Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00186509 Renewal 04/19/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The 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
6400.145(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. 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
SIN-00076374 Renewal 04/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(b)Individual #1's psychiatric review's did not include medication and dosages for the 2/6/15 and 12/15/14 appointments. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the ISP to address the social, emotional and environmental needs of the individual related to the symptoms of the diagnosed psychiatric illness. 1. LSS Medical Coordinator is responsible to educate, oversee & ensure the individual¿s psychiatric reviews include medication and dosages for all psychiatric sessions/appointments. 1a. LSS Residential Service Worker (RSW¿s) are responsible to attached current physician order sheets for the physician to review and sign off on. If the physician choses to keep a copy of current orders, a second copy must be made and attached to the summary. 2. LSS Medical Coordinator is responsible to review all summaries as they are turned in to assure the physician¿s orders are attached. If an appointment summary is submitted to the medical department without the physician orders attached, the staff (RSW) will be contacted by the Medical Coordinator to provide the physician orders immediately to be filed. 3. LSS Medical Coordinator is responsible to educate and train the house staff (RSW¿s & House Supervisors) in regards to the process in having current physician orders attached to the appointment summaries for the physician to review and sign off on via email and Care tracker (see attached documentation). 05/07/2015 Implemented
6400.181(e)(7)Individual #1's assessment did not include knowledge of the danger of heat sources and the ability to sense and move away quickly. The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. 1. LSS Case Coordinators is responsible to ensure the assessments include the individual¿s knowledge of the danger of heat sources and the ability to sense and move away quickly. LSS Case Coordinators will indicate and/or be more specific when reporting progress and/or non-progress from year to year. LSS Case Coordinators will also specify reasons for progress and/or non-progress areas as well as what we will be done differently regarding interventions to help promote progress if applicable. 2. LSS Case Coordinators corrected Individula¿s#1 assessment summary specifying the individual¿s knowledge of the danger of heat sources and the ability to sense and move away quickly. (See attached assessment). 05/07/2015 Implemented
6400.181(e)(12)Individual #1's assessment did not include recommendations for specfic area's of training, programming, and services. The assessment must include the following information: Recommendations for specific areas of training, programming and services. 1. LSS Case Coordinators is responsible to ensure the assessments include recommendations for specific areas of training, programming, and services. 2. LSS Case Coordinators corrected Individula¿s#1 assessment summary specifying the individual¿s recommendations for specific areas of training, programming, and services (See attached assessment). 05/07/2015 Implemented
6400.181(e)(13)(ii)Individual #1's assessment did not show progress and growth over the last 365 calendar days and current level in motor and communication skills. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. 1. LSS Case Coordinators is responsible to ensure the assessments include the individual¿s progress over 365 days and current level in motor and communication skills. LSS Case Coordinators will indicate and/or be more specific when reporting progress and/or non-progress from year to year. LSS Case Coordinators will also specify reasons for progress and/or non-progress areas as well as what we will be done differently regarding interventions to help promote progress. 2. LSS Case Coordinators corrected Individula¿s#1 assessment summary which included more detailed progress and growth over the 365 days in regards to motor and communication skills (see attached assessment). 05/07/2015 Implemented
6400.181(e)(13)(iv)Individual #1's assessment did not show progress and growth over the last 365 calendar days and current level in personal adjustment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. 1. LSS Case Coordinators is responsible to ensure the assessments include the individual¿s progress over 365 days and current level in personal adjustment. LSS Case Coordinators will indicate and/or be more specific when reporting progress and/or non-progress from year to year. LSS Case Coordinators will also specify reasons for progress and/or non-progress areas as well as what we will be done differently regarding interventions to help promote progress. 2. LSS Case Coordinators corrected Individula¿s#1 assessment summary which included more detailed progress and growth over the 365 days in regards to personal adjustment (see attached assessment). 05/07/2015 Implemented
