Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00254820 Renewal 11/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)At the time of the inspection the floor in the basement was lifting in one corner.Floors, walls, ceilings and other surfaces shall be in good repair. The area of flooring that was lifting in the corner has been repaired by maintenance personnel on 11/18/24 12/02/2024 Implemented
SIN-00210265 Unannounced Monitoring 07/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(a)At the time of the physical walkthrough, the water pressure in the upstairs bathroom was adjusted to a slow trickle and didn't hold pressure.A home shall have hot and cold running water under pressure. On 8/10/2022, the water pressure in the upstairs bathroom was reset to standard water pressure by the program manager. 09/20/2022 Implemented
6400.74At the time of the inspection, the outside steps leading to the front of the home had the textured paint chipping, leaving stairs without a non-skid surface.Interior stairs and outside steps shall have a nonskid surface. On 9/16/2022, the LNB maintenance department placed non-skid strips on the outside steps. 09/20/2022 Implemented
6400.82(f)At the time of the inspection, there was no hand soap available in the upstairs bathroom.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. Hand soap was placed in the upstairs bathroom after the inspection on 8/10/2022 by the program manager. 09/16/2022 Implemented
6400.143(a)Individual #1 has a history of refusing to cooperate with the blood pressure protocol that was developed. Individual #1 is to have their blood pressure checked daily. Individual #1 refused to have their blood pressure checked 5 days in a row in May 2022. In addition, Individual #1 refused to cooperate with having their blood pressure checked 7 times in June 2022. There is no documentation that Individual #1 was educated on the importance of following doctor's recommendations.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. On 8/26/2022, LNB's Director of Programming, educated Individual #1 on the importance of following doctor's recommendations. Individual #1 nodded his head when the conversation was completed. 08/26/2022 Implemented
6400.144Individual #1 had a blood pressure protocol developed 11/16/21 in which the Individual was to have their blood pressure checked daily. From January 2022 through July 2022, there were 17 days in which the blood pressure was not tracked. Individual #1 has a bowel movement protocol in which Individual #1 is to receive Miralax every three days. If Individual #1 has no bowel movement in 4 days, on the 5th day, an additional dose of Miralax is to be administered. Based on Individual #1's bowel movements logs, Individual #1 should have received an additional dose of Miralax on 7/5/22 and didn't. Individual #1 is to have their weight checked weekly. The directions on the weekly weight charts indicate that if Individual #1 experiences a significant weight change, the changes must be reported to the director immediately. In January 2022, Individual #1 gained a total of 11 pounds. In the first week of April 2022, Individual #1 lost 6 pounds. By the end of the month, Individual #1 had lost a total of 7 pounds. In June 2022, Individual #1 gained 7 pounds. From the last week in June 2022, to the first week in July 2022, Individual #1 lost 13 pounds. There is no clarification as to what a "significant weight change" would be.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. On August 3, 2022, Individual #1 saw their PCP for an annual check-up. Staff discussed Individual #1's weight and the PCP responded "Individual #1's weight does fluctuate. This is not concerning unless their BMI is below 18.5 The blood pressure plan was discontinued on 8/4/2022 when the Propranolol was discontinued. The blood pressure was being tracked; the issue was the number of refusals (17). individual can become very agitated when BP is checked. Will display severe SIB, vocalize loudly, pull the BP cuff off of his arm and throw it across the room or hit staff. To respect individual's choice to refuse to participate in the plan, staff would attempt to measure BP 2 or 3 times before documenting a refusal. As far as the bowel movement plan, the staff that work at the home have been retrained in bowel movement plan. attached bowel movement training log. 09/26/2022 Implemented
6400.32(d)Altering a device to limit the intended function can be considered restrictive. During the physical walkthrough at Individual #1's home, the water pressure in the upstairs bathroom was adjusted to a slow trickle to prevent Individual #1 from playing in the water. Limiting the function of the water without an associated plan or education for the water concern is not considered respectful treatment to individual #1.An individual shall be treated with dignity and respect.The water pressure in the upstairs bathroom was reset to standard pressure on 8/10/2022 by the program manager. Individual #1 was educated by LNB's Director of Programming, on 8/26/2022, on water safety and the hazards that are created when floors, walls and fixtures become wet. Individual #1 nodded their head when the conversation was completed. 09/26/2022 Implemented
