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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.32(f) | Individual #1 is completely reliant on agency staff to transport them to their home, day program, in and around the community, and any areas where service provisions are provided by the agency. On 3/3/23, Staff #3 took Individual #1 from the Recreational Center to another residential location. Staff #3 reported to agency management that Individual #1 "argued with staff the entire way from the recreational center to the other residential location stating they were told they didn't have to go; it was their right; staff is lying to them." Individual #1 portrayed to staff they understood they had a right to refuse to participate in activities and services. There are no records that the individual's concerns about their rights being violated were follow up on by the agency. | An individual has the right to refuse to participate in activities and services. | o Individual #1 does not reside at Lifestyle Support Service anymore (licensing inspection was on 5.17.2023). The team has corrected this by re-educating Field Specialists that individuals have the right to refuse any activity or event, but per our policy a manager should be called to process the mitigation. |
12/06/2023
| Implemented |
| 6400.34(a) | Individual #1 has two legal guardians. The home did not inform and explain all of Individual #1's rights defined in 55 Pa. Code § 6400.31-33 to the individual and their legal guardians annually. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | o Individual #1 does not reside at Lifestyle Support Service anymore (licensing inspection was on 5.17.2023). The team has corrected this by adding in the missing items on the Individual Rights signed form that is reviewed yearly. |
12/13/2023
| Implemented |
| 6400.51(b)(5) | Individual #1 was transported to other agency homes 23 times from December 2022 and March 4, 2023, to receive service provisions for most of the day or evening. When the individual was transported to the other agency homes, they remained at the homes anywhere from 4-12 hours each time. Staff #1 worked with Individual #1 during the service provisions between December 2022 and March 2023. The home was unable to produce records that they received in-person orientation in Individual #1's individual-specific plans, assessments, restrictive procedures, behaviors, and health and services needs prior to working with the individual.
The home failed to produce records of in-person orientation being provided to Staff #1 on Individual #1's individual specific plans, protocols, behavior support plans, restrictive behavior support plans, and other health and safety related needs. The following training sign in sheets were produced, each indicating that the staff signing the form completed an independent read of the individual's plans. | The orientation must encompass the following areas: Job-related knowledge and skills. | o Individual #1 does not reside at Lifestyle Support Service anymore (licensing inspection was on 5.17.2023). The team has corrected this by reviewing the files of individuals with a support plan and anyone working in other homes to have them sign off on a review of individual record sheet (verbal training completed). |
12/29/2023
| Implemented |
| 6400.186 | Individual #1's individual support plan (ISP) from December 2022 to September 2022 states "there is a mechanism in place so that the individual can use, without fear of intimidation, when they are not satisfied with services. {The individual} often repeats themselves when speaking to staff and claims they do not listen to them. When {the individual} does not get their way, they may say that they feel threatened or say that they will get staff fired. {The individual} is encouraged to write down any problems or concerns they may have."
On 10/16/23, Staff #4 and #10 reported to the Department that Individual #1 doesn't have a mechanism in place to use and neither staff were aware this statement was in Individual #1's ISP for staff to implement.
There are no records of the agency's or staff's attempt to have Individual #1 write down their concerns to report or attempts to use any mechanism the individual could use, without fear or intimidation, when they are not satisfied with their services. There are no records that the individual's concerns about their rights being violated were followed up on by the agency.
Individual #1 has a restrictive behavior support plan that was updated on 2/15/23. The following was in their plan:
Predictors of situations in which behaviors are likely to occur: no schedule, not a morning person, and transitions.
Changes needed to be made by staff to remove likelihood of target behavior occurring: allow the individual to assist in development of the schedule to allow them control of daily choices and use positive encouragement to wake them for the day. The schedule for the next day should be reviewed the evening prior and all expectations in the home should be posted for them to visually see and ensure everyone understands what is expected. Staff must prepare the individual for transitions as they demonstrate difficulty moving from one activity to another. It is encouraged to use the communication logbook in the home setting. The communication logbook is to be used as a reference for the individual to review what they were previously instructed. Staff are to always allow the individual to make choices within aspects of their daily routine and allow the individual time to consider their options. Ff the individual struggles with arguing with others, staff are to prompt them to calm down. They are not to get into an argument or debating with them.
· Signals the individual is becoming agitated: intrude personal space, verbal aggressing (yelling, screaming, arguing), make threat of harming other or running away, threats of physical violence, will punch, and hit objects around them.
· The plan includes many techniques to utilize for redirection if staff become aware the individual is becoming agitated.
