| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.82(f) | There was no soap available in the home's bathroom at the time of inspection. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The poison safe soap was added to the home immediately upon notice of the violation by the inspector and had been present in the home. |
07/20/2022
| Implemented |
| 6400.110(e) | The home has three levels and has a wireless interconnected smoke detector system. At the time of the inspection, the basement smoke detector did not sound with the smoke detectors on the other two levels of the home. The provider attempted to resynchronize the smoke detectors, but the issue was not resolved by the conclusion of the inspection.
**The provider corrected the the issue after the inspection. A licensing inspector visited the home the morning after the inspection, and the smoke detectors on all three levels of the home were connected when tested. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The smoke detectors were functioning, able to be wirelessly connected, and were located on each level but were giving us trouble during the inspection. This was rectified within 24 hours and verified by another inspector. |
08/31/2022
| Implemented |
| 6400.51(b)(1) | The orientation training received by Staff #1 and Staff #2 did not encompass the following training area(s): The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | 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. | Staff 1 & 2 had all necessary training completed within 48 hours of the notification of the violation. |
08/05/2022
| Implemented |
| 6400.51(b)(2) | The orientation training received by Staff #1 and Staff #2 did not encompass the following training area(s): 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. | 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. | Staff 1 & 2 had all necessary trainings within 48 hours of notification of the violation. |
08/05/2022
| Implemented |
| 6400.51(b)(3) | The orientation training received by Staff #1 and Staff #2 did not encompass the following training area(s): Individual rights. | The orientation must encompass the following areas: Individual rights. | Staff 1 & 2 received individual rights training within 48 hours of receiving the violation. |
08/05/2022
| Implemented |
| 6400.51(b)(4) | The orientation training received by Staff #1 and Staff #2 did not encompass the following training area(s): recognizing and reporting incidents. | The orientation must encompass the following areas: recognizing and reporting incidents. | Staff 1 &2 received recognizing and reporting incidents within 48 hours of receiving the violation. All LVAS staff will be required to complete recognizing and reporting incidents by 8/29/22. |
08/05/2022
| Implemented |
| 6400.165(c) | Individual 1 is prescribed a Pro re Nata (PRN) Acetaminophen 325MG Tablet with instructions to "Take 2 tablets by mouth every 6 hours as needed for mild pain (Pain Score 1-3)." The medication is packaged in a blister pack by the pharmacy such that there is a single tablet in each blister, i.e., in order to administer the medication as prescribed, staff would need to pop two blisters of the blister pack and remove one tablet from each. When administering medication in the home, staff write their initials and the date of administration next to the blister(s) of the blister pack that they are removing medication from. The following dates written on the blister pack are paired with only one blister, denoting that only one tablet was given for that administration: 4/20, 4/22, 4/27, 5/15, 5/18, 5/19, 5/20, 5/24, 5/29, and 5/30. There are two blisters associated with the date 5/26; however, it is unclear whether both tablets were given with one administration or if only one tablet was given on two separate administrations occurring on the same day. The fact that there is no other blister pack of this medication in the home and that there are no other blisters popped and missing tablets on the blister pack rules out the possibility that this was simply a documentation error. The totality of evidence supports that staff in the home were administering one 325mg tablet---rather than the two 325mg tablets that are prescribed---at each PRN administration; therefore, this medication was not being administered to Individual 1 as prescribed. | A prescription medication shall be administered as prescribed. | Evidence of the staff being given retraining on appropriate PRN administration was sent to the investigator. |
08/05/2022
| Implemented |
| Article X.1007 | Lehigh Valley Adult Services is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15).¿ OAPSA requires that all necessary criminal history background checks be conducted prior to the date of hire. Staff #2 was hired on 3/28/2022 and a Pennsylvania State Police criminal history background check was not requested until 3/30/2022, | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | LVAS re-ran the criminal history of the staff in question to ensure that he met the standards for OAPSA. |
10/01/2022
| Implemented |