Pennsylvania Department of Health
LEBANON VALLEY HOME, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LEBANON VALLEY HOME, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey completed on September 21, 2023, at The Lebanon Valley Home, it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care; however, the facility was not in compliance with the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:
Based on a review of nursing time schedules it was determined that the facility failed to meet the minimum nursing staff to resident ratios for 11 of 14 days reviewed.

Findings include:

Review of nursing schedules for 14 days from July 30 to August 5, 2023, and September 14 to September 20, 2023, revealed the following:

The facility failed to meet the minimum Licensed Practical Nurse (LPN) to resident ratio of one LPN for 40 residents on night (11:00 p.m. to 7:00 a.m.) shift on 11 days (July 30 and 31, 2023, August 1, 2, 3, 4, and 5, 2023, and September 15, 16, 19, and 20, 2023).

Plan of Correction - To be completed: 11/30/2023

Staffing Schedules have been reviewed to determine where additional staffing is required.

The Director of Nursing or Designee will monitor the staff hiring process to continue to on board Nursing Staff for the night shift to ensure proper staffing ratios are met.

The emergency staffing plan will be utilized if the staffing ratio is not able to be met to include resident census management.

The Director of Nursing /Designee will audit the Nursing Schedules and Timecards weekly to ensure the proper nursing ratios are met.

Results of the Audits will be addressed at the Quarterly Quality Assurance Performance Improvement meetings.

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