| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | At the time of the inspection, the financial logs being kept for individual #1 did not indicate a starting amount of funds, the balance after funds were spent or an ending monthly balance. The financial log also had multiple months on the same form without a starting and ending balance for each month. Individual #1 also has several income streams such as EBT card for groceries, an Aetna card for other expenses like groceries or medicine, cash monies from the individual's pay that the family manages, etc.
Recommendation for POC is to have a separate monthly ledger for each source of income, recorded monthly with a starting and ending balance for each month to better track finances. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | LNB revised the account ledger form. If an individual has multiple accounts/funding sources, separate ledgers will be kept for each source monthly. There is also a separate sign off form for the accounts of each individual. All of the funds that are accounted for in the money book are listed. |
11/13/2024
| Implemented |
| 6400.144 | Individual #1's yearly physical was completed on 8/23/23 and 8/26/24. On the most recent physical dated 8/26/24, the PCP indicated "PSA ordered" to check for prostate health. However, the actual orders were due on or around 11/7/24 and the individual still has not had this bloodwork completed and this is an annual requirement. The provider does not have any documentation that they reached out to the provider requesting that these orders be placed or an update as to why the order had not yet been placed after so much time had elapsed since the annual physical. | 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.
| had his PSA lab work completed on November 12, 2024. The results were within normal range |
11/12/2024
| Implemented |
| 6400.44(c)(1) | Staff #1 is listed on the agency Attachment # 4 as a Program Specialist. Staff # 3 has a master's degree however does not have 1 year of work experience working directly with individuals with an intellectual disability or autism. | A program specialist shall have one of the following groups of qualifications: A master's degree or above from an accredited college or university and 1 year of work experience working directly with individuals with an intellectual disability or autism. | The Program Specialist title was removed from staff #1. Staff #1 is currently transitioning to a newly created position. This position will include conducting certified investigations, scheduling, and training. |
11/11/2024
| Implemented |
| 6400.50(a) | Staff #1 and staff #3's Orientation training sheet labeled "Initial Training Requirements" did not include the source or length of training.
The annual trainings for Person Centered Planning, Incident Management, Rights and Abuse are covered in the agency QA&I annual trainings. The length of each of the training topics is not included in Staff # 5's training log. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | LNB has revised their initial training form to include the name of the training, date and length of trainings, trainer and source of training. A training sign in log will be completed everyday of initial training to document the attendees. Training certificates and training content will be maintained in the training filing cabinet. |
12/02/2024
| Implemented |
| 6400.165(g) | Individual #1 is prescribed a medication to treat symptoms of a psychiatric illness (Zoloft), however the individual has not been seen by a licensed physician or psychiatrist at least every 3 months and there is no documentation showing the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | 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. | has been on the waiting list at WellSpan Philhaven since March 21, 2024. A virtual appointment was made with Dr. on December 11, 2024. This appointment will be Eric's 3 month psychotropic medication review. |
12/06/2024
| Implemented |
| 6400.182(c) | Individual #1 is prescribed a psychotropic medication to treat symptoms of "mood disorder" however the most recent ISP dated 10/01/2024 under the seen plan (social/emotional information) states the individual, "has no mental health diagnoses and is quite healthy regarding their emotional well-being". The ISP has not been updated to reflect this change. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | On December 5, 2024, an isp change letter was sent to 's supports coordinator. The letter provided updates to 3 sections of 's ISP that were omitted at his November 4, 2024 ISP meeting. |
12/06/2024
| Implemented |