6400.52(c)(6)The following staff who worked in the home from December 2021 through July 2022 did not receive the ISP specific training for Individual #1-Staff #1 through Staff #8. The following staff who worked in the home from December 2021 through July 2022 did not receive the Bruise Documentation Training for Individual #1 that was developed on 11/16/21: Staff #1 through Staff #6. The following staff who worked in the home from December 2021 through July 2022 did not receive the training on Individual #1's SEEN Plan that was developed on 11/16/21: Staff #1, Staff #3-Staff #5, and Staff #8-Staff #10. The following staff who worked in the home from December 2021 through July 2022 did not receive the training on Individual #1's toileting protocol that was developed on 11/16/21: Staff #1-Staff #5 and Staff #9-Staff #10. The following staff who worked in the home from December 2021 through July 2022 did not receive training on Individual #1's Blood Pressure Protocol that was developed on 11/16/21: Staff #1-Staff #4, Staff #11, and Staff #12. The following staff who worked in the home from December 2021 through July 2022 did not receive training on Individual #1's Bowel Movement Protocol that was developed on 10/27/21: Staff #1, Staff #3-Staff #4, Staff #7-Staff #8, and Staff #12.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 everyone's 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
6400.195(a)Individual #1's access to water was restricted by staff by setting the bathroom sink to a slow trickle and also by placing a lock on the laundry room door. Individual #1 does not have a restrictive procedure plan associated with either said things.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.The sink was removed from the laundry room on 3/15/2022. The water pressure in the upstairs bathroom was reset to standard pressure on 8/10/2022 by the program manager. At Individual #1's ISP meeting on 8/23/2022, the ISP was updated. A statement was added in the General Health and Safety Risks Section, "The basement door is kept locked as it's where the laundry detergent and other cleaners/poisonous materials are stored." 09/26/2022 Implemented
SIN-00178923 Renewal 11/03/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)Bathroom items- There was no hand soap in the main bathroom.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. Hand soap was provided in the main bathroom immediately upon discovery of none present. Staff were retrained by the Program Specialist on expectations and responsibilities regarding the supplying of hand soap and paper towels for the individuals. Refer to the supporting documentation which includes the training content and the training attendance form. 11/21/2020 Implemented
SIN-00146603 Renewal 02/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(c)Program Specialist staff #5 date of hire was 4/5/18. There was no documentation of official transcripts or degree that she has an associate's degree or higher education. Unofficial transcripts in record with no date of receipt; copy of associates degree in record with no date of when she received the degree; and agency didn't attempt to get a copy of official transcripts until 2/13/19 during licensing inspection. A program specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with intellectual disability. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with intellectual disability. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with intellectual disability.Official transcript of Program Specialist staff #5 was obtained and submitted on 3/19/19. A new employee checklist has been created. This checklist will be completed by the hiring manager. Each item on the checklist (if applicable) will be completed/submitted prior to the employee starting first day of work (including training). The checklist includes applicable credentials/qualifications for various positions such as a Program Specialist. Upon completion/submission of all applicable items on the checklist, the hiring manager will sign and date the new employee checklist and submit to Human Resources. Human Resources will review the checklist along with the submitted documents. If Human Resources finds the checklist and documents to be accurate and in order, they will then schedule the employee's first day of training. New employee checklist was reviewed by CEO with all managers and Human Resources during weekly management meeting on 3/20/19. 03/20/2019 Implemented
6400.46(f)There was no documentation that staff #2 and staff #3 received training in fire safety from a fire safety expert; or that they received the requires training specific to the home(s) each person was working at.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 new hires will receive home specific fire safety training during orientation/initial training prior to working at the home. In addition to the required fire safety training, trainer will also show a video specific to the home staff were hired for which will show the location of the exits, meeting place, and location of all fire extinguishers in the home. 03/13/2019 Implemented
6400.46(i)Staff #2 initial date of hire was 2/27/18 and did not have first aid and CPR training completed until 8/28/18; over the 6-month time frame.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. LNB scheduled a manager to attend CPR/First Aid instructor training so that there is an additional trainer to assist with insuring that staff are trained within 6 months of hire. Both trainers will monitor the due dates of new hires to insure that they are trained within 6 months of hire. The manager is enrolled in the CPR/First Aid instructor training course on 4/17/19, 4/18/19. 04/18/2019 Implemented
