| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(3) | Individual #1's physical dated 1/30/26 note under immunization for Tetanus/Diphtheria (every 10 years) 3/30/16. Individual #1 is overdue on their Tetanus/Diphtheria. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | 6400.141 (c)(3) The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.
Individual #1's physical dated 1/30/26 note under immunization for Tetanus/Diphtheria (every 10 years) 3/30/16. Individual #1 is overdue on their Tetanus/Diphtheria. The individual has since died so no follow-up will happen in this instance, however, the issue is being addressed systemically as indicated below. |
06/19/2026
| Implemented |
| 6400.141(c)(15) | Individual #1's physical dated 1/30/26 under the recommended diet and special instruction section was left blank. | The physical examination shall include:Special instructions for the individual's diet. | 6400.141 (c)(15) The physical examination shall include: Special instructions for the individual's diet.
Individual #1's physical dated 1/30/26 under the recommended diet and special instruction section was left blank. The individual has since died so no follow-up will happen in this instance, however, the issue is being addressed systemically as indicated below. |
06/19/2026
| Implemented |
| 6400.142(f) | There was no record or documentation of dental hygiene plan for Individual #1 in their record. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Individual #1 is deceased, therefore, a dental hygiene plan cannot be developed for the individual at this time. To prevent this from occurring with other individuals, Program Supervisors and the Program Specialist were trained on 9/16/26 on reviewing individual records to ensure required health documentation is present and complete, including a written dental hygiene plan unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. See attachment 1. |
09/16/2026
| Implemented |
| 6400.143(a) | Individual #1 had an OBGYN appointment on 1/23/25 and the form noted "PT declined pelvic exam". There is no record or documentation that Individual #1 received training on the importance of pelvic exams. On 4/28/25 Individual #1 had a dental examination and under the Physician or consult order section of the form it noted "recommended new denture but pt refused it." There is no record or documentation that Individual #1 was trained on the importance obtaining new dentures. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | 6400.143 (a)An individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record.
Individual #1 had an OBGYN appointment on 1/23/25, and the form noted "PT declined pelvic exam". There is no record or documentation that Individual #1 received training on the importance of pelvic exams. On 4/28/25 Individual #1 had a dental examination and under the Physician or consult order section of the form it noted "recommended new denture but pt refused it." There is no record or documentation that Individual #1 was trained on the importance obtaining new dentures. The individual has since died, therefore, no action will be taken in this instance, however, retraining will be done with all agency staff. |
06/19/2026
| Implemented |
| 6400.144 | Individual #1 had a 2/6/26 Cardiology appointment and attached to the after-visit form was an agency form and it noted under the physician or consultant orders "there is a prior order for TEE that was not completed. Please schedule this." Upon Licensing Representative reviewing Individual #1's medical records it was noted on multiple after visit summary forms (12/6/25, 12/4/25) for Individual #1 under the "what's next" section of the form that Individual #1 had an appointment scheduled for December 15, 2025 for TEE with Anesthesia at 10 AM. Individual #1 did not have the TEE performed. The agency did not provide/arrange medical services as prescribed for Individual #1. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| 6400.144 Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
Individual #1 had a 2/6/26 Cardiology appointment and attached to the after-visit form was an agency form and it noted under the physician or consultant orders "there is a prior order for TEE that was not completed. Please schedule this." Upon Licensing Representative Reviewing Individual #1's medical records it was noted on multiple after visit summary forms (12/6/25, 12/4/25) for Individual #1 under the "what's next" section of the form that Individual #1 had an appointment scheduled for December 15, 2025, for TEE with Anesthesia at 10 AM. Individual #1 did not have the TEE performed. The agency did not provide/arrange medical services as prescribed for Individual #1. The individual has since died; therefore, no action will be taken in this instance. However, retraining was conducted. |
06/19/2026
| Implemented |
| 6400.32(c) | Individual #1 had an appointment on 3/3/26 with an Orthopedic Care Specialist and was ordered/prescribed a trigger finger splint. The agency form that was attached to the after-visit summary form noted in the physician or consult order "trigger finger splint can be obtained over-the- counter." Agency T-Log completed by Staff #3 (Shantel Frith) for their shift from 3/5 at 11pm to 3/6 at 9am, documents that Staff #3 and Individual #1 went to CVS on 3/6 and got Individual #1's finger splint. The agency neglected Individual #1 by delaying needed care to Individual #1 as they were order/prescribed a finger splint at Individual #1's Orthopedic Care Specialist appointment on 3/3/26, and the agency did not obtain the finger splint for Individual #1 until 3/6/26.
