| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff #2's criminal background checks were not completed within five days of his date of hire. He was hired on 06-21-19 and the checks were not completed until 08-21-19. | 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.
| In its first annual site inspection on March 5, 2020, Lehigh Valley Human Services violated 21(a) CRIMINAL HISTORY CHECK (for both Staff 1 and Staff 2). It is imperative that a background check be conducted on all staff who will come in contact with Individuals in service to protect their health, safety and rights. Further, the background check should be completed within 5 working days after the staff person¿s date of hire and shall be maintained in their personnel file for inspection. In order to make certain that no staff is permitted to work in a home without having first had a criminal background check, LVHS will implement a new ONBOARDING Process. Prior to any staff person being allow to begin working in the home, the ONBOARDING form must be signed off by the CEO, Dr. Subrina Taylor. The ONBOARDING form ensures that all required documents (including background checks) have been submitted, reviewed and verified. The CEO will be responsible for ensuring that this plan is fully implemented so that this violation does not recur. See attached ONBOARDING form, marked as LVHS A. |
03/16/2020
| Implemented |
| 6400.151(a) | Staff #2 had a late initial physical. He was hired on 06-21-19 and did not have a physical completed until 07-12-19. | 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. | In its first annual site inspection on March 5, 2020, Lehigh Valley Human Services violated 151(a) STAFF PHYSICALS (for both Staff 1 and Staff 2). It is crucial that a physical examination be conducted for all staff working with individuals in services BEFORE THEY ARE PERMITTED TO WORK IN THE HOMES to ensure that staff are healthy so that the health and safety of individuals in service is maintained. Moreover, these physicals shall be maintained in the staff¿s personnel file for inspection and repeated every 2 years. In order to make certain that no staff is permitted to work in a home without a valid physical, LVHS will implement a new ONBOARDING Process. Prior to any staff person being allow to begin working in the home, the ONBOARDING form must be signed off by the CEO, Dr. Subrina Taylor. The ONBOARDING form ensures that all required documents (including physical examinations) have been submitted, reviewed and verified. The CEO, Dr. Subrina Taylor will be responsible for ensuring that this plan is fully implemented and the problem does not persist. See attached ONBOARDING form, marked as LVHS A. |
03/16/2020
| Implemented |
| 6400.151(c)(2) | Staff #2 had a late initial TB test. He was hired on 06-21-19 and did not have a TB test completed until 07-05-19. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | In its first annual site inspection on March 5, 2020, Lehigh Valley Human Services violated 151 (C)(2) TB TESTING (for both Staff 1 and Staff 2). It is critical that all staff undergo TB testing BEFORE THEY ARE ALLOWED TO WORK IN THE HOMES to ensure that they are healthy and free COMUNICABLE diseases so that the health, safety and rights of individuals in services are protected. Additionally, these TB test/results shall be maintained in the staff¿s personnel file for inspection and repeated every 2 years. In order to make certain that no staff slip through the crack. In order to make certain that no staff is permitted to work in a home without a valid TB Test, LVHS will implement a new ONBOARDING Process. Prior to any staff person being allow to begin working in the home, the ONBOARDING form must be signed off by the CEO. The ONBOARDING form ensures that all required documents (including the TB Test) have been submitted, reviewed and verified. The CEO, Dr. Subrina Taylor will be responsible for ensuring that this plan is fully implemented to prevent recurrence. See attached ONBOARDING form, marked as LVHS A. |
03/16/2020
| Implemented |
| 6400.181(a) | Individual #2's initial assessment was completed late. He was admitted 06-24-19 and the assessment was not completed until 09-03-19. | 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. | In its first annual site inspection on March 5, 2020, Lehigh Valley Human Services violated 181 (a) INITIAL ASSESSMENT (Individual 2). It is required that all individuals shall have an assessment completed 60 days after admissions and annually thereafter. The assessment ensures that the Provider is participating in program planning and delivering appropriate service to the individual. The CEO was ¿acting¿ as the Program Specialist but she realizes that she was not providing the full attention to details necessary in this role. In order to ensure that all individuals receive the assessment 60 days after admission and that the full focus needed to provide Individuals a quality like experience, the Provider has hired a full-time Program Specialist. The Program Specialist will be responsible for ensuring that all assessments are completed in a timely manner. Moreover, the Program Specialist will sign a job description which outlines his/her duties which shall include the 60 day assessment requirement. See Program Specialist Job Description with sign-off requirement, marked as LVHS D. The PROGRAM SPECIALIST will be responsible for ensuring that this plan is fully implemented. He is supervised by the CEO. |
03/02/2020
| Implemented |
| 6400.34(b) | Individual #2 did not have a signed rights statement in his file. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | On March 5, 2020, in its first annual site inspection, Lehigh Valley Human Services violated 31(b) SIGNED STATEMENT/INDIVIDUAL RIGHTS (for both Individual 1 and Individual 2). It is vital that individuals be informed of their Individual Rights to guard and protect their rights to appropriate treatment and services. Further, a signed statement showing that individuals have been informed of their rights upon admission and annually thereafter. An Admission packet has been developed with all required forms that must be signed. This statement shall be maintained in the individual¿s records for future inspection. The CHIEF OF OPERATIONS, Sharazada McMillan will be responsible for ensuring that this plan is fully implemented to prevent recurrence. See attached Rights Policy and sign-off sheet, marked as LVHS-B that has been developed. This form was mailed to the legal guardian of the individual in question (CR) because his mother is currently unable to visit due to the CORVID-19 Pandemic. Once the form is returned with the guardian¿s signature it will be placed in the individual¿s file. We have listed a completion date of May 30 to allow ample time for the guardian to return the signed form. |
05/30/2020
| Implemented |