Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00254816 Renewal 11/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The rear patio door (left side) did not open without use of force. It did not slide easily.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. On 11/18/24, provider's maintenance personnel repaired the rear patio door so that left side slides easily when opening and closing. 12/05/2024 Implemented
6400.104The individual living in this home temporarily evacuated the home on 10/19/23 and the home has been empty since that time. Regulation 6400.104 requires that the notification letter to the fire department be kept current. There was no documentation showing that the fire department was updated on this change.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Provider sent a letter to the local fire department on 11/18/24 containing the current status of the location. The letter also states the letter will be updated should changes occur in the future. 11/18/2024 Implemented
SIN-00239624 Unannounced Monitoring 11/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Staff #1, #3, and #4 were videotaped removing food from dumpsters on 7/3/23. (Videos provided by staff #1). Individual #2 was seen to be present in the agency vehicle at the time of the dumpster diving activity. Food items that were removed from the dumpster were then shown (in the video) to be laid out on Individual #2's kitchen counter. Staff #1 stated that the food items were then served to Individual #2 and guests at a picnic celebrating the 4th of July. Individual #3 states the food was taken home by an employee, but she did not provide the name of that employee. Staff #1 stated she felt uncomfortable with the activity but went along due to peer pressure. Staff #2 who is in management, stated she was unaware of the dumpster diving activity involving individuals. She had heard staff talking about dumpster diving in the office but thought they were discussing their personal lives not anything work related. Staff #5 who is also in management, stated that she participated in this activity on her personal time with staff #3 on more than 1 occasion but stated that individuals were never involved, nor did she know it was occurring on company time. Staff #4 participated in dumpster diving with Staff #5 one time which was not on company time. Staff #3 was also observed smoking in front of individual #2 during this activity. Allowing an individual #2 to witness dumpster diving for food items that were then taken to individuals home is humiliating to the individual. This act deprives individual #1 of human dignity.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Staff #3 and #4 have been issued disciplinary action for this incident. Disciplinary action was not issued to Staff #1 as they are no longer employed with the agency. On 2/28/24, during the weekly management meeting, CEO reviewed concerns related to outcome of certified investigation (Attachment #1) with management personnel. CEO discussed expectations of management personnel moving forward. 03/11/2024 Implemented
6400.43(b)(1)LNB Smoking policy states "Employees will refrain from smoking in front of/around individuals. This includes in the home or in the community. Employees are prohibited from smoking in the agency vehicle. If employees are utilizing their personal vehicle to transport individuals, smoking will be restricted while the individual is present in the vehicle." In the video provided from 7/3/23, staff can be seen smoking while looking into dumpsters. Individual #2 was in the vehicle (which can be seen in the video) at the time and able to view the staff smoking.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. Staff #3 has been issued disciplinary action for violating the smoking policy. On 2/28/24, during the weekly management meeting, CEO reviewed concerns related to outcome of certified investigation (Attachment #1) with management personnel. CEO discussed expectations of management personnel moving forward. 03/08/2024 Implemented
6400.32(d)Removing food from a dumpster and then laying the food out on the individual's counter constitutes both undignified and disrespectful treatment of individual #2 as cited in 16.An individual shall be treated with dignity and respect.Staff #3 and #4 have been issued disciplinary action for this incident. Disciplinary action was not issued to Staff #1as they are no longer employed with the agency. On 2/28/24, during the weekly management meeting, CEO reviewed concerns related to outcome of certified investigation (Attachment #1) with management personnel. CEO discussed expectations of management personnel moving forward. 03/08/2024 Implemented
SIN-00214461 Renewal 11/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment completed 3/9/22 did not review compliance for 6400.217.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. On 11/16/22, management personnel were retrained in the correct method to complete self-assessments for each home as per regulations. 11/16/2022 Implemented
