| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1 had $25 Burger King Gift Card. The ending balance was documented as zero. However, based on the transactions deducted; individual #1 should still have $2.28 available on the gift card. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Life's New Beginning reimbursed individual #1 $2.28 on 8/25/2022. |
09/21/2022
| Implemented |
| 6400.22(f) | Checks from Individual #1's bank account are being written out directly to staff. | There may be no commingling of the individual's personal funds with the home or staff person's funds. | Life's New Beginning wrote a petty cash reimbursement in individual #1's name. |
08/26/2022
| Implemented |
| 6400.82(f) | At the time of the physical walkthrough, there were no paper towels or individual hand towels available in the bathroom the individuals use. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Paper towels were immediately placed in the upstairs bathroom at the time of the inspection. |
09/16/2022
| Implemented |
| 6400.18(b)(2) | Individual #1 did not receive their Lamotrigine the evening of 6/1/22 or the morning of 6/2/22. The missed dose on 6/1/22 was not reported in EIM until 7/8/22. The missed dose from 6/2/22 has yet to be reported. Individual #1 missed their dose of Latuda on 6/1/22. It was not reported in EIM until 7/8/22. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | The medication omission for Individual #1 was entered into HCSIS on 8/29/2022. |
08/29/2022
| Implemented |
| 6400.19(a)(5) | Investigations that have occurred for both Individual #1 and Individual #2 do not take into account, incident history. There is a pattern in which Staff #2 is continuously named a target for multiple types of abuse/neglect. Since 2020, there have been four confirmed incidents in which Staff #2 was the target. | In investigating an incident, the home shall review and consider the following needs of the affected individual: Incident history. | Staff #2 has been terminated from employment, effective 8/25/22 |
09/26/2022
| Implemented |
| 6400.20(a)(1) | Since 2020, there have been four confirmed incidents of abuse/neglect/rights violations between Individual #1 and Individual #2, all with Staff #2 as the target. There is no analysis of the cause for any of these confirmed incidents. | The home shall complete the following for each confirmed incident: Analysis to determine the cause of the incident. | Staff #2 has been terminated from employment, effective 8/25/22. |
09/26/2022
| Implemented |
| 6400.31(f) | Staff #2 has four confirmed incidents of abuse/neglect/rights violations at this home, between the two individuals. There are two additional "unconfirmed" incidents of abuse/neglect with the individuals in this home. Neither Individual #1 nor Individual #2 were ever asked if they wanted Staff #2 to continue working in their home and provide their care. Individual #2 has stated that they do not like Staff #2. | An individual who has a court-appointed legal guardian, or who has a court order restricting the individual's rights, shall be involved in decision-making in accordance with the court order. | Staff #2 has been terminated from employment, effective 8/25/22 |
09/27/2022
| Implemented |
| 6400.32(c) | On 7/13/22, multiple people witnessed Staff #2 grab Individual #2 by the arm, while shouting at the individual. Staff #2 mistreated Individual #2; in that Staff #2 was shouting at Individual #2, forcing Individual #2 to go to a doctor's appointment that they did not want to go to, and forcing Individual #2 to leave day program when Individual #2 was not ready to leave day program. Staff #2 was also giving Individual #2 a difficult time about the shirt that Individual #2 chose to wear while attending day program. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Staff #2 has been terminated from employment, effective 8/25/22 |
09/26/2022
| Implemented |
| 6400.32(d) | On 1/25/22, Staff #2 wrote in the daily T-Logs, "Individual #2 was especially awful this morning. Berating me & Tourette's. Just rude and super unpleasant." Staff #2 has been named the target on six investigations since 2020 between the two Individuals in the home. Four of these incidents have been confirmed. There is no documentation that either individual was asked if they were comfortable with Staff #2 continuing to work in the home. Staff #2 continues to provide services to the Individuals. Initially, the EIM for Incident 9055941 had this language in the EIM: "Future incidents may be avoided if Individual #2's mental health is effectively managed." This is disrespectful to the Individual indicating that the Individual was at fault for the incident that occurred at day program. | An individual shall be treated with dignity and respect. | Staff #2 has been terminated from employment, effective 8/25/22
This information was written in the staff communication log which is kept in a locked area. Individuals do not have access to the communication log nor do they read this information. The communication log is to be used for staff to exchange written information between shifts. Examples would include household concerns, upcoming appointments, community activities, errands, etc. |
09/27/2022
| Implemented |
| 6400.32(u) | On 7/13/22, Staff #2 arrived at day program to pick up Individual #2 to take them to a doctor's appointment. Individual #2 stated multiple times that they did not want to go to the doctor's appointment that day and that they were not sick. Staff #2 forced Individual #2 go to the doctor. Individual #2 does have the right to refuse medical appointments. | An individual has the right to make health care decisions. | Staff #2 was terminated on 8/25/2022.
Individual #2 has a history of objecting to leaving day program early to attend appointments. The staff at individual #2's house attempt to schedule appointments either in the morning or afternoon to not interfere with individual #2's routine. LNB's Director of Programming added a team procedure to address individual #2's right to refuse medical appointments and offers strategies to educate individual #2 on the importance of attending appointments. |
10/03/2022
| Implemented |
| 6400.52(c)(6) | The following staff who worked in the home from December 2021 through July 2022 did not receive training on Individual #1's ISP or Individual #2's ISP: Staff #3.
The following staff who worked in the home from December 2021 through July 2022 did not receive training on Individual #1's Behavior Support Plan: Staff #3.
The following staff who worked in the home from December 2021 through July 2022 did not receive training on Individual #1's dental hygiene plan developed on 6/1/21: Staff #2 and Staff #4.
The following staff who worked in the home from December 2021 through July 2022 did not receive training on Individual #1's Seen Plan: Staff #2 and Staff #5.
The following staff who worked in the home from December 2021 through July 2022 did not receive training on Individual #1's Personal Care Wiping Plan that was developed on 4/12/21: Staff #3.
The following staff who worked in the home from December 2021 through July 2022 did not receive training on Individual #1's Body Check Protocol that was developed on 6/1/21: Staff #2 and Staff #5. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Provider continues to face an ongoing, significant staffing crisis. Current vacancy rate is approximate 47%. Unfortunately, this staffing crisis/shortage has negatively impacted various areas of services, despite everyones best efforts. Management, including CEO, Director of Programming, both Quality Managers, Trainer, and Program Managers have been working direct care hours and scheduling as their main job responsibilities; working seven (7) days a week, 10-14 hour days. DSPs are working a significant number of overtime hours. The staff have been trained in the plans cited above and training logs have been signed/dated to reflect the training was completed. |
10/30/2022
| Implemented |
| 6400.163(h) | At the time of the physical walkthrough, Individual #1's Nasal Spray had expired in May 2022 and had not been disposed of. Individual #1's Acetaminophen expired in July 2021 and had not been disposed of. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Completed revised medication audit form on 9/28/2022. |
09/28/2022
| Implemented |