| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | Fire drill record from fire drill conducted on 4/30/20 does not have an evacuation time listed. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | All LVHS house directors attended a Training Meeting on April 30, 2021 2:00pm-5:30pm (See Appendix 5). In this meeting Regulation 6400.101 - 6400.114 (with specific emphasis on 6400.112). RCG 112a ¿ 112i was also reviewed in the training. |
04/30/2021
| Implemented |
| 6400.141(a) | Individual #1 moved into the home on 3/22/21. A physical was not completed within the 12 months prior to admission as required. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | All LVHS house directors attended a Training Meeting on April 30, 2021 2:00pm-5:30pm (See Appendix 5). In this meeting Regulation 6400.141(a), 6400.141 (b) and 6400.12 (d) was reviewed in the training. |
04/30/2021
| Implemented |
| 6400.151(a) | Documents submitted record a hire date of 8/23/20 for Staff #2. Pre-employment/new hire physical for Staff #2 submitted for review is dated 10/12/20. Pre-employment physicals are required to be completed within 12 months prior to employment. | 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. | LVHS will no longer accept physicals that are not completed on the LVHS Pre-employment Physical Form. In the past, Provider accepted other forms and they do not always include the information to meet the requirements of 6400.151 (a) (b) (c). In this case, a new physical was completed BUT it occurred after the hire date, causing Provider to be deficient on this requirement. |
05/12/2021
| Implemented |
| 6400.151(c)(3) | The physical submitted for Staff #1 dated 11/5/20 did not contain a statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals as required. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The LVHS Pre-Employment Physical form has been updated to include the statement and a check-off verifying that the potential staff member is ¿free of communicable diseases¿, as required in 64001.51(c ) (3) |
05/12/2021
| Implemented |
| 6400.181(a) | An initial assessment dated 4/16/21 for Individual #1 was submitted for review. It could not be determined that the assessment was specifically for Individual #1 due to the amount of information in the document referring to another individual, conflicting information in the document and the lack of information required. The section for notes in the "Elopement" portion of the assessment contains a paragraph describing past behaviors of another individual. The section for notes in the "Clothing" portion of the assessment contains a paragraph describing progress for another individual in this area. The section for "Community integration & recreational activities" contains a paragraph describing another individual's involvement in the community. The section for notes in the "Sexuality" portion of the assessment contains a paragraph describing concerns in this area for another individual. The assessment did not contain the functional strengths, needs and preferences of Individual #1. The assessment did not include the likes, dislikes and interests of the individual. Conflicting information for the supervision care needs of the individual was written within the assessment. The supervision section of the assessment listed "15-minute nighttime checks" while the "Home Safety" indicated that overnight awake staffing was not required. The "Summary of Supervision needs" section of the assessment indicates that Individual #1 requires a supervision level of "primarily earshot" in the community while the "Community safety" section indicates that he has 60 minutes where he can be "left safely unattended" in the community. The "Summary of Supervision needs" section allows for "15-minutes of alone time within his bedroom" with the "Home Safety" section indicates that "120+" minutes are allowed. Documentation of Individual #1's disability, a lifetime medical history, recommendations for specific areas of training, programming and services and the current level of the individual's health were not included or assessed in the document. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | LVHS, as other Providers has struggled with finding and maintaining good staff. We acknowledge that we currently lack expertise in this area because provider has terminated three Program Specialist over the course of the past 3 years because of inadequate work performance. At this time, LVHS is in the process of hiring a new PS who has experience providing PS work in an ID setting. References will be carefully checked to ensure that the candidate has the required experience. An assessment template has been developed that captures all 6400.181 requirements. This template will be used in the future for all LVHS assessments to ensure that all requirements are met. |
06/30/2021
| Implemented |
| 6400.18(a)(1) | Enterprise Incident Management (EIM) report #8808935 entered for Individual #2 on 2/16/2021 was in excess of the 24-hour required reporting timeline. Incident report # 8808935 indicates the date of the incident to have occurred on 2/11/2021. 24-hour reporting of a death into the EIM system is required. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Death | Provider failed to file a death report on 2/11/21 after an individual supported by LVHS passed away in the hospital. Provider filed the report on 2/16/21 after it was prompted by Northampton County AE that the report should have been filed on 2/11/21. Provider¿s Incident Manager (Dr. Subrina Taylor) reviewed section RCG 6400.18(a) to educate herself and establish clarity on her reporting responsibility. Further, she reviewed Provider¿s own Incident Management Policy (which did in fact specify that an EIM should be submitted for individuals in service NO MATTER the location of death). Provider is now clear on this matter. |
05/10/2021
| Implemented |