6400.46(j)Staff #1 had a documented training "med logs" on 8/30/17 for .5 hours; however, there was no training content kept determining what was trained regarding med logs. No training content kept for staff #1 for practicum observer training on 8/2/17, 9/12/17, 10/26/17. No documentation kept for who's dental protocol staff #1 was trained on 10/4/17 or who's dental hygiene plans were reviewed on 10/4/17. No training content kept for staff #1 training "team procedures, blood O2 level, pulse rate, oral temperature" on 9/13/17 and "procedures for drink mixtures" on 9/20/17 and "outcomes/programming" on 10/11/17. . No training content, the hours of training, or the trainer that provided the training indicated for all of staff #2 orientation training and 30 day trainings. No training content, the hours of training, or the trainer that provided the training indicated for all of staff #3 orientation training and 30 day trainings. No training content, hours of training, or the trainer that provided staff #5 her orientation training or training on her Program Specialist duties. Training content not kept for staff #4 24 hours training. i.e. "annual training see plan on 9/27/17"; "everyday lives conference on 1/9/18"; "TGA business conference 2018 on 4/13/18". Staff #2 received training from a medication trainer, staff #6, on 5/30/18 "routes of medication." This training included inhalants, patches, suppositories, and nose sprays that are not approved routes of medication via the department's medication administration training course. A medical professional did not provide training on these additional routes to any staff in their agency in person (or at all.) Staff #3 received training in other routes of medication administration not approved by 6400 by a medication trainer #7 on 12/3/18. This is not allowed.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.Orientation and 30 day training form was revised to include the trainer's name, date, # of hours of training. The form will also include the trainer and employee's signature as verification that training was completed. Training content for is currently kept for each training in a binder/file for reference. Medication trainers have discontinued training staff in the area of "routes of medication" (inhalants, patches, suppositories and nose sprays). This is no longer part of medication training curriculum. Should an individual be prescribed any of these medications, staff will be trained by a healthcare professional. 02/13/2019 Implemented
6400.168(a)Staff #2 had initial medication training. She passed her exams on 4/5/18 and had 3 observations done 4/5/18. 1 observation done 7/2/18, 1 observation done 7/17/18, and 1 observation done 7/20/18. According to medication administration guidelines, she should have completed all 4 observations within 30 days of 4/5/18. She did not do so, therefore, she was allotted an additional 45 days passed the 30 day requirement to complete all 4 observations, plus 2 additional observations. This was not completed by 6/20/18. According to medication training guidelines staff #2 had an additional 30 days to complete the additional observations (7 total); she only completed 6 observations by 7/20/18 and staff #7 certified staff #2 to pass medications. Staff #2 has been passing medications since 7/20/18. 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. Medication Admin Trainer reviewed the initial training requirements with Practicum Observers. Med Trainer reviewed the number of med observations to be completed within 30 days of passing the exam as well as the number of med passes required if it is past the 30 days. Staff #2 was retrained in DPW Med Admin course on 2/15/19. The first 2 med observations were conducted on 2/15/19. Three more med observations were conducted on 2/16/19. In addition, Med Trainer is training additional Practicum Observers so there are ample Practicum Observers available to conduct med observations in a timely manner. 02/16/2019 Implemented
6400.168(c)Staff #1 has been signing staff's meditation training as a practicum observer; however, she is not certified to be a practicum observer. Her initial practicum observer training documentation does not include a pass or fail for her multiple-choice test, the initial practicum summary sheet completed with a trainer pass or fail date and signature, or documentation that staff #1 passed or failed the three MAR reviews (mar review forms attached were blank for a pass date and no practicum summary sheet to indicate she passed). Medications administration training of a staff person shall be conducted by an instructor who has completed the Department's Medications Administration Course for trainers and is certified by the Department to train staff. Medication Admin Trainer obtained correct/proper summary certification form for Practicum Observers from the Med Admin Trainer website. Staff #1 was re-trained by a Med Admin Trainer in the Practicum Observer course. Med Admin Trainer documented the passing scores for the multiple choice exam, MAR review exams, as well as the 3 supervised med observations on the certification summary form. Med Admin trainer will keep informed of new forms by checking the Med Admin Trainer website. Med Admin trainer will insure that all tests are properly scored and the scores are documented immediately. 02/16/2019 Implemented
SIN-00223028 Unannounced Monitoring 04/13/2023 Compliant - Finalized
SIN-00214465 Renewal 11/07/2022 Compliant - Finalized
SIN-00164943 Renewal 01/02/2020 Compliant - Finalized