As per staff and individual interviews, Staff #2 is a favored staff of Individual #1. Staff daily notes documented by Staff #2 on 2/13/26 record that Staff #2 told Individual #1 that if Individual #1 does not "behave" that Staff #2 would not work with Individual #1 on the weekend. This causes Individual #1 distress.
On 3/4/26, it was documented in a staff note that after Individual #1 had gotten into an argument with her housemate, that Staff #2 refused to talk to Individual #1 for the rest of the evening due to Individual #1's behavior.
Individual #1 was subjected to psychological abuse by Staff #2. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Staff #2 was placed on administrative leave pending investigation once LVHS became aware of the concerns. Staff #2 is no longer employed by LVHS. Staff were trained by The Advocacy Alliance on 7/9/26 on Incident Management. Staff were also trained on the agencies updated Incident Management Policy on 8/19, 8/20, and 8/21/26. LVHS staff were reminded that communication, attention, or preferred staffing cannot be withheld because of an individual's behavior. See attachment 2 and attachment 3.
Following medical appointments, staff are responsible for immediately scanning all medical documentation for review. Program Supervisors and the Program Specialist were trained on 9/16/26 to ensure medical documentation is received, reviewed, and completed in its entirety and that physician orders and recommendations, including over-the-counter medical items, are followed through and completed timely. See attachment 1.
All staff will be trained on 9/22/26 and 9/23/26 on the process and expectation for scanning medical documentation immediately following an appointment so that orders, recommendations, and required follow-up can be reviewed and addressed timely. Agenda and sign in sheets will be provided after the trainings. |
09/24/2026
| Implemented |
| 6400.46(a) | Staff #1's date of hire is 11/12/25 and there was no record of documentation that Staff #1 received training in fire safety before working with individuals in the documents/ records provided via email to the Licensing representative. | 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. | 6400.46 (a) 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.
Staff #1's date of hire is 11/12/25 and there was no record of documentation that Staff #1 received training in fire safety before working with individuals in the documents/ records provided via email to the Licensing representative. Staff were immediately trained in fire safety. |
06/19/2026
| Implemented |
| 6400.51(b)(2) | There was no record or documentation that Staff #1 and Staff #2 received orientation training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in the documents/ records provided via email to the Licensing representative. | 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. | 6400.51(b)(2) 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.
There was no record or documentation that Staff #1 and Staff #2 received orientation training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in the documents/ records provided via email to the Licensing representative. Staff 1 and 2 were trained immediately. |
06/19/2026
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness and had a medication review on 9/8/2025, then not again until 1/26/2026 which exceeds the 3-month timeframe required by this regulation. | 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. | 6400.165 (g) 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 documenting the reason for prescribing the medication, the need to continue the medication and the necessary dosage.
Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness and had a medication review on 9/8/2025, then not again until 1/26/2026, which exceeds the 3-month timeframe required by this regulation. The clinical review was scheduled immediately. |
06/19/2026
| Implemented |
| 6400.166(a)(11) | Individual #1's Medication Administration Record (MAR) dated 3/23/26-4/22/26 on the document did not list a diagnosis or purpose for the following medications prescribed and administered to individual #1: Methocarbamol 500 mg tab, Acetaminophen 500 mg tablet, Zonisamide 100 mg capsule. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | 6400.166 (a) (11) A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.
Individual #1's Medication Administration Record (MAR) dated 3/23/26-4/22/26 on the document did not list a diagnosis or purpose for the following medications prescribed and administered to individual #1: Methocarbamol 500 mg tab, Acetaminophen 500 mg tablet, Zonisamide 100 mg capsule. The individual has since died; therefore, no intervention will be made in this case, however a system solution has been developed and listed below. |
06/25/2026
| Implemented |
| 6400.166(a)(12) | The Medication Administration Record (MAR) for Individual #1 is dated for the administration period of 3/23/26-4/22/26. However, when staff administer medications, staff document the dates as 1,2,3,4, etc. which appear to be the day administration occurs. Due to staff not documenting the month along with the day when administering medication and the documented days not matching with the period of 3/23/26-4/22/26, the actual date of administration cannot be determined. The MAR must include the date of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | 6400.166(a)(12) A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration.