| 6400.32(r)(1) | A pin key locking door knob was on the bedroom door of Individual #1. Individual #1 is able to lock the door when he is inside but the existing lock does not allow him to lock the door when not in his bedroom. No key was available at the time of the inspection. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | Provider provided inadequate locks on bedroom doors for individuals to secure their belongings from the outside of the bedroom. Provider has ordered key entry locks that are being placed on bedroom door #1 and #2. Installation will be completed by 5/21/21. Individuals will be given a bedroom key to maintain with their house key (which they already have) which will provide them with privacy when they are in their bedroom. Further, the individual will be able to secure their belongings with this key when they leave their bedroom or house. Provider will conduct trainings on May 25, 26, 27 and 31, 2021 to train staff about the bedroom lock requirement and to ensure they understand the individual¿s rights. Dr. Subrina Taylor is responsible for implementing this POC. |
05/31/2021
| Implemented |
| 6400.46(d) | Staff #1 and Staff #2 received online CPR/First Aid training. CPR/First Aid training must include an in person component in order to satisfy regulation. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Provider¿s certified CPR Instructor (Rasheda McMillan) adjusted requirements (due to the Covid-19 Pandemic) for all staff who had been previously certified under her instructorship. The adjustment included a waiver of the rescue breathing and compression demonstration portion of the test. However, all new staff (who had not been previously trained under this instructor) were required to complete the demonstration prior to working in the homes. Provider has completed a training where all staff were required to demonstrate rescue breathing and chest compressions to pair with the online education provided by the Certified CPR instructor during the peak of the COVID-19 pandemic. See Appendix 1 |
04/30/2021
| Implemented |
| 6400.52(c)(1) | The training records provided for Staff #1 did not contain documentation of training on person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships as required. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Provider¿s Orientation and annual training curriculum did not specifically list person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. Although these subjects are integrated into the training, this is not adequate to meet 6400.52( C ) (1). Provider has completed a training where all staff attended a supplemental training including these topics (see Appendix 2). These topics were also updated in Provider¿s orientation curriculum on 4/30/21. |
04/30/2021
| Implemented |
| 6400.52(c)(2) | The training records submitted for Staff #1 did not contain documentation of training on abuse as required. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Provider¿s Orientation and annual training did not specifically list training on abuse. Although, this subject is typically covered under Incident management in orientation and annual training , still it is not adequate to cover the 6400.52 (C ) (2) requirement for abuse. Provider has completed a training where all staff attended a supplemental training including this topic (See Appendix 2). The topic was also updated on Provider¿s orientation curriculum (Appendix 3). |
04/30/2021
| Implemented |
| 6400.52(c)(5) | The training records submitted for Staff #1 did not contain documentation of training on the safe and appropriate use of behavior supports if the person works directly with an individual. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Provider¿s Orientation and annual training did not specifically list training safe and appropriate use of behavior supports. Although this training is typically covered under the topic of behavior plans, still it is not adequate to meet requirements under 6400.52 (C ) (5). Provider has completed a training where all staff attended a supplemental training including this topic (See Appendix 2). The topic was also updated on Provider¿s orientation curriculum (Appendix 3). |
04/30/2021
| Implemented |
| 6400.52(c)(6) | The training records submitted for Staff #1 and #2 did not contain documentation of training on the individual plan as required. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Provider routinely reviews the ISP and it¿s contents and details with new staff before they are allowed to work in the house. The staff is required to complete the review first then in a meeting with the PS (where a review of highlights of the ISP is conducted). Staff are required to sign the ISP front cover sheet which is stored in the home. The signed ISP was available in the home and Provider failed to realize that this documentation should have been sent as part of staff training (prior to the site inspection). Sign-off sheets are being provided to show that this training did occur prior to staff working in the homes. (Appendix 4) |
05/14/2021
| Implemented |
| 6400.213(1)(i) | The "Personal Data Summary" sheet submitted for Individual #1 did not contain identifying marks. A review of the contents of Individual #1's record also did not contain any identifying marks. Identifying marks are required to be part of the Individual record. The "Personal Data Summary" sheet submitted for Individual #1 did not contain his religious affiliation. A review of the contents of Individual #1's record also did not contain his religious affiliation. Religious affiliation is required to be part of the Individual record. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | LVHS Management staff met on May 7, 2021 for a training on 6400.213(1)(i). After the training and reviewing the regulations, a new ¿personal Data Summary¿ sheet was developed for immediate implementation. The data sheet meet the requirements of 6400.213. See Appendix 8. |
05/07/2021
| Implemented |