| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | No attestation of PA residency for past 2 years for any of the new hires and no FBI criminal history record checks were done. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| To ensure compliance with 55 PA Code Chapter 6400.21(b) LNL Home Services (LNL) will obtain either an attestation of residence or a FBI background check for each of employees who have direct contact with individuals will be required to provide an attestation of Pennsylvania residence as part of their application process. This attestation will serve as proof that the individual is a resident of Pennsylvania for the past 2 years, in accordance with the regulations. |
06/19/2024
| Implemented |
| 6400.64(a) | The light switch outlet cover in the bathroom, wall and tub needs cleaning. The inside of the tub is beginning to form mildew. Inside oven covered with grease and Grime. | Clean and sanitary conditions shall be maintained in the home. | 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 of correction. 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 |
| 6400.112(c) | On the fire drill record for 3/1/24 the area on the record where time of drill was listed was left blank. | 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. | To ensure compliance with55 PA Code Chapter 6400.112(c), as well as 55 PA Code Chapter 6400.112(g), we will implement a plan to ensure that record keeping reflect all the required information:
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. |
07/10/2024
| Implemented |
| 6400.141(a) | Individual 1's annual physical dated 5/4/23 is currently out of date at the time of this inspection. Staff stated that he is scheduled for August. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | To maintain compliance with55 PA Code Chapter 6400.141(a), individual 1 received his annual physical on 05/23/24. To ensure 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. |
05/23/2024
| Implemented |
| 6400.141(c)(6) | Individual 1's file did not have a current TB test and also there was no information regarding a TB test from the past two years. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Individual 1 received his TB test on 05/23/2024. To ensure compliance with 55 PA Code Chapter 6400.141(c)(6) regarding annual physicals and tuberculin skin testing for all individuals will establish protocol for conducting annual physicals for all employees, contractors, and individuals served by LNL Home Services. To ensure that these physicals include tuberculin skin testing by the Mantoux method every two years for individuals aged one year or older by designating a qualified healthcare professional to perform the tuberculin skin testing and interpret the results accurately. The Program Manager will ensure that the results are documented appropriately in each individual's medical records. A detailed protocol is outlined in the Plan to Maintain compliance below. |
05/24/2024
| Implemented |
| 6400.151(a) | No physical exam was provided for staff member 1. | 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 |
06/19/2024
| Implemented |
| 6400.181(e)(7) | The assessment for individual 1 did not discuss the individual's knowledge of the danger of heat sources | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | An assessment of individual 1ability to avoid heat sources was conducted. By history and real time assessment it was revealed that the Indvidual has a limited capacity to avoid heat sources. As an ongoing precaution the individual has arms reach supervision around heat sources. He does not use the stove or microwave. A request was made to the individual 1 support coordinator to include and expand the heat assessment in the ISP. To ensure compliance with LNL Home Services 55 PA Code Chapter 6400.181(e)(7) regarding individual assessments involving the evaluation of an individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources exceeding 120°F that are not insulated, each plan will be reviewed by the Program Specialist with specific attention to heat source dander. A detailed plan to maintain compliance follows below. |
06/19/2024
| Implemented |
| 6400.18(i) | Incident with discovery date of 01/14/24 involving individual 1 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 identified 01/14/24 involving incident 1 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. Below is the detailed plan to Maintain Compliance: |
07/10/2024
| Implemented |
| 6400.24 | There were several staff members with criminal histories and there is no documentation that during the hiring process a case-by-case decision about whether to hire the person that includes consideration of the following factors: The nature of the crime; facts surrounding the conviction; time elapsed since the conviction; the evidence of the individual's rehabilitation; and the nature and requirements of the job. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | To ensure compliance with 55 PA Code Chapter 6400.24, which mandates the review of criminal history records for each potential new employee as part of the hiring process, LNL Home Services document the review of all existing employee¿s criminal history. LNL will implement a detailed plan to document the review of criminal history records for all candidates being considered for employment. The Plan to Maintain Compliance is delineated below. |
07/10/2024
| Implemented |
| 6400.46(b) | Documentation that fire safety training was done by a fire safety expert for staff member 1 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. |
07/10/2024
| Implemented |