The Medication Administration Record (MAR) for Individual #1 is dated for the administration period of 3/23/26-4/22/26. However, when staff administer medications, staff document the dates as 1,2,3,4, etc. which appear to be the day administration occurs. Due to staff not documenting the month along with the day when administering medication and the documented days not matching with the period of 3/23/26-4/22/26, the actual date of administration cannot be determined. The MAR must include the date of administration. The individual has since died; therefore, no intervention will be made in this case, a system solution has been developed and listed below. |
06/26/2026
| Implemented |
| 6400.166(b) | Individual #1's is prescribed Albuterol HFA 90 MCG Inhaler, inhale 2 puffs by mouth every 6 hours as needed for wheezing. Individual #1's Medication Administration Record (MAR) does not document or record an administration of Individual #1 receiving/administering the albuterol on 2/3/26.
Individual #1 was prescribed Acetaminophen 325 mg tab, take 3 tablets by mouth every 8 hours for 7 days. The medication started on 2/26 at 8pm. There was no documentation of staff initials on the Medication administration Record MAR for the 8am administration of the medication on 3/2/26.
Individual #1's MAR and hospital records/documents the Individual #1 was in the hospital on 3/26/26, however Staff #2 documented a 4pm administration of Saline Mist 065% Nose Spray to Individual #1 on 3/26/26. The medication could not have been administered as Individual #1 was not present in the home. The MAR did not contain accurate information. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | 6400.166 (b) The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.
Individual #1's is prescribed Albuterol HFA 90 MCG Inhaler, inhaling 2 puffs by mouth every 6 hours as needed for wheezing. Individual #1's Medication Administration Record (MAR) does not document or record an administration of Individual #1 receiving/administering the albuterol on 2/3/26.
Individual #1 was prescribed Acetaminophen 325 mg tab, take 3 tablets by mouth every 8 hours for 7 days. The medication started on 2/26 at 8pm. There was no documentation of staff initials on the Medication administration Record MAR for the 8am administration of the medication on 3/2/26.
Individual #1's MAR and hospital records/documents the Individual #1 was in the hospital on 3/26/26, however Staff #2 documented a 4pm administration of Saline Mist 065% Nose Spray to Individual #1 on 3/26/26. The medication could not have been administered as Individual #1 was not present in the home. The MAR did not contain accurate information. Staff were immediately retrained on the importance of providing accurate information on the MAR. |
06/26/2026
| Implemented |
| 6400.186 | Individual #1's Individual Support Plan (ISP) last updated 6/15/2026, under the general Health and safety risks section states that Individual #1 is unable to self-medicate at this time as they are not able to distinguish between medications, does not know the prescribed dose and typically only knows the time to take medications out of routine. Individual #1's assessment dated 9/1/25, states under the section of the individual's ability to self-administer medications that "Individual #1 is unable to self-administer medications. She is unable to read the Medication Administration Record and does not express a desire to do so. Staff daily note on 2/3/26-2/4/26 at 11pm documents that "Individual #1 kept coughing in the car and used her inhaler ." Individual #1's is prescribed Albuterol HFA 90 MCG Inhaler, inhale 2 puffs by mouth every 6 hours as needed for wheezing. Individual #1's Medication Administration Record (MAR) does not document or record an administration of Individual #1 receiving/administering the albuterol on 2/3/26. The agency is not implementing Individual ISP as Individual #1 is not assessed as being self-medicating. | The home shall implement the individual plan, including revisions. | 6400.186 The home shall implement the individual plan, including revisions.
Individual #1's Individual Support Plan (ISP) last updated 6/15/2026, under the general Health and safety risks section states that Individual #1 is unable to self-medicate at this time as they are not able to distinguish between medications, does not know the prescribed dose and typically only knows the time to take medications out of routine. Individual #1's assessment dated 9/1/25, states under the section of the individual's ability to self-administer medications that "Individual #1 is unable to self-administer medications. She is unable to read the Medication Administration Record and does not express a desire to do so. Staff daily note on 2/3/26-2/4/26 at 11pm documents that "Individual #1 kept coughing in the car and used her inhaler." Individual #1's is prescribed Albuterol HFA 90 MCG Inhaler, inhaling 2 puffs by mouth every 6 hours as needed for wheezing. Individual #1's Medication Administration Record (MAR) does not document or record an administration of Individual #1 receiving/administering the albuterol on 2/3/26. The agency is not implementing Individual ISP as Individual #1 is not assessed as being self-medicating. Staff were immediately retrained. |
06/26/2026
| Implemented |