| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The self-assessment dated 3/18/22 indicated that there was a violation for 6400.167a1, 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.
| Management personnel were retrained in the correct method to complete a self-assessment for each house. |
11/16/2022
| Implemented |
| 6400.22(d)(1) | (Repeated Violation -- 7/7/22) Individual #1 receives SNAP Benefits. The documentation provided as verification of Individual #1's monthly SNAP Benefits is not current and up to date. No SNAP Benefit logs were provided for December 2021 or January 2022. There was a SNAP Log for February 2022, however the balances were not documented. The amounts recorded on the February SNAP Benefit Log did not match the receipts. Receipt #4 was for $102.79 and was documented as $137.31 and Receipt #6 was for $137.75 and was documented as $178.31. The ending SNAP Benefit balance for March 2022 did not match the beginning SNAP Benefit balance for April 2022. There was no SNAP Benefit Log for June 2022. The SNAP Benefit Logs for both July and August 2022 had math errors. There was a receipt provided for 7/28/22 totaling $19.63. This amount was not included on the July SNAP Benefit Log. No SNAP Benefit Logs were provided for September or October 2022. The SNAP Benefit Log provided for November 2022 had nothing written on it. There was a SNAP Benefit Log provided that had no dates and no information written on it, making it impossible to tell what month it was for. In addition, EBT printouts were provided for August, September, and October 2022. Two transactions listed on the August EBT transactions were not logged on the SNAP Benefit Log for that month: 8/6/22-$24.10 and 8/7/22-$17.52. | 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. | Management personnel were retrained in SNAP EBT Card procedures and proper documentation. |
12/07/2022
| Implemented |
| 6400.141(c)(13) | The allergies listed on Individual #1's most recent annual physical completed on 8/26/22 do not match the allergies listed on Individual #1's ISP or in other medical records for Individual #1. Individual #1 is allergic to Valproic Acid. This medication is not listed as an allergy on their most recent annual physical. | The physical examination shall include: Allergies or contraindicated medications. | An addendum to Individual #1's physical was sent to their PCP and asked the PCP to add the allergy (valproic acid) to the PCP's copy of Individual #1's 2022 physical form. |
11/09/2022
| Implemented |
| 6400.143(a) | (Repeated Violation -- 7/7/22) Individual #1 refused to use their Nizoral Shampoo six times in January 2022. They refused to wash with their Benzoyl Peroxide 5 times in January 2022 and refused to use the Clindamyacin four times in January 2022. There is no documentation that staff educated Individual #1 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. | A form was developed that documents when staff have conversations with Individual #1 regarding the importance of following Doctor's orders when the individual refuses medications/medical plans or protocols. |
11/12/2022
| Implemented |
| 6400.144 | (Repeated Violation -- 7/7/22) Individual #1 has a bowel movement protocol. If Individual #1 goes three days with no bowel movement, their PCP is to be called to receive further directions. Individual #1 had no bowel movement 5/14/22, 5/15/22, and 5/16/22. No documentation was provided that Individual #1's PCP was called. Individual #1 had no bowel movement on 5/18/22, 5/19/22, or 5/20/22. No documentation was provided that Individual #1's PCP was called. | 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 12/19/2022, LNB's Director of Programming reviewed the bowel plan for individual #1 at a staff meeting. |
12/19/2022
| Implemented |
| 6400.212(a) | Individual #2's September 2022 bank records were in Individual #1's financial records. | A separate record shall be kept for each individual.
| Individual #2's September 2022 bank record was removed from Individual #1's file folder and placed in the correct file folder. |
11/11/2022
| Implemented |
| 6400.18(b)(2) | (Repeated Violation -- 7/7/22) On 12/1/21, Individual #1 received their 4pm dose of Lamotrigine at 7:15pm. This medication error was not reported to EIM. Individual #1 did not have their ammonium lactate applied on 9/21/22. This medication error was not reported to EIM. | 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. | On 11/11/2022, the late admission of the 4pm Lamotrigine was entered in HCSIS. On 12/1/2021, there were also 2 omissions of medication for individual #1 (Incident #8942201). The quality manager that entered the omissions neglected to enter the late admission. This QM resigned from LNB in late December 2021. |
11/14/2022
| Implemented |
| 6400.52(c)(6) | (Repeated Violation -- 7/7/22) Individual #1's ISP was updated in May 2022. The following staff worked with Individual #1 after the ISP was updated and did not have training on Individual #1's updated ISP: Staff persons #6-11. Individual #1's Dental Hygiene Plan was updated on 8/16/22. The following staff worked with Individual #1 without being trained on the updated Dental Hygiene Plan: Staff persons #10-12. Individual #1 has a Foot Care Plan that was updated on 5/11/22. The following staff worked with Individual #1 and did not receive training on the updated Foot Care Plan: staff persons #8, 10, and 11. Individual #1 has a Behavior Support Plan that was implemented on 10/14/21. Staff person #9 did not receive training on the Behavior Support Plan and has provided care to Individual #1. | 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. | Staff #'s 7, 9, and 12 no longer work for LNB. Staff #'s 6, 10, and 11 were trained in the plans previously but neglected to sign the updated plans. Staff #8 was trained in all of individual #1's health and safety plans by the Quality Manager but neglected to sign the foot care plan training log on 8/23/22. |
12/16/2022
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Omeprazole that is to be taken at least 30 minutes prior to breakfast and dinner. On 2/17/22, Individual #1 was given the Omeprazole at 5:12pm and dinner at 5:30pm, which was not at least 30 minutes before the meal as prescribed. On 5/6/22, Individual #1 received their Omeprazole at 6:05pm and their dinner at 6:30pm. On 5/18/22, Individual #1 received both their Omeprazole and dinner at 6:25pm. On 6/6/22, 6/8/22, 6/13/22, and 6/15/22, Individual #1 received their Omeprazole at the same time as their dinner. | A prescription medication shall be administered as prescribed. | On 12/19/2022, LNB's Director of Programming reviewed the instructions for the administration of Omeprazole for Individual #1. Staff will document the administration of the medication and then individual will eat their meal 30 minutes after the administration of Omeprazole. Staff will then document the meal time on the medication record. The employees that administered the medication on 2/17/22, 5/6/22, 5/18/22, 6/6/22, 6/8/22, 6/13/22 and 6/15/22 no longer work for LNB. |
12/19/2022
| Implemented |
| 6400.165(g) | Individual #1 is prescribed psychotropic medications. No documentation was provided that listed the date of the psychiatric medication review, the reason the psychiatric medications were prescribed, the names and doses of the psychiatric medications prescribed, or the need to continue the medications. There were two medical appointment summaries showing Individual #1 had a Psych Med Review on 1/20/22 and 4/21/22 and not again since. | 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. | 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 |
| 6400.167(a)(1) | Individual #1 did not have their ammonium lactate applied on 9/21/22. | Medication errors include the following: Failure to administer a medication. | The ammonium lactate was administered on 9/21/2022 as prescribed. Staff #8 neglected to sign the medication record after the administration. The medication was signed on 11/11/2022 by staff #8. |
11/11/2022
| Implemented |