| 6400.162(a) | In April 2026, Delta Community Supports Inc. identified through an internal self-audit that numerous staff members had not successfully completed the Department's initial medication administration training course. Specifically, staff failed to complete all required components of the training including the completion and proper documentation of the mandatory medication observations necessary to demonstrate competency.
As a result, untrained staff members administered medications without successful course completion in accordance with the Department's medication administration requirements. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | Following the discovery of missing documentation related to residential staff medication administration certifications, the Training Director immediately began scheduling classes to recertify all residential staff with any missing or incomplete documentation. The classes have been and will continue to be scheduled for the following dates: 5/9/2026, 5/11/2026, 5/12/2026, 5/15/2026, 5/28/2026, 5/29/2026, 5/30/26. Classes will continue weekly between Bucks and Delaware County.
In addition, a new tracking process was implemented to address the current corrective action plan and ensure ongoing compliance moving forward. Attachment #1 outlines the following within each tab: all CL staff (Community Living staff), CC staff (Community Center staff), retraining plans, schedules, PO-certified staff (Practicum Observers), Medication Trainers, and certification information.
This spreadsheet will be maintained on an ongoing basis by the Training Administrative Assistant following all formalized training conducted by the Training Director. All identified retraining will occur on or before 6/12/2026.
No new hires or Community Center staff added to the spreadsheet will be authorized to work in a residential home until they have completed and passed the classroom medication administration class and two mock observations. At this point they will be designated as "yellow" within Attachment #1. "Green" status will only be assigned once initial training and all four required observations have been successfully completed. Observations 3 and 4 will be scheduled for day one in the group home and further training will not continue until these have been completed. Once observations 3 and 4 are complete staff will be converted to "green" on the tracking spreadsheet. All supporting training documentation, including the two required observations, will be verified and filed by the Training Administrative Assistant.
Moving forward if an employee is unable to complete the medication administration training and two mock observations with a passing mark during new hire orientation, this will result in immediate separation of employment.
Additionally, all fill-in coverage for residential homes from other programs must be approved by both the PA State Director and the Senior Director of Community Supports. This process will ensure that no employee who is not fully certified in medication administration works in a residential setting.
Finally, all residential staff listed within the retraining tab must complete the full training requirements by 6/12/2026 or they will no longer be authorized to work in a residential home. Until training is completed, the identified backup plans listed in attachment #1 will remain in place. |
06/12/2026
| Not Implemented |
| 6400.169(a) | Staff #1's last Completed certification date was 7/15/21. | 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). | Staff #1 Retook initial training 7/15/2021, 2025 Med Observations & MAR Reviews occurred 3/25/25 and 12/14/25 |
06/12/2026
| Not Implemented |