| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | The "LVH Services Monthly Financial Reconciliation Form" completed for Individual #1 for the months of October 2022-February 2023 did not include documentation of deposits. The 10/22 form documented a total of $127.83 in withdrawls. There was no beginning or ending balance. The 11/22 form documented a total of $100.68 in withdrawls. There was no beginning or ending balance. The 12/22 form documented 21 withdrawls with no total and no beginning or ending balance. The 1/23 form documents a total of $147.58 withdrawls with no beginning or ending balances. The 2/23 form documents a total of $60.39 in withdrawls with no beginning or ending balances. Documentation of all funds received by or deposited with the home shall be recorded on an up-to-date financial record. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Provider will retrain staff on the financial reconciliation form, the form will be reviewed by the Program Specialist and Program Manager on a monthly basis to ensure accuracy. |
04/17/2023
| Implemented |
| 6400.112(c) | Documentation of fire drills conducted on 9/7/22 and 9/21/22 did not indicate if the fire alarms or smoke detectors in the home were operative. Locations of alarms/detectors were listed without noting the if they were operative at the time of the drill. | 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. | Provider will retrain staff on fire drill log completion and will ensure refresher trainings are completed twice a year on fire drills and completion of reports. Program Manager is responsible for ensuring the reports are completed in an accurate and timely manner. |
05/31/2022
| Implemented |
| 6400.112(i) | Documentation of fire drills conducted on 1/21/22, 2/15/22, 3/14/22, 6/7/22, 7/19/22, 10/27/22, 11/20/22, 12/21/22, 1/7/23, 2/17/23 and 3/4/23 did not include notation of a fire alarm or smoke detector being set off during the drills. | A fire alarm or smoke detector shall be set off during each fire drill. | Provider has retrained staff on fire drill log completion and will ensure refresher trainings are completed twice a year on fire drills and completion of reports. Program Manager is responsible for ensuring the reports are completed in an accurate and timely manner. |
04/18/2023
| Implemented |
| 6400.181(a) | Assessments for Individual #1 were dated as being completed on 1/20/21 and 12/3/22. This exceeds the annual time frame requirement. Assessments shall be completed on an annual basis. | 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. | Provider has created a annual paperwork tracker to ensure all documentation is completed in a timely manner. This tracker will be reviewed monthly and updated to reflect what is needed. |
04/01/2023
| Implemented |
| 6400.46(b) | It could not be determined that fire safety training conducted for Staff #1 on 9/5/22 and 10/28/22 was conducted by a fire safety expert. Greater detail was requested. A link was provided by Staff #4 in response. The link was a general search for fire safety videos. It could not be verified which video was used for training, the content nor the qualifications of the instructor. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Provider has contracted with Allentown Fire Department to facilitate the annual fire training. Captain Christopher will be facilitating the training on May 10 & May 17. |
06/01/2023
| Implemented |
| 6400.50(a) | Orientation training for Staff #1 conducted on 9/5/22 covering "Threp did, ISP/BSP training, CPR and First Aid, Client Rights, Recognizing and Reporting Incidents, HIPPA, Med Training and Fire Safety" did not include a start time, end time or length of training. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Providers trainer has updated the training sign in sheet to reflect more detail, including the length of time and training content. |
05/01/2023
| Implemented |
| 6400.51(a)(3) | Documented hire date for Staff #1 was 9/5/22. Training records submitted indicate that training on the application of person-centered practices first occurred on 10/28/22, training on community integration first occurred on 12/12/22, and training on supporting individuals to develop and maintain relationships first occurred on 12/12/22. Training on stated topics must occur within 30 days after hire or prior to working alone with individuals. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | Provider has created a yearly calendar to reflect all necessary yearly trainings, as well as "new hire orientation" trainings.
(staff trained 3/23/23 -CH 5/5/23) |
04/01/2023
| Implemented |
| 6400.51(b)(1) | Documented hire date for Staff #1 was 9/5/22. Training records submitted indicate that training on Individual Choice did not occur. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Provider has created a yearly calendar to reflect all necessary yearly trainings, as well as "new hire orientation" trainings.
(staff trained 3/23/23 -CH 5/6/23) |
04/14/2023
| Implemented |
| 6400.51(b)(2) | Documented hire date for Staff #1 was 9/5/22. There was no documentation to support that training on 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 had occurred as required. | The orientation 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 has created a yearly calendar to reflect all necessary yearly trainings, as well as "new hire orientation" trainings.
(staff trained 3/23/23 -CH 5/5/23) |
05/01/2023
| Implemented |
| 6400.165(g) | Documentation of three-month medication reviews occurring on 1/15/23, 2/16/23, 9/22/22 and 9/8/22 were submitted. The 2/16/23 report did not include documentation of the dose of the medications nor the need to continue. There was notation of an appointment to occur on 10/13/22 on the 9/22/22 visit form but no documentation of the 10/13/22 appointment occurring was provided. The time frame between the 9/22/22 and the 1/15/23 exceeds the three-month time frame. The 9/22/22 appointment documentation does not include the dose of the medications reviewed. Documentation of review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage was not documented as consistently occurring or recording all required items. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Provider will ensure reviews are taking place every three months, if not documented on the reason the review did not take place. |
04/01/2023
| Implemented |