| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.103 | The emergency evacuation plan has the language that the individuals will be transported "to the nearest LSS site/group home. If that is not an option, staff and individuals will be transported to the closest hotel in the area. A second evacuation document in the record included the following language: As a temporary site, individuals of this residence are to be transported by an agency vehicle or staff member's personal vehicle to the nearest safe agency home. If that is not an option, staff and individuals should be transported to either the Comfort Inn or the Cottage Motel, both of which are located in Ebensburg. Emergency evacuation plan must include specific location to which individuals will be evacuated. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| ¿ What we did to correct?
o LSS revised #8 of its Emergency Disaster Plan to be more specific in regards where the consumers report to if unable to report back to their residence.
o Individuals will review the revised Emergency Disaster Plan Procedures verified with signatures.
¿ How to prevent?
o LSS Compliance Coordinator will ensure to specify in each home plan the exact temporary location address the consumers are to report to as well as the exact back-up hotel address.
o LSS management personnel will be trained on LSS¿s Central Region Corrective action plan.
¿ Implementation date of correction?
o June 4th, 2021.
¿ Who is responsible for each step?
o LSS Compliance Coordinator
o LSS Program Specialist.
o LSS Corporate Compliance Coordinator & Executive Program Director for training on CAP. |
06/04/2021
| Implemented |
| 6400.141(c)(14) | Individual #1's most recent physical dated 1/21/21 indicates that in the event of a medical emergency there is information that would be pertinent to treat the individual. However, under the section on the physical in which this information is to be listed, is blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | ¿ What we did to correct?
o LSS Wellness Coordinator notified the physician on 5/1/21 requesting the physical revision. The physician¿s office corrected the physical on 5/6/21.
o LSS will review consumer physicals ensuring there are no blanks on the form. Physicians will be contacted to obtain the necessary medical information if blanks are discovered.
¿ How to prevent?
o The consumers physical examination shall include medical information pertinent to diagnosis and treatment in case of an emergency.
o WC & LSS Compliance Coordinator will review all consumer physicals ensuring no blanks exist.
o WC will contact the consumers physician when blanks are discovered on the physical to obtain the necessary medical information/documentation to meet the regulation.
o LSS management personnel will be trained on LSS¿s Central Region Corrective action plan.
¿ Implementation date of correction?
o June 4th, 2021
¿ Who is responsible for each step?
o LSS Wellness Coordinators.
o LSS Compliance Coordinator.
o LSS Corporate Compliance Coordinator & Executive Program Director for training on CAP. |
06/04/2021
| Implemented |
| 6400.144 | (Repeat from Unannounced monitoring from 6/15/20 to 10/26/20) On 12/26/20, Individual #1's PCP recommended they be referred to dermatology. As of 4/21/21, Individual #1 did not have an appointment with dermatology scheduled. On 2/5/21, it was ordered that Individual #1 is to have their blood sugar checked twice a day. As of 4/21/21, Individual #1 is only having their blood sugar checked once daily, as opposed to twice a day. Individual #1 has a blood sugar protocol in place in which if Individual #1's blood sugar goes above 180; the wellness coordinator is to be contacted. Individual #1's blood sugar was 185 on 6/6/20, 208 on 7/30/20, and 188 on 3/11/21. No documentation was provided verifying that Individual #1's wellness coordinator was contacted. | 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.
| ¿ What we did to correct?
o LSS Wellness Coordinator made a dermatology referral for the individual as prescribed for 4/23/21.
o Wellness Coordinator received an order from the individuals physician on BS to be taken 2xs per day.
o Wellness Coordinators educated house staff to contact Wellness Coordinator when BS goes above 180.
¿ How to prevent?
o Wellness Coordinator & LSS Compliance Coordinator will review all individuals appointment summaries upon submission from the group home ensuring recommendations are follow-up with as prescribed following regulation 6400.144.
o LSS management personnel will be trained on LSSs Central Region Corrective action plan.
¿ Implementation date of correction?
o June 4th, 2021.
¿ Who is responsible for each step?
o LSS Wellness Coordinators.
o LSS Compliance Coordinator.
o LSS Corporate Compliance Coordinator & Executive Program Director for training on CAP. |
06/04/2021
| Implemented |
| 6400.145(1) | The Emergency Medical Plan for Individual #1 does not list Individual #1's hospital of choice. The Emergency Medical Plan lists the following three hospitals: Conemaugh Memorial Medical Center, Miner's Medical Center, and UPMC. The plan states that the hospital is pending consumer's choice. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | ¿ What we did to correct?
o LSS Wellness Coordinator (WC) will consult with consumers and/or legal guardians asking their hospital preference followed by revising medical plan accordingly.
¿ How to prevent?
o The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency.
o LSS management personnel will be trained on LSSs Central Region Corrective action plan.
¿ Implementation date of correction?
o June 4th, 2021.
¿ Who is responsible for each step?
o LSS Wellness Coordinators
o LSS Corporate Compliance Coordinator & Executive Program Director for training on CAP. |
06/04/2021
| Implemented |
| 6400.216(a) | During the virtual inspection conducted at the home on 4/20/21, Individual #1's medical book was in an unlocked cabinet in the kitchen. | An individual's records shall be kept locked when unattended.
| ¿ What we did to correct?
o LSS locked the individuals medical record in med closet located at 112 Aspen Lane, Patton PA 16668.
¿ How to prevent?
o LSS will post a reminder in the group homes indicating individual records shall be kept locked when unattended.
o LSS management personnel will be trained on LSSs Central Region Corrective action plan.
