| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | The following staff members criminal background checks were completed more than 5 days after date of hire.
Staff #9 -d.o.h.10/05/2021-crim check 6/27/22
Staff #10 -d.o.h.3/19/2022-crim check 4/8/22
Staff #11 -d.o.h.-4/18/2022-crim check 6/2/22
Staff #12 -d.o.h.-3/26/2022-crim check 4/8/22 | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Moving forward LSHS will do criminal background checks for staff persons, who will have direct contact with individuals within 5 working days after the date of hire in compliance with 55 PA Code Chapter 6400 21(a) regulation. |
10/26/2022
| Implemented |
| 6400.71 | Emergency numbers are not listed on or near the phone. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| LSHS have listed Emergency numbers on or near the phone in case there is an Emergency. Staff persons and individuals have also been informed and made aware of these numbers. |
10/26/2022
| Implemented |
| 6400.77(b) | The first aid kit did not contain a thermometer or scissors. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | LSHS has included thermometer and scissors in all first aid kits in each home occupied by individuals. Thermometers and scissors are a very important part of the first aid kit which contains antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of ipecac, if individuals 4 years of age or younger or an individual likely to ingest poisons, is served. In our case, we are serving individuals. |
10/26/2022
| Implemented |
| 6400.24 | Lifetime Skills 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). Staff #4 Hire date of 03/04/2022 did not include attestation of living in the state of Pennsylvania for the past 2 consecutive years. Staff #5 Hire date of 05/16/2022 did not include attestation of living in the state of Pennsylvania for the past 2 consecutive years. Staff #6 Hire date of 03/15/2021 did not include attestation of living in the state of Pennsylvania for the past 2 consecutive years. Staff #7 Hire date of 03/19/2021 did not include attestation of living in the state of Pennsylvania for the past 2 consecutive years. Staff #8 Hire date of 04/09/2021 did not include attestation of living in the state of Pennsylvania for the past 2 consecutive years. Staff #13 Hire date of 05/24/2022 did not include attestation of living in the state of Pennsylvania for the past 2 consecutive years. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | LSHS complies with applicable Federal and State statutes and regulations and local ordinances and regulations such as 62 P.S 1007. of the Public Welfare Code including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with Older Adult Protective services Act. We have continued to do criminal checks for staff persons hired and will continue to do so. Any prospective staff persons must have criminal history checks done 5 working days prior to starting to work with an individual. |
10/26/2022
| Implemented |
| 6400.163(d) | The medication for Individual #5 is not being keep in an area or container that is locked. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Prescriptions for this individual are kept in an area or container that is locked without access to the individual. The staff person with medication training assigned to the individual is the person responsible to give the individual medication only. The individual does not have access to the medication area or container that is locked. |
10/26/2022
| Implemented |
| 6400.166(a)(1) | A medication record is not being kept indicating the time, date and name and initials of the person(s) administering the Meds | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. | LSHS have medication records being kept indicting the time, date and name and initials of persons administering the Meds for this individual. Staff personnel found not indicating the time, date and name and initials of persons administering the medications shall be reprimanded and must redo Medication training so that such errors are never repeated. |
10/26/2022
| Implemented |