| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Oven buildup of grease and Grime. Bathroom shower needs cleaning. | Clean and sanitary conditions shall be maintained in the home. | All bathrooms and kitchens in each of the LNL homes received a deep cleaning. To ensure compliance with 55 PA Code Chapter 6400.64(a), we will implement a rigorous cleaning protocol for the bathroom and oven, monitored through a weekly checklist as delineated in detail in the attached plan to maintain compliance. Automatic oven cleaning functions will be supplemented with hands on cleaning including the use of oven specific cleansers. Likewise, the bathroom cleaning will include bathroom specific sanitizing agents. |
06/19/2024
| Implemented |
| 6400.67(a) | The linoleum Floor has a long crack that needs to be replaced or repaired. Kitchen cabinet knob missing. | Floors, walls, ceilings and other surfaces shall be in good repair. | The cracked linoleum was removed and replaced with new flooring. The Kitchen cabinet knob also replaced. To remain in compliance with 55 PA Code Chapter 6400.67(a), we will implement a detailed plan for inspecting the floors and walls of each room to ensure they are in good repair. This plan will be executed on a monthly basis and will involve the use of a comprehensive checklist as outlined in the plan to maintain compliance below. |
06/19/2024
| Implemented |
| 6400.72(a) | Individual 2's room, the left window by driveway and right window by closet has no screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The identified missing screens have been replaced. To ensure compliance with 55 PA Code Chapter 6400.72(a), we will implement a detailed and specific plan to assure that all windows have screens in place. This plan will be executed on a monthly basis and will involve the use of a comprehensive checklist as outlined in the provider's plan to maintain compliance. |
06/19/2024
| Implemented |
| 6400.112(g) | The start time for the fire drills for a period of 7 months in 2023 was 12:00 am. | Fire drills shall be held on different days of the week and at different times of the day and night. | Beginning immediately fire drills will be initiated at varying times.
To ensure compliance with 55 PA Code Chapter 6400.112(g), we will implement a plan to ensure fire drills are conducted at different times and days:
1. Schedule Diversity: Fire drills will be scheduled at various times throughout the day and night to ensure all staff and residents are familiar with the procedure. This will include early morning, afternoon, evening, and late-night drills. The schedule will be randomized to avoid predictability.
2. Record Keeping: LNL will maintain fire drill log that records the date, time, and participants of each drill. The log will also include any issues encountered during the drill and the steps taken to address them. Monthly reviews and training are outlined in the Plan to Maintain Compliance below. |
06/19/2024
| Implemented |
| 6400.141(a) | The last annual physical exam done for individual 3 was 09/23/22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual 3 is scheduled to receive his annual physical on 07/05/24. To remain in compliance with 55PA Code Chapter 6400.141(a) To assure that all individuals have documented current physicals LNL will develop a comprehensive tracking spreadsheet that will record each individual's health care appointments. This spreadsheet will serve as a centralized system for monitoring health care schedules, ensuring that no appointment is missed or overlooked. A detailed plan to prevent recurrence is outlined in the Plan to Maintain Compliance below. |
07/05/2024
| Implemented |
| 6400.144 | 04/04/23 dental exam ordered a follow-up exam for 10/04/23 for individual 3 and the exam was not done. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| A dental exam was scheduled for individual 3 on 06/19/2024.
LNL is committed to maintaining compliance with 55 PA Code Chapter 6400.144. To achieve this, we will develop a comprehensive tracking spreadsheet that will record each individual's health care appointments. This spreadsheet will serve as a centralized system for monitoring health care schedules, ensuring that no appointment is missed or overlooked.
The Program Manager will play a crucial role in this process. On a monthly basis, they will review the health care appointment tracking spreadsheet. This review will involve a thorough check of all entries, ensuring that the information is up-to-date and accurate. Following the review, the Program Manager will transfer all upcoming appointments for the next month to the office calendar. This step ensures that all relevant parties are aware of the upcoming appointments and can prepare accordingly. Monthly reviews will be supported by quarterly meeting as outlined below in the plan to Maintain Compliance. |
06/19/2024
| Implemented |
| 6400.18(i) | Incident with discovery date of 09/14/23 involving individual 3 was not finalized within 30 days and no extension was granted. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | The identified incident concerning resident three (3) was submitted for finalization. To comply with the Office of Developmental Programs (ODP) regulation 55 PA Code Chapter 6400.18(i), our organization will implement a comprehensive plan ensuring all incidents are finalized within 30 days of discovery. Here is the detailed plan:
Incident Finalization Protocol: Upon the discovery of an incident, the staff will immediately report it through the Department¿s information management system or on a form specified by the Department. An investigation will be initiated within 24 hours, and the home will take immediate action to protect the health, safety, and well-being of the individual involved. The incident report will be finalized through the Department¿s information management system within 30 days of the incidents discovery. If an incident cannot be finalized within this timeframe, the home will notify the ODP in writing, detailing the necessity for an extension and providing a clear explanation for the delay. To ensure the continued compliance with this protocol the ongoing compliance plan is detailed in the Providers plan to maintain compliance below. |
06/12/2024
| Implemented |
| 6400.165(g) | Individual 3 takes medication for bipolar disorder and there was no evidence of a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, and the need to continue the medication. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual 3 was scheduled for a medication review with his prescriber on 06/19/2024
LNL is committed to maintaining compliance with 55 PA Code Chapter 6400.141(a). To achieve this, we will develop a comprehensive tracking spreadsheet that will record each individual¿s health care appointments. This spreadsheet will serve as a centralized system for monitoring health care schedules, ensuring that no appointment is missed or overlooked.
The Program Manager will play a crucial role in this process. On a monthly basis, they will review the health care appointment tracking spreadsheet. This review will involve a thorough check of all entries, ensuring that the information is up-to-date and accurate. Following the review, the Program Manager will transfer all upcoming appointments for the next month to the office calendar. This step ensures that all relevant parties are aware of the upcoming appointments and can prepare accordingly. |
06/19/2024
| Implemented |
| 6400.185(4) | Services to assist individual 3 to achieve desired outcomes was not addressed in the ISP. | The individual plan, including revisions, must include the following: Services to assist the individual to achieve desired outcomes. | In order that LNL may continue to remain in compliance with 55 PA Code Chapter 6400.185(4) Services to assist individual 3 will continue to be recorded in the individual's daily progress notes and summarized in his quarterly assessment. The protocol to ensure that the individuals goals are met will serve as a means to ensure that documentation is consistent across all three modalities, progress notes, quarterly/annual assessments and ISP.LNL Home Services (LNL) will implement a comprehensive compliance plan to adhere to the standards set forth in 55 PA Code Chapter 6400.185(4) as well as 55 PA Code Chapter 6400.185(3), ensuring that each individual's desired outcomes are thoroughly incorporated into their Individual Service Plan (ISP). This plan will include the establishment of monthly meetings that bring together the individual's Supports Coordinator and LNL¿s treatment team, which comprises the Program Specialist, Program Director, and the individual themselves. These meetings will be grounded in a Person-Centered approach, focusing on the individual¿s growth and the maintenance of previously established goals.
To facilitate these meetings, LNL will create an environment that encourages open communication and collaboration, allowing for the individual¿s preferences and strengths to be at the forefront of the discussion. The treatment team will review the individual¿s functional abilities, service needs, and desired outcomes, as outlined in the ISP, and make adjustments as necessary to reflect the individual¿s evolving aspirations and achievements. |
07/10/2024
| Implemented |