 11/4/16, a designated member of the Human Resources department is responsible to ensure that all prospective employees who will have direct contact with individuals and reside outside of Pennsylvania, will have an application submitted for a Federal Bureau of Investigation criminal history record check in addition to the Pennsylvania criminal history record check, within 5 working days after person¿s date of hire. This designated member of the Human Resources department tracks all application dates in order to verify compliance. 04/03/2017 Implemented
SIN-00095180 Renewal 12/22/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff person #1's Pennsylvania criminal history check on 8/12/15 was completed more than 5 days after the date of hire 5/18/15. 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. Going forward, the Human Resources compliance specialist will ensure that Pennsylvania criminal history check is completed within 5 days of the date of hire.[Quality manager/Program Designee will complete quarterly audits of files to ensure that all criminal history checks are completed to adhere to all regulations. Effective within 15 days of receipt of this plan of correction DD 8.16.16] 06/10/2016 Implemented
Article X.1007Bancroft 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 person #1 date of hire 5/18/15 and a Pennsylvania criminal history check was completed on 8/12/15. REPEATED VIOLATION 9/12/14When, 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.Bancroft is currently completing all new hire verifications prior to scheduling on-site orientation. Currently, all criminal background paperwork is completed upon hire and submitted for criminal background checks. The recruiter within the Human Resources department will review all criminal background documentation for completion prior to scheduling new staff orientation within the organization. The new hire will be unable to schedule orientation without the proper clearances completed. The Human Resources Compliance Manager will complete quarterly comparison audits to ensure the background checks are completed and data entered prior to orientation date. 07/26/2016 Implemented
SIN-00052482 Renewal 08/07/2013 Compliant - Finalized