|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | There is no ventilation in 1st floor half bathroom. Ceiling fan is also inoperable. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| On Thursday June 5, 2024, a maintenance request was submitted through our Worxhub computer maintenance system by the Residential Coordinator to fix the ceiling fan in Bathroom #1. The work was completed on 6/6/2025. |
08/16/2024
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(d) | THE TRAINING RECORD FOR STAFF #1 INDICATED THAT THE STAFF COMPLETED 21.75 HOURS OF TRAINING IN THE TRAINING YEAR OF 2016 WHICH IS LESS THAN 24. | Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. | The training record for Staff #1 indicated that the staff completed 21.75 hours of training in the year 2016, which is less than 24 hours.
Staff #1 has 17.5 hours of training to date for 2017. He has satisfied his annual training elements to date. He will have additional trainings at his assigned work location to encompass all ISP's for the individuals, behavior support training as well as Quality Management. These areas will give staff #1 the 24 hours of training required. The training Policy and Procedure was revised as of 8/2017 to address the following: Each Calendar year (January-December) Staff (Program specialists and direct service workers) who are employed for more than 40 hours per month will have at least 24 hours of training, Policy and Procedures were updated and staff will be completely trained by 9/30/2017. Please refer to below for revised policy:
Annual Staff Training
-All employees employed by Divine Providence CLA's on a full time, part time, or PRN basis holding positions associated with care and supervision of individuals being severed, are responsible for attending a minimum of 24 hours of staff development and training per training year. The training year will follow the calendar year and will run from January through December.
- All staff are required to have 24 hours of training annually. CPR and PEI Training as required by their position and job description.
- All staff members are required to complete their annual training within 365 days of the previous completed training date.
- Staff members will be sent notification of their assigned training dates via mail 40 to 45 days prior to the assigned session date with additional notification sent to department supervisors and schedulers.
- Staff are required to maintain current certification in CPR/AED and First Aid as required by their position and job description.
- All staff will be required to attend annual CPR/AED/ First Aid refresher classes in addition to the bi-annual certification requirements set forth by American Red Cross and American Heart Association.
- All participants must complete and successfully pass the skill assessment and competency demonstrations required to attain and maintain CPR/AED/First Aid certification.
- Participants who fail to demonstrate competency will remediate with the American Red Cross trainer until competency has been demonstrated.
- All nursing staff will maintain certification in the professional rescuer CPR/AED (BLS)
- All employees attending Staff Effectiveness and ST/PEI annual training must complete and successfully pass all required examination and skill competency assessments as required per the curricula.
¿ Participants who fail to demonstrate competency will remediate with the Staff Effectiveness/ST/PEI trainer until competency has been demonstrated.
¿ All staff will be responsible for completing those trainings specific to the regulatory agency overseeing the program to which they are assigned.
¿ All original training records will remain on file within the training department and will be recorded in the Training Database.
The Director of Staff Training completes training record audits on a monthly basis and reports any discrepancies to the Director of Community Programs and the Administrator. |
09/30/2017
| Implemented |
| 6400.46(f) | FIRE SAFETY TRAINING FOR STAFF #1 WAS CONDUCTED ON 06/13/2016 AND THEN AGAIN ON 07/19/2017 WHICH IS MORE THAN 1 YEAR APART. | 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 for Staff #1 was conducted on 6/13/2016 and then again on 7/19/2017 which is more than 1 year apart. Staff # 1 completed the annual fire safety training for 2017. For 2018, staff #1 will be scheduled to complete Fire Safety training a month in advance of the last Fire Safety date (to remain within 365 days compliance.). The training policy was revised for all employees and all staff will be trained by 9/30/2017. Policy reference notes below:
Annual Staff Training
¿ All employees employed by Divine Providence CLA¿s on a full time, part time, or PRN basis holding positions associated with care and supervision of individuals being severed, are responsible for attending a minimum of 24 hours of staff development and training per training year. The training year will follow the calendar year and will run from January through December.
¿ All staff are required to have 24 hours of training annually. CPR and PEI Training as required by their position and job description.
¿ All staff members are required to complete their annual training within 365 days of the previous completed training date.
¿ Staff members will be sent notification of their assigned training dates via mail 40 to 45 days prior to the assigned session date with additional notification sent to department supervisors and schedulers.
¿ Staff are required to maintain current certification in CPR/AED and First Aid as required by their position and job description.
¿ All staff will be required to attend annual CPR/AED/ First Aid refresher classes in addition to the bi-annual certification requirements set forth by American Red Cross and American Heart Association.
¿ All participants must complete and successfully pass the skill assessment and competency demonstrations required to attain and maintain CPR/AED/First Aid certification.
¿ Participants who fail to demonstrate competency will remediate with the American Red Cross trainer until competency has been demonstrated.
¿ All nursing staff will maintain certification in the professional rescuer CPR/AED (BLS)
¿ All employees attending Staff Effectiveness and ST/PEI annual training must complete and successfully pass all required examination and skill competency assessments as required per the curricula.
