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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.33(a) | On 11/23/15, Direct Service Worker #2 heard yelling coming from the bathroom. Direct Service Worker #2 entered the bathroom. Direct Service Worker #2 observed that Individual #1's t-shirt was ripped. Individual #1 was shaking and appeared "very nervous and upset." Direct Service Worker #1 was standing in front of the "grab bar" across from the toilet blocking Individual #1 using the "grab bar." Direct Service Worker #1 stated, "S/he won't let me change him/her." On 11/23/15, at approximately 10:50 PM, Direct Service Worker #1 said to Direct Service Worker #3 that "[Individual #1] was being an ass." In the morning of 11/24/15, while Direct Service Worker #4 was assisting Individual #1 with his/her shower, several scratches were observed under Individual #1's arm and on his/her neck and bruises on his/her forearm. | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | Worker #2 notified supervisor on 11/24/2015 of alleged incident. Immediately upon notification of incident of alleged incident, Lifesteps suspended worker #1 pending results of investigation. Separation of employment with worker #1 then occurred on December 2. Staff at service location retrained between December 7 and December 14, 2015 on: 1) Lifesteps process for Incident Reporting; 2) Mandatory Reporting of Abuse or Neglect as indicated in our employee handbook; 3) Adult Protective Services Mandatory Reporting definitions and requirements issued by Department of Human Services. Agency staff to be retrained at In Service in August 2016. [Within 60 days of receipt of the Inspection Summary, CEO or designee will begin quarterly trainings for 1 year of all Direct Service Workers and other staff that come in contact with Individuals being served in all community living homes. The four trainings will be on abuse and neglect, mandatory reporting and following the ISP of each individual. CEO or designee will review the ISP for each Individual to ensure the specifics are included in at least one training so direct service workers are trained in the specifics including environmental strategies of each Individual¿s ISP. At least one of the four trainings will be conducted by an outside source. (AS 12/21/15)] |
12/17/2015
| Implemented |
| 6400.185(b) | On 11/23/15, Direct Service Worker #1 was heard yelling at Individual #1 while providing care to him/her in the bathroom. The Social Emotional Environmental Plan for Individual #1, review date 9/7/15, in the Basic Environmental Strategies section reads, "use a gentle and soft tone of voice" and "do not try to disagree with [Individual #1]." The following interventions are to be used: "do not engage in long explanations or argue with [Individual #1]" and "allow [Individual #1] to take the lead, giving assistance only as needed." In addition, reportedly Direct Service Worker #1 often becomes loud causing the individuals to become anxious and worried. | The ISP shall be implemented as written. | Worker #2 notified supervisor on 11/24/2015 of alleged incident. Immediately upon notification of alleged incident, Lifesteps suspended worker #1 pending results of investigation. Separation of employment with worker #1 then occurred on December 2. Staff at service location retrained on ISP as written between November 29 and December 16, 2015. [Within 60 days of receipt of the Inspection Summary, CEO or designee will begin quarterly trainings for 1 year of all Direct Service Workers and other staff that come in contact with Individuals being served in all community living homes. The four trainings will be on abuse and neglect, mandatory reporting and following the ISP of each individual. CEO or designee will review the ISP for each Individual to ensure the specifics are included in at least one training so direct service workers are trained in the specifics including environmental strategies of each Individual's ISP. At least one of the four trainings will be conducted by an outside source. (AS 12/21/15)] |
12/17/2015
| Implemented |
| Article X.1007 | Lifesteps is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including 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). There was an allegation of physical abuse on at 5:15 PM on 11/23/15. The incident was not reported to the Area Agency on Aging until 3:05 PM on 11/24/15. | 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. | Worker #2 notified supervisor on 11/24/2015 of alleged incident. Immediately upon notification of alleged incident, Lifesteps suspended worker #1 pending results of investigation. Separation of employment with worker #1 then occurred on December 2. Staff at service location retrained between November 29 and December 16, 2015 on: 1) ISP as written; 2) Lifesteps process for Incident Reporting; 3) Mandatory Reporting of Abuse or Neglect as indicated in our employee handbook; 4) Adult Protective Services Mandatory Reporting definitions requirements issued by Department of Human Services. [Within 60 days of receipt of the Inspection Summary, CEO or designee will begin quarterly trainings for 1 year of all Direct Service Workers and other staff that come in contact with Individuals being served in all community living homes. The four trainings will be on abuse and neglect, mandatory reporting and following the ISP of each individual. CEO or designee will review the ISP for each Individual to ensure the specifics are included in at least one training so direct service workers are trained in the specifics including environmental strategies of each Individual's ISP. At least one of the four trainings will be conducted by an outside source. (AS 12/21/15)] |
12/17/2015
| Implemented |
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