| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The oven and the wall over the stove are covered with grease and grime. | Clean and sanitary conditions shall be maintained in the home. | All bathrooms and kitchens have been deep cleaned. To ensure compliance with 55 PA Code Chapter 6400.64(a), LNL will implement a rigorous cleaning protocol for the bathroom and oven, monitored through a weekly checklist as delineated in detail in the plan below 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. |
06/12/2024
| Implemented |
| 6400.101 | Basement door has a latch that is inaccessible from the inside, locks from the outside. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| In order to be in compliance with 55 PA Code Chapter 6400.101 the lock that was inaccessible from the inside of the basement door was removed and lock that was accessible from both sides of the door was installed. In order to ensure that similar issues do not occur moving forward a maintenance checklist and monthly review process was established. The plan is outlined in detail below in the Provider's Plan to Maintain Compliance. |
07/01/2024
| Implemented |
| 6400.112(c) | For the period from May 2023 through December 2023 there was not time of drill or duration of the drills listed on the fire drill record. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | In order to ensure compliance with 55 PA Code Chapter 6400.112(c) the time of the drill and the duration of the drill was clearly labeled on the fire drill log. LNL will implement a plan to ensure fire drills are conducted at different times and days and that record keeping reflect all the required information:
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 a 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 detail in the Plan to Maintain Compliance outlined below. |
07/10/2024
| Implemented |
| 6400.151(a) | No physical examination was done for staff member 3. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Any staff without documentation of an up-to-date physical was required to obtain one prior to returning to work. To ensure compliance with 55 PA Code Chapter 6400.151(a), LNL Home Services (LNL) will implement the following plan:
1. Pre-Employment Physical Examination:
a. Review pre-employment documentation of all new staff, including temporary, substitute, and volunteer staff, to confirm a documented physical examination within 12 months prior to their start date.
b. Verify that the physical examination includes all necessary components as outlined in the regulation.
2. Biennial Physical Examination:
a. Schedule and track regular physical examinations for staff every two years to maintain ongoing compliance
A detailed plan to Maintain Compliance is outlined below |
07/10/2024
| Implemented |
| 6400.151(c)(3) | There is no statement in 05/20/24 physical exam that staff member 4 is free of communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Any staff without documentation of an up-to-date physical, including a statement the staff person was free of communicable diseases, was required to obtain one prior to returning to work. To ensure compliance with 55 PA Code Chapter 6400.151(c)(3), LNL Home Services (LNL) will implement the following plan:
1. Pre-Employment Physical Examination:
a. Review pre-employment documentation of all new staff, including temporary, substitute, and volunteer staff, to confirm a documented physical examination within 12 months prior to their start date.
b. Verify that the physical examination includes all necessary components as outlined in the regulation.
2. Biennial Physical Examination:
a. Schedule and track regular physical examinations for staff every two years to maintain ongoing compliance as detailed in the plan below. |
07/10/2024
| Implemented |
| 6400.151(c)(4) | Information of medical problems which might interfere with the health of staff member 4 was not adressed in the physical exam of 05/20/24. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | Any staff without documentation of an up-to-date physical was required to obtain one prior to returning to work. To ensure compliance with 55 PA Code Chapter 6400.151(c)(4), LNL Home Services (LNL) will implement the following plan:
1. Pre-Employment Physical Examination:
a. Review pre-employment documentation of all new staff, including temporary, substitute, and volunteer staff, to confirm a documented physical examination within 12 months prior to their start date.
b. Verify that the physical examination includes all necessary components as outlined in the regulation.
2. Biennial Physical Examination:
a. Schedule and track regular physical examinations for staff every two years to maintain ongoing compliance |
07/10/2024
| Implemented |
| 6400.46(b) | Documentation that fire safety training was done by a fire safety expert for staff members 2, 3, and 4 was not provided. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | To ensure LNL Home Services (LNL) remains compliant with 55 PA Code Chapter 6400.46(b) regarding fire safety a Certified Fire Safety Expert train staff member 1 in the specified areas of fire safety, evacuation procedures, fire drill responsibilities, meeting place protocols, smoking safety procedures, proper use of fire extinguishers, smoke detectors, and fire alarms, as well as the importance of notifying the local fire department promptly after a fire is discovered. A detailed plan to maintain compliance is outlined below. |
08/01/2024
| Implemented |