¿ Participants who fail to demonstrate competency will remediate with the Staff Effectiveness/ST/PEI trainer until competency has been demonstrated.
¿ All staff will be responsible for completing those trainings specific to the regulatory agency overseeing the program to which they are assigned.
¿ All original training records will remain on file within the training department and will be recorded in the Training Database.
All required trainings are listed below:
Required Training
Trainings required for staff each year include but are not limited to:
¿ CPR/AED and First Aid
¿ Standard Precautions, OSHA, Personal Protective Equipment and Infection Control
¿ HR Topics ¿ including staff grievance policy
¿ Department and Organization Policies and Procedures
¿ Staff Effectiveness
¿ Safety Techniques and Personal Emergency Interventions (as needed)
¿ Individual and Behavioral Health Emergencies
¿ HIPAA and Confidentiality
¿ Client Rights and Grievance Policy
¿ Accurate Billing
¿ Documentation of HCBS Delivery
¿ Incident Management and Prevention of Abuse and Neglect
¿ Quality Management Plan
¿ Recognizing, Reporting and Investigating an Incident
¿ Fire Safety and Chemical Safety
¿ Emergency Preparedness
¿ Code of Conduct
¿ Mission and Core Values
¿ Active Treatment
¿ Effective Communication and Documentation
¿ Understanding ID Principles and Values
¿ Safe Driving Practices
¿ Medical Topics
The Director of Staff Training completes training record audits on a monthly basis and reports any discrepancies to the Director of Community Programs and the Administrator. |
09/30/2017
| Implemented |
| 6400.151(a) | THE PREVIOUS PHYSICAL EXAM FOR STAFF #1 IS DATED 06/10/2015 AND THE CURRENT PHYSICAL EXAM IS DATED 07/26/2017 WHICH IS MORE THAN 2 YEARS APART. | 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. | Previous physical exam for staff #1 (Abdulai Kamara) is dated 6/10/15 and the current physical exam dated 7/26/17 which is more than 2 years apart.
Going forward, all employees will follow the policy written for Clearances and Physicals:
Clearances and Physicals
Pre-Hire
¿ FBI, PA Criminal History and PA Child Abuse clearances are completed and must be received prior to any candidate being hired and starting work at DPV or DGV.
¿ Any clearance that is returned with a rap sheet is flagged for a Rap Sheet Review Meeting. The candidate is not hired until a determination is made at the Rap Sheet Review Meeting.
o Participants in the Rap Sheet Review Meeting include the HR Director, Administrator, Divisional Executive Director and, if needed, the Department Director.
o Candidates convicted of misdemeanors and/or felonies specified as prohibited offences per the Employee Disclosure Statement are not hired.
o Rap sheets containing other offences are reviewed and a decision is made to hire or not. Factors taken into consideration include the nature of the offence[s], the number of offences, the length of time since the last offence, the candidate¿s age at the time of the offence[s], the candidate¿s interview, work history and references.
¿ All candidates must have a physical and PPD test [or chest X-Ray as determined by the physician] prior to being hired and starting work at DPV or DGV.
¿ The physical form is reviewed for completeness, including the physician¿s statement that the candidate is free from communicable disease, by the HR Recruiter prior to the candidate¿s start date.
¿ A candidate with a physical or PPD [or Chest X-Ray] result that is questionable is not permitted to begin work until the question is resolved. A final determination is made by the appropriate HR Director.
¿ All documents are kept in the permanent personnel file.
Current Employees
¿ All three clearances are re-run every three years. Employees must have a new physical and PPD [or chest X-Ray] completed every two years. It is the responsibility of the Workers¿ Compensation, Leave Management, and Credentialing Specialist in the HR Department to keep an accurate, up to date list of all employees of DPV and DGV and their clearance and physical due dates. Employees and their supervisors are notified of upcoming clearance and physical due dates two to three months in advance. The list is sent out every Friday, and the employee¿s names and items due are color coded to show compliance, 30 days due and 45 days due. Employees who do not complete their clearance[s] or physical by the due date are removed from the schedule until we receive the required clearance[s] or physical.
¿ All documents are kept in the permanent personnel file.
The
Position Qualifications
¿ It is the responsibility of the HR Recruiter to screen candidates for any educational, experience, or licensure required for the position for which the candidate is being considered.
o Where a professional license, certification or specified college degree is required for the position it is also the responsibility of the Hiring Manager and/or Department Director to ensure that the appropriate document is presented.
¿ Copies are made of diplomas, certified transcripts or other approved documentation and placed in the permanent personnel file.
¿ Copies are also made of licenses [driver¿s, nursing, etc.] required for the position and placed in the permanent personnel file.
¿ Required experience is verified through references and/or HR employment checks.
Personnel files are kept in the Human Resources Office. |
09/30/2017
| Implemented |
|
|