| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There was nine gallon, five gallon, and two and a half gallon containers of Behr paint found unlocked in the basement. REPEATED VIOLATION 9/3/15 | Poisonous materials shall be kept locked or made inaccessible to individuals. | The paint was removed and a lock was placed on the basement door on 1/21/16 by the facilities management department. The program associates and program specialist/manager are responsible to ensure that paint is secure and that the basement door is locked. |
01/21/2016
| Implemented |
| 6400.151(a) | Staff person #3 did not have documentation of a physical exam completed prior to the date of hire on 9/9/15. REPEATED VIOLATION 9/12/14 | 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. | New hires will complete a physical during the hiring screening process prior to starting new staff orientation. All employees shall have a physical examination every 2 years . Bancroft's Human resources department will track this and files will be kept on site in the PA broomall office for review.
Staff person #3's whose date of hire is 9/9/15, will have a physical examination in their file within 30 days. The Human Resources Recruiter will ensure that all staff have a physical completed upon hire and a copy of the physical will be placed in their personnel file. |
07/30/2016
| Implemented |
| 6400.181(f) | Individual #1's assessment dated 11/10/15 was not sent to the supports coordinator. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| ISP process was reviewed with the program managers on 6/9/16. Program managers/specialist designee acting program specialist while position is hired. Information will be forwarded to the SC in a timely manner. Program directors are currently interviewing for program specialist position. Going forward, the program specialist/manager or designee will ensure that assessments are provided to the supports coordinator as needed. The program director or designee will ensure that all assessments are completed, signed and dated and submitted as needed
See attachment #3 pm meeting minutes |
06/09/2016
| Implemented |
| 6400.183(5) | Individual #1's social emotional and environmental plan was not updated. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | SEP plan was for Individual #1 was updated on 6/7/16. Process going forward will be that Program Specialist/ Managers will ensure assess the individuals for a plan of social, emotional and environmental plan are updated for individuals if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. . Program Directors will monitor this process. Program managers were trained on this process on 6/9/16.ND's SEP plan was updated on 6/7/15. Process going forward will be that Program Managers will access the individual for a plan of medication reduction , review quarterly, and update the plan annually. This will be monitored by program directors. Program managers were trained on this process on 6/9/16. See attachment #3, # Individual #1's PLAN / manager meeting minutes |
06/09/2016
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not document hair and eye color. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | The name, sex, admission date, birthdate and social security number, language or means of communication spoken or understood by the individual, the race, height, weight, color of hair, color of eyes and identifying marks, religious affiliation, the next of kin, and a current, dated photograph have been added to the Individual's record on 6/8/2016. See Individual's Face Sheet for ND |
06/08/2016
| Implemented |
| 6400.213(9) | Individual #1's record did not have a current ISP. | Each individual's record must include the following information: A copy of the current ISP. | Current ISP is in program book dated 6/8/16 Individual #1 current ISP is currently in program book dated 6/8/16. The Program Manager/Specialist is responsible for ensuring the current ISP is in the program and the Program Directors or designee will audit to ensure the current ISP's are maintained in the programs. |
06/08/2016
| Implemented |
| Article X.1007 | Bancroft 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 9/21/15 did not have a Pennsylvania criminal history check completed only a New Jersey FBI. Staff person #2 date of hire 9/8/15 did not have a Pennsylvania criminal history check completed only a New Jersey FBI. REPEATED VIOLATION 9/12/14 | When, 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 |