Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00186515 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 LSSs 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 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. ¿ 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
SIN-00167952 Renewal 02/19/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66No light outside the door off the kitchen side egress.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Outside light installed above outside doorway to meet regulation 6400.66. Compliance Coordinator will ensure all homes have lights to meet regulation 6400.66 when conducting house checks. Any violations will be reported to safety committee and maintenance to have lighting installed. 02/25/2020 Implemented
6400.141(c)(3)Individual #1's physical 6/17/19 did not include the immunizations for individuals 18 years of age or older as recommended by the United States Public HealthThe physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. LSS Wellness Coordinator is responsible to attach the individual's immunization record to the physical form prior to the individual's physical. This will remain attached to the physical and be placed in the individual's record. Policy created in which Wellness Coordinator and Compliance Coordinator will review all individual's annual physical examination form upon submission from the group home ensuring the physical examination form is filled out fully and in compliance with regulation 141 (c)(3) to include immunization record. LSS Executive Program Director will conduct a final review once the Wellness Coordinator, Program Specialist and Compliance Coordinator review the physical form.Executive Program Director will initial the appointment summary/physical when regulation is met. Wellness Coordinator and Compliance Coordinator have been trained on policy by Executive Program Director. 03/02/2020 Implemented
6400.141(c)(11)Individual #1's physical 6/17/19 did not include an assessment of the individual's health maintenance needs.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Policy created in which Wellness Coordinator and Compliance Coordinator will review all individual's annual physical examination form upon submission from the group home ensuring the physical examination form is filled out fully and in compliance with regulation 141 (c)(11). Once it is verified by Wellness Coordinator and Compliance Coordinator that the regulation has been met, both will sign off on the verification form. LSS Executive Program Director will conduct a final review once the Wellness Coordinator, Program Specialist and Compliance Coordinator review the physical form. LSS Executive Program Director will initial the appointment summary/physical when regulation is met. Wellness Coordinator and Compliance Coordinator have been trained on policy by Executive Program Director. 03/02/2020 Implemented
SIN-00237677 Renewal 03/19/2024 Compliant - Finalized
SIN-00123131 Renewal 01/03/2018 Compliant - Finalized