SIN-00178920 Renewal 11/03/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.70At the time of inspection, there was not a telephone that was easily accessible to Individual #1. The only telephone in the home was in the staff office, which is inaccessible to Individual #1.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. A corded handset/cordless answering system has been purchased. The corded handset has been installed in the office at the home. The cordless handset is accessible to individual #1, however, staff will continue to implement individual's approved restrictive BSP as written, as it relates to monitoring the phone for safety. Refer to supporting documentation which includes individual's most recent approved restrictive BSP and picture of new phone system. 11/19/2020 Implemented
SIN-00164939 Renewal 01/02/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(a)There is no fire extinguisher on the first floor of the home.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The individual residing in this home exhibits dangerous and violent behaviors towards self and others. This has included past incidents of throwing/swinging the fire extinguisher at staff members. For the safety of the individual as well as for the safety of others, the fire extinguisher is mounted in the garage, directly outside of the dining room area. The location of the fire extinguisher has been added to the individual's restrictive behavior support plan and to the home specific fire safety training. Staff have been trained on the updated fire safety training and the BSP update. See attached house specific fire safety training/BSP update. 02/12/2020 Implemented
6400.144Individual #1 had a follow up appointment on 5/10/19 with her podiatrist and she didn't attend the appointment.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. Follow up podiatrist appointment for individual #1 was scheduled and attended on 1/14/20. Staff were retrained on the proper procedure for medical appointments, including the importance of ensuring individuals attend any and all follow up appointments. See attached training content titled, "Medical Appointments". 02/12/2020 Implemented
6400.166(d)On 11/4/19, Individual #1 was prescribed Dicyclomine for cramps by her Gastrologist. Medication wasn't administered due to direction of her Psychiatrist. Alternative Medication for pain/cramps wasn't implemented until 11/20/19. Individual #1 is diagnosed with hearing loss of the right ear and is recommended to be evaluated yearly by an ENT. Her most recent ENT evaluation was completed on 7/6/17.The directions of the prescriber shall be followed.Staff were retrained in the procedure for medical appointments and procedure when individuals are prescribed medications. This training included protocol when/if another treating clinician directed medications not be administered. See attached training content titled, "Medical Appointments". Individual #1 had ENT exam completed on 2/4/20. See attached medical form. Staff were retrained in the procedure for medical appointments. See attached training content titled, "Medical Appointments". 02/12/2020 Implemented
SIN-00125160 Renewal 12/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)There was a golf ball size amount of lint found in the lint trap of the dryer. Floors, walls, ceilings and other surfaces shall be free of hazards.All DSP's and managers have received re-training on the requirement of ensuring the lint trap is emptied on a regular basis. This has been added to the communication log daily task checklist. Each day, staff are responsible for checking the lint trap and emptying, if applicable. Staff will sign the task checklist acknowledging they completed the task. Refer to attachment #7 01/11/2018 Implemented
SIN-00105060 Renewal 12/21/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.145(3)The emergency medical plan did not include emergency staffing.The home shall have a written emergency medical plan listing the following: An emergency staffing plan.The emergency medical plan has been revised to include emergency staffing. The emergency staffing is as follows: LNB has implemented a 24 hour on call system for emergencies. In the case of an emergency, staff will contact the on call personnel for assistance. The on call personnel will immediately respond to and assist with any emergency situation. Should the on call personnel require assistance, they will contact an LNB Director for immediate assistance. All staff have been retrained in the emergency medical plan by CEO. The revised emergency medical plan has been replaced in each individual¿s records by the Program of Manager of each site location. See attachments #1, #2 and #4. 01/25/2017 Implemented
6400.213(11)Individual #1's Individual Support Plan (ISP) indicated Individual #1 required 2:1 staffing ratio. Individual #1 requires 3:1 staffing ratio. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. ISP updates have been sent to all team members by program specialist. These updates included the current staffing ratio. Program specialists have been re-trained in ISP content by CEO. See attachment #9, #23 and #24. 01/23/2017 Implemented
SIN-00146599 Renewal 02/12/2019 Compliant - Finalized