6400.183(6)(ii)Individual #1's ISP did not contain a protocol to eliminate the use of restrivtive procedures and a protocol for addressing the underlying causes or antecedents of the behavior. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: A protocol for addressing the underlying causes or antecedents of the behavior. 1. LSS Behavioral Specialist is responsible to ensure the individual¿s ISP contains the protocol to eliminate the use of restrictive procedures and a protocol for addressing the underlying causes or antecedents of the behavior via email notifications to the individual¿s SC¿s. LSS¿s Behavioral Specialist will file all email correspondence in the individual¿s BSP binder. 2. LSS¿s Behavioral Specialist sent an email on 4/28/15 at approximately 8:50am to Individual #1¿s Support Coordinator (Trudy M.) identifying the revisions that needed to be made to the ISP (see attached email). 2a. LSS¿s Case Coordinator is responsible to follow-up with the Individual #1¿s SC ensuring the corrections were made via email. 3. LSS¿s Behavioral Specialist is responsible during annual ISP meetings to read the ISP behavior support section to ensure that the information pertaining to use of restrictive procedures and a protocol for addressing the underlying causes or antecedents of the behavior is included and/or correct. 4. LSS Behavioral Specialist will request via email that the individual¿s SC write in the Individual¿s ISP see attached BSP. LSS Behavioral Specialist will then submit the entire plan to be attached to the consumers ISP to ensure all BSP information is included in the Individual¿s ISP. All correspondences will be filed in consumers BSP binder. 05/11/2015 Implemented
6400.183(6)(iii)Individual #1's ISP did not include a protocol to eliminate the use of restrictive procedures including the method and timeline for eliminating the use of restricitive procedures. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: The method and timeline for eliminating the use of restrictive procedures. 1. LSS Behavioral Specialist is responsible to ensure the individual¿s ISP contains the protocol to eliminate the use of restrictive procedures including the method and timeline for eliminating the use of restrictive procedures via email notifications to the individual¿s SC¿s. LSS¿s Behavioral Specialist will file all email correspondence in the individual¿s BSP binder. 2. LSS¿s Behavioral Specialist sent an email on 4/28/15 at approximately 8:50am to Individual #1¿s Support Coordinator (Trudy M.) with the BSP attached specifically identifying what needed corrected in the ISP (see attached email). 2a. LSS¿s Case Coordinator is responsible to follow-up with the Individual #1¿s SC ensuring the corrections were made via email. 3. LSS¿s Behavioral Specialist is responsible during annual ISP meetings to read the ISP behavior support section to ensure that the information pertaining to the method & timeline for eliminating the use of restrictive procedures is included and/or correct. 4. LSS Behavioral Specialist will request via email that the individual¿s SC write in the Individual¿s ISP see attached BSP. LSS Behavioral Specialist will then submit the entire plan to be attached to the consumers ISP to ensure all BSP information is included in the Individual¿s ISP. All correspondences will be filed in consumers BSP binder. 05/11/2015 Implemented
6400.183(6)(iv)Individual #1's ISP did not include a protocol to eliminate the use of restricitive procedures including a protocol for intervention or redirection without utilizing restricitive procedures. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following A protocol for intervention or redirection without utilizing restrictive procedures. 1. LSS Behavioral Specialist is responsible to ensure the individual¿s ISP contains the protocol to eliminate the use of restrictive procedures including a protocol for intervention or redirection without utilizing restrictive procedures via email notifications to the individual¿s SC¿s. LSS¿s Behavioral Specialist will file all email correspondence in the individual¿s BSP binder. 2. LSS¿s Behavioral Specialist sent an email on 4/28/15 at approximately 8:50am to Individual #1¿s Support Coordinator (Trudy M.) with the BSP attached specifically identifying what needed corrected in the ISP (see attached email). 2a. LSS¿s Case Coordinator is responsible to follow-up with the Individual #1¿s SC ensuring the corrections were made via email. 3. LSS¿s Behavioral Specialist is responsible during annual ISP meetings to read the ISP behavior support section to ensure that the information pertaining to the method & timeline for eliminating the use of restrictive procedures is included and/or correct. 4. LSS Behavioral Specialist will request via email that the individual¿s SC write in the Individual¿s ISP see attached BSP. LSS Behavioral Specialist will then submit the entire plan to be attached to the consumers ISP to ensure all BSP information is included in the Individual¿s ISP. All correspondences will be filed in consumers BSP binder. 05/11/2015 Implemented