¿ Implementation date of correction?
o June 30th, 2021.
¿ Who is responsible for each step?
o LSS group home Staff.
o LSS Field Specialist
o LSS Corporate Compliance Coordinator & Executive Program Director for training on CAP. |
06/30/2021
| Implemented |
| 6400.18(c) | Individual #1 was prescribed Carnation Instant Breakfast on 1/22/21. Individual #1 is to drink one drink two times a day. Individual #1 was only administered the Carnation Instant Breakfast in the afternoon of 1/28/21, the afternoon of 1/29/21, and the morning of 1/30/21. The Carnation Instant Breakfast was not discontinued until 2/2/21. Individual #1's family was only notified that Individual missed the dose of this medication on 2/1/21. However, there were multiple doses of this medication that were not administered from 1/22/21 to 2/2/21. | The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual. | ¿ What we did to correct?
o LSS WC will contacted the consumers legal guardian on 5/11/21 making them aware of med error on 1/22/21 ¿ 2/2/21.
o LSS Wellness Coordinator entered the Error in HCSIS on 4/21/21.
¿ How to prevent?
o WC will ensure consumers family and/or legal guardian is contacted either via phone or email within 24hrs. of incident discovery relating to medical.
o WC will document & file family or guardian contact in the consumer¿s medical chart.
o LSS management personnel will be trained on LSS¿s Central Region Corrective action plan.
¿ Implementation date of correction?
o June 4th, 2021
¿ Who is responsible for each step?
o LSS Wellness Coordinators
o LSS Corporate Compliance Coordinator & Executive Program Director for training on CAP. |
06/04/2021
| Implemented |
| 6400.18(b)(2) | (Repeat from Unnannounced monitoring from 6/15/20 to 10/26/20) Individual #1 was prescribed Carnation Instant Breakfast on 1/22/21. Individual #1 is to drink one drink two times a day. Individual #1 was only administered the Carnation Instant Breakfast in the afternoon of 1/28/21, the afternoon of 1/29/21, and the morning of 1/30/21. The Carnation Instant Breakfast was not discontinued until 2/2/21. There was a medication error reported to EIM on 2/23/21. However, it only addressed the missed dose of medication on one date: 2/1/21. Individual #1 had missed doses of this medication from 1/22/21 to 2/2/21 when the medication wasn't discontinued that were not reported to EIM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | ¿ What we did to correct?
o LSS Incident Manager will re-educate LSS Wellness Coordinators on reporting the following incidents, alleged incidents & suspected incidents through the ODP information management system or on a form specified by the department within 72 hours of discovery.
o Wellness Coordinators (WC) will re-educate the group homes on the reporting guidelines pertaining to regulation 6400.18b(2).
¿ How to prevent?
o LSS shall report the following incidents, alleged incidents & suspected incidents through the ODP information management system or on a form specified by the department within 72 hours of discovery by a staff person.
o WC will ensure all medications errors are entered into HCSIS within 72 hrs. of discovery.
o When medications are unavailable from pharmacy due to insurance issues, LSS will make purchase until issue is resolved.
o LSS management personnel will be trained on LSS¿s Central Region Corrective action plan.
¿ Implementation date of correction?
o June 30th, 2021
¿ Who is responsible for each step?
o LSS Wellness Coordinators
o LSS Incident Manager
o LSS Corporate Compliance Coordinator & Executive Program Director for training on CAP. |
06/30/2021
| Implemented |
| 6400.166(a)(9) | Individual #1 was prescribed Prevident toothpaste on 10/21/20. The prescription did not include the frequency of administration. Individual #1 has sporadically been utilizing the toothpaste since that date. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | ¿ What we did to correct?
o Wellness Coordinator received a specific order on how many days the prevident is to be used dated on 4/23/21.
¿ How to prevent?
o A prescription medication shall be administered as prescribed.
o Wellness Coordinator will review all dentist orders to ensure frequency of administration is identified in the order.
o LSS management personnel will be trained on LSSs Central Region Corrective action plan.
¿ Implementation date of correction?
o June 4th, 2021
¿ Who is responsible for each step?
o LSS Wellness Coordinator.
o LSS Corporate Compliance Coordinator & Executive Program Director for training on CAP. |
06/04/2021
| Implemented |
| 6400.167(a)(1) | Individual #1 is to have petroleum jelly applied topically to genitals daily. Individual did not receive application of petroleum jelly from 11/3/20 to 11/20/20. Individual #1 was prescribed Carnation Instant Breakfast on 1/22/21. Individual #1 is to drink one drink two times a day. Individual #1 was only administered the Carnation Instant Breakfast in the afternoon of 1/28/21, the afternoon of 1/29/21, and the morning of 1/30/21. The Carnation Instant Breakfast was not discontinued until 2/2/21. | Medication errors include the following: Failure to administer a medication. | ¿ What we did to correct?
o LSS Wellness Coordinator d/c the ordered on 2/2/21.
o LSS Wellness Coordinator provided the consumer petroleum jelly.
¿ How to prevent?
o A prescription medication shall be administered as prescribed.
o LSS will purchase any item that can be purchased over the counter if there is an order that the consumers insurance will not cover the cost.
o LSS management personnel will be trained on LSS¿s Central Region Corrective action plan.
¿ Implementation date of correction?
o June 4th, 2021
¿ Who is responsible for each step?
o LSS Wellness Coordinator.
o LSS Corporate Compliance Coordinator & Executive Program Director for training on CAP. |
06/04/2021
| Implemented |