Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00254817 Renewal 11/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(b)At the time of the inspection the non-slip strips along the driveway were coming loose. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The non-skid strip, including the section that came loose on the wooden beam lining the driveway, was tacked down by provider's maintenance personnel on 11/18/24. This will prevent the non-skid stripping from becoming separated and will assist it to remain in place under more severe conditions (ie rain, wind, hail, snow, etc.). 11/18/2024 Implemented
SIN-00214462 Renewal 11/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment completed 3/14/22 -- 3/16/22 did not review compliance for 6400.167a8 and 6400.167c.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 a self assessment for each house per regulations. 11/16/2022 Implemented
6400.15(c)The self-assessment dated 3/14/22 -- 3/16/22 indicated that there were violations for 6400.14b and 6400.62a, but there was no plan of correction included.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. On 11/16/22, management personnel were retrained in the correct method to complete a self assessment for each house. 11/16/2022 Implemented
6400.22(c)Individual #1 was required to purchase their own toiletries on the dates listed below. Per PA 6100 regulations, these items are to be provided by the provider agency. · 6/28/22 -- Shampoo and Shave Cream totaling $10.87 · 7/6/22 -- Toothpaste and body wash totaling $10.00 Additionally, Individual #1 has not given consent to purchase staff tickets or admission fees for activities they want to attend or participate in. On the dates listed below, Individual #1 purchased tickets for staff members: · 3/24/22 - $19 was spent on a jump fee and $3.50 on jump socks for a staff member at Altitude York (the purchase total was $45) · 6/27/22 - $34 was spent on 2 additional tickets to Lake Tobias (each ticket was $17 and a $3 coupon was used so the total was $48 for 3 tickets) · 8/26/22 - $97.33 was spent on 3 tickets to Do Portugal Int CircusIndividual funds and property shall be used for the individual's benefit. Individual #1 has been reimbursed for each purchase listed, totaling $197.20. On 11/16/22, management personnel were retrained on items covered under room and board/provider's responsibility. In addition, training was provided on when an individual's and/or guardian's consent is required (i.e. to purchase admission tickets for staff) and this decision/consent must be in writing. The staff from this particular home were retrained in the same content on 11/23/22 11/23/2022 Implemented
6400.165(g)Individual #1 takes psychotropic medications. There is no record of Individual #1 having a quarterly medication review during the review period of 12/1/21 through 11/9/22If 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.Several attempts have been made by various managers to get the necessary quarterly medication reviews from the psychiatric clinician. These attempts have been made verbally and through text/email. These were submitted to licensing personnel during the agency's inspection. All reviews have been virtual since the beginning of covid. 12/20/2022 Implemented
SIN-00164940 Renewal 01/02/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)There is no smoke detector in the attic, which is accessible. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. This area is a crawl space located in the ceiling of a closet. There are no pull down steps attached to the space. This space is not utilized for any reason. It would be unsafe for the individual or staff to access this area. This area has been made inaccessible by LNB's maintenance team. Please see attached picture. A new fire drill log has been created to monitor attic and crawl space areas. See attached fire drill log 02/02/2020 Implemented
6400.111(a)There is no fire extinguisher in the attic, which is accessible.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. This area is a crawl space located in the ceiling of a closet. There are no pull down steps attached to the space. This space is not utilized for any reason. It would be unsafe for the individual or staff to access this area. This area has been made inaccessible by LNB's maintenance team. Please see attached picture. A new fire drill log has been created to monitor attic and crawl space areas. See attached fire drill log. 02/02/2020 Implemented
SIN-00125161 Renewal 12/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(f)Staff #1 had fire safety training completed on 6/30/2016 and not again until 10/9/2017.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. All DSP's and managers have re-trained in fire safety procedures. This includes the requirement that each DSP and PS must receive fire safety training on an annual basis. In addition to initial training requirements, LNB requires all DSP's and PS's complete fire safety training twice a year. This occurs in the months of October and April to ensure fire safety is completed timely. The Administrative Assistant has been designated to track all fire safety training and ensure it is completed in the months of April and October to avoid any future late fire safety training. Refer to attachment #1-Licensing review-re-training 2017 01/10/2018 Implemented
6400.112(i)Fire drill conducted on 11/12/2017 did not indicate which alarm or smoke detector was set off during the fire drill. This section on the form was left blank. A fire alarm or smoke detector shall be set off during each fire drill.All DSP's and managers have been re-trained in fire safety procedures and required documentation. A fire safety checklist has been created to be completed by a manager following each fire drill. Refer to attachments #1-Licensing review/re-training 2017, #2-completed fire drill and #3-fire drill checklist. 01/11/2018 Implemented
6400.195(a)Individual #1's restrictive procedure plan implemented on 2/27/2017 did not include the restrictive component of manual restraints. Individual #1 was manually restrained by staff on the following dates according to Enterprise Incident Management (EIM): 12/16/16, 12/24/16, 12/30/16, 3/8/17, 3/25/17, 4/8/17, 4/12/17 (two times), 4/15/17, 5/5/17, 5/10/17, 5/20/17, 7/6/17, 7/7/17, 7/8/17, 7/17/17, 7/31/17 and 8/26/17. The use of manual restraints was not added and implemented to his/her restrictive procedure plan until 9/7/2017.For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to use of restrictive procedures. Program Specialists have been re-trained in regulation 6400.195(a) in addition to Life's New Beginning policy on "Use of Restrictive Techniques". Refer to attachment #10 01/10/2018 Implemented
SIN-00105555 Unannounced Monitoring 12/21/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Laundry Detergent and 2 containers of paint were unlocked in the basement. Hydrogen Peroxide was unlocked in the living room closet.Poisonous materials shall be kept locked or made inaccessible to individuals. The program manager removed the paint from the home and moved the hydrogen peroxide to a locked area (staff office) where it will be stored. Program manager purchased locked cabinet for basement to store poisonous materials such as laundry detergent. All staff were retrained by CEO in procedure for storing/using poisonous materials if individuals are not safe with them. A safety checklist was created that will be completed monthly for each site location. This safety checklist will include monitoring poisonous materials. LNB¿s safety committee will review the monthly safety checklists and address any issues/concerns. See attachments #1, #2 and #6. 01/25/2017 Implemented
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
6400.168(a)Staff #1 did not complete the initial medication administration training. Only 2 observations were completed. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. Current medication trainer was retrained on 12/26/16 by another medication trainer that LNB uses as an outside training consultant. This training included how to conduct medication observations and how to properly complete the necessary paperwork. See attachments #3. The first new hire since LNB's licensing was on 1/30/17. A medication course will be conducted the week of 1/30/17 that will include four med observations. 02/10/2017 Implemented
6400.185(b)Individual #1's restrictive procedure plan and Individual Support Plan indicated sharp objects need to be locked. 2 pairs of scissors were unlocked and accessible in the bathroom. The ISP shall be implemented as written.Both pairs of scissors have been relocated to a locked area (staff office) where they will be stored when not in use. Staff have been retrained on the content of this regulation by CEO. See attachments #1 and #2. 01/25/2017 Implemented
SIN-00234125 Renewal 11/07/2023 Compliant - Finalized
SIN-00195510 Renewal 11/01/2021 Compliant - Finalized
SIN-00178921 Renewal 11/03/2020 Compliant - Finalized
SIN-00146600 Renewal 02/12/2019 Compliant - Finalized