The agency is aware the individual struggles with transitions and transitions are the cause of behaviors. However, from December 4, 2022, to March 4, 2023, Lifestyle Support Services Inc., transferred Individual #1 from their home to stay at other residential home locations 23 times, for lengths of time varying from 12-hour overnight stays from 8pm-8am, and 12-hour daytime stays from 8am-8pm, and lesser hours in between. Documentation of any techniques staff used with Individual #1, the night before or the morning of the transitions, was never produced during the inspection.
On 3/13/23 Staff #12 provided a witness statement to the agency, stating the morning of 3/4/23, Individual #1 was dropped off at a different residential location for the day. The agency did not produce records that any transitional encouragement or discussions occurred with the individual on 3/3/23 the night before, or the morning on 3/4/23.
As stated above, Staff #3 reported they argued with Individual #1 most of the day on 3/3/23. The individual's plan does not state that arguing with the individual is an approved de-escalation technique to use when the individual is becoming, or is agitated, but rather a technique that staff should avoid. Staff #3 did not document any de-escalation techniques used on 3/3/23.
continued on next 186 violation description. | The home shall implement the individual plan, including revisions. | o Individual #1 does not reside at Lifestyle Support Service anymore (licensing inspection was on 5.17.2023). The individuals Behavior Support Plan and ISP are no longer something that can be changed. |
12/29/2023
| Implemented |
| 6400.186 | continued from first 186 violation description.
Individual #1's restrictive behavior support plan states, interventions should be used in all environments (home and community). Behaviors could present themselves at any point during community outings or in the home setting. During a virtual discussion with agency management on 10/16/23, Staff #4 confirmed that all techniques to use and have available for staff to use with Individual #1 to de-escalate or prevent target behaviors, are not available to Individual #1 when they transitioned to other residential home settings and received service provisions between December 2022 and March 2023. Individual #1's visual expectations chart, their list of expectations the family has established, and the communication logbook that are techniques outlined in the individual's restrictive behavior support plan to use for de-escalation, were never taken to other residential home settings for staff to use. It's unclear if Individual #1 had any items of pleasure with them during any of these transitions to other homes, to ensure they had access to items they enjoyed that could assist with de-escalating behaviors.
During the 10/16/23 meeting, it was reported to the Department that the agency did not review or document what items the individual had with them when transitioned to other residential locations. Staff #4 reported to the Department that Individual #1 was a guest in the home. However, the locations of the homes the individual was transferred to 23 times, are licensed residential settings chosen by the agency as the individual's home location for the day to receive residential service provisions, not guest accommodations.
Per Individual #1's restrictive behavior support plan provided during the inspection, specific data collection during behavior intervention plan implementation is used to measure intervention effectiveness. Staff are to document and record daily, or when behaviors occur, the targeted behaviors and interventions used. The only behavior data provided during the inspection were weekly, individual functional assessment reports from 1/2/23-1/8/23, 1/30/23-3/12/23, and a total tally of behaviors for December 2022. The weekly functional assessment reports state "yes" the individual had multiple behaviors weekly. But the reports do not document anything specific to the behaviors or list the prevention and intervention strategies used.
Agency staff have documented they have been engaging in argumentative behavior with the individual on multiple occasions, which is not conducive to assist the individual with behavioral support, and arguing is a technique identified in the individual's behavior plan to avoid. | The home shall implement the individual plan, including revisions. | o Individual #1 does not reside at Lifestyle Support Service anymore (licensing inspection was on 5.17.2023). The individuals Behavior Support Plan and ISP are no longer something that can be changed. |
12/29/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | During the virtual inspection held on 4/20/21, the doorway leading outside from the basement was not equipped with lighting. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| ¿ What we did to correct?
o LSS will installed an exterior light outside of the basement exit
¿ How to prevent?
o LSS Field Specialist will visually check all exterior exits in group homes ensuring lights exist to ensure safety and to avoid accidents utilizing the self-assessments.
o LSS management personnel will be trained on LSSs Central Region Corrective action plan.
¿ Implementation date of correction?
¿ Who is responsible for each step?
o LSS maintenance department to install light
o Field Specialist.
o LSS Corporate Compliance Coordinator & Executive Program Director for training on CAP. |
06/01/2021
| Implemented |
| 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 LSSs Central Region Corrective action plan.
¿ Implementation date of correction?
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 |
| 6400.145(1) | The Emergency Medical Plans for Individual #1 and Individual #2 do not list their 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. | 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?
¿ 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 |
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