6400.183(7)(iii)Individual #1's ISP did not include the assessment of the indivduals potential to advance in vocational programming. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. 1. LSS Case Coordinator is responsible to ensure the individual¿s ISP identifies the individual¿s potential to advance in vocational programming via meetings and via email notifications to the individual SC¿s. LSS Case Coordinators will file all email correspondence in the individual¿s Program Book. LSS Case Coordinator emailed the individual¿s SC on 5/7/15 requesting the information pertaining to the individual¿s potential to advance in vocational programming in the Individual¿s ISP (see attached email correspondence). 05/11/2015 Implemented
6400.195(d)Individual #1's restricitive procedure plan shall be reviewed, approved, and signed and dated by the chairperson of the restricitive procedure review committee and the program specialist. The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months. 1. LSS Behavior Specialist is responsible to ensure the individual¿s restrict procedure plan is reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist prior to use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least 6 months. 2. The Behavior Support Plan was modified to have a signature location directly on the plan for the HR committee chair to sign the document. (See attached signature page). 3. LSS¿s Behavior Specialist will have Individual #1¿s BSP re-signed utilizing the BSP revised format (see attached signature page). 05/11/2015 Implemented
SIN-00047788 Renewal 03/18/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature in the bathroom exceeded 130 degrees Fahrenheit.(b) Hot water temperatures in bathtubs and showers may not exceed 120°F. The water tank was replaced at the Portage house (see attachment 1). Water temperature was tested five consecutive days after installation of new water tank. All tests meeting regulatory requirements (see attachment 2). LSS Licensing Compliance Department implemented a Hot Water Temperature Tracking form to ensure water temperatures meet regulatory requirements (see attachment 3). Program Field Managers are responsible in monitoring water temperatures at all group homes once a month utilizing an electronic version of the Hot Water Tracking form. Field Managers are to document date of test, temperature, who they reported to and name of the person doing the test. [Fully Implemented] 04/02/2013 Implemented
6400.181(c)The assessment for Individual #1 does not include how the assessed skills were formulated.(c) The assessment shall be based on assessment instruments, interviews, progress notes and observations. LSS assessment signature/cover page was revised to include how the assessed skills were formulated (see attachment 4). LSS Case Program Coordinators are responsible in completing the assessment signature/cover page for all annual assessments. Program Case Coordinators are responsible to identify how skills were formulated on each assessment. [Partially Implemented] 04/02/2013 Implemented
6400.181(e)(8)The assessment for Individual #1 does not indicate the individual's ability to evacuate in the event of a fire.(8) The individual's ability to evacuate in the event of a fire. LSS Assessment Summary was revised to include an "Evacuation" ssection. All current and future assessments will include the individual's ability to evacuate in the event of a fire (see attachment 5). [Partially Implemented] 04/02/2013 Implemented
6400.181(e)(13)(i)The assessment for Individual #1 does not include progress and growth in areas (i) through (ix).(13) The individual's progress over the last 365 calendar days and current level in the following areas: (i) Health. LSS revised the Assessment Summary to include check boxes identifying either progress or no progress for each specific domain (see attachment 5). LSS Program Case Coordinators are responsible to identify whether the individual has either progressed or not progressed for each specific domain when completing the individual's assessment summary. [Partially Implemented] 04/02/2013 Implemented
6400.181(e)(14)The assessment for Individual #1 does not include the ability to temper water.(13) The individual's progress over the last 365 calendar days and current level in the following areas: (14) The individual's knowledge of water safety and ability to swim. LSS revised the Assessment Summary to include check boxes identifying either progress or no progress for each specific domain (see attachment 6). LSS Program Case Coordinators are responsible to include the individual ability to temper their own water in the Assessment Summary (see attachment 6). [Partially Implemented] 04/02/2013 Implemented
6400.181(f)There is no documentation that plan team members were informed of the results of the assessment 30 calendar days prior to the ISP meeting.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). LSS developed an Assessment Summary Notification Letter for team members which indicates the date that the Assessment was sent to Plan Team Members (see attachment 7). LSS Program Case Coordinators are responsbile for sending team members the Assessment Summary Notification Letter 30 days prior to the ISP meeting. A copy of the letter will be filed in the consumer's program book (see attachment 7). 04/02/2013 Implemented
SIN-00237671 Renewal 03/19/2024 Compliant - Finalized
SIN-00123127 Renewal 01/03/2018 Compliant - Finalized