Pennsylvania Department of Health
LEHIGH VALLEY VASCULAR INSTITUTE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LEHIGH VALLEY VASCULAR INSTITUTE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of an off-site special monitoring survey conducted on June 20, 2024, following a State Licensure follow-up survey completed on April 25, 2024, at Lehigh Valley Vascular Institute. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.

Plan of Correction:

551.63 LICENSURE Submission of plan of correction:

551.63 Submission of Plan of Correction

A plan of correction shall be submitted to the Department within 30 days of receipt of written
notification by the Department. The plan shall be attested to by the signature of the chairman of the governing body or the person in charge. The plan of correction shall be submitted to the governing body as
a whole for its review at its regular meeting.

Observations:

Based on a review of Department of Health documentation, it was determined that the facility failed to submit an acceptable plan of correction within thirty (30) days of receipt of written notification by the Department of Health.
Findings include:
Review on June 20, 2024, of Department of Health documentation revealed Lehigh Valley Vascular Institute was issued a 2567 [Statement of Deficiencies] for event S3NB12 on May 20, 2024. The facility has not submitted an acceptable plan of correction as of June 20, 2024.
The facility received a deficiency related to 033(m) Governing Body Responsibilities- failure to maintain personnel policies and practices which adequately support sound patient care including written job description for each type of job in the ASF.
The facility received a deficiency related to Drugs & Biologicals- failure to ensure disposal of used medication vials, used syringes, and used needles were rendered unrecoverable.

Plan of Correction - To be completed:

An approved Plan of Correction is not on file.

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