| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency completed a self-assessment of the home on 6/23/2024. The certificate of compliance expired on 6/18/2024. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| COO has scheduled the next self-assessment for the week of October 1, 2024. |
10/02/2024
| Not Implemented |
| 6400.16 | On 7/18/24, Human Resource Specialist #1 came to the home to obtain keys and found Individual #1 alone in the home. The direct service workers that were providing supervision to Individual #1 departed the home to get food for themselves and Individual #1. Individual #1 was left unsupported in the home. A crisis occurred with Individual #1. Individual #1 attempted to cut her neck with a nail file and stab her wrist with an ink pen. Individual #1 requested to go to the Hospital and repeatedly said she would kill herself. Individual #1 banged her head off a brick wall in front of the police. Individual #1's individual plan, last updated on 6/14/24 reads, "Two to one supervision is necessary to ensure [Individual #1]'s safety. In the outcome action plan of this individual plan reads, "One staff will maintain line of sight distance from [Individual #1] and the other staff must maintain a line of hearing distance at which they can immediately respond in the event of a crisis situation, and both staff must always be on the property." | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Training specialist requested SC to update ISP 7.24.24. The ISP has been updated to match appropriate staffing levels so that instances of abuse/neglect do not occur. [ADDITIONAL INFORMATION FROM CEO ON 8/29/24: The direct service workers involved in leaving Individual #1 alone were immediately suspended pending a full investigation. Individual #1 was promptly taken to the hospital for evaluation and treatment, with counseling and support services provided to ensure their well-being. On 7/24/24, the Program Director and Training Specialist conducted a review of Individual #1's Individual Support Plan (ISP) to ensure it accurately reflected their current needs and supervision levels. A significant discrepancy in staffing levels was identified, leading the Training Specialist to contact the Supports Coordinator (SC) to request updates to the ISP. During staff meeting 8/5/24 COO reminded staff about adhering to the individual's plan with focus on the specific needs and supervision levels required for individuals like Individual #1 and prohibition of abuse and neglect. During the bi-monthly incident management training by the COO, Program Director, and Training Specialist the training will cover the importance of adhering to ISP and individual staffing needs as well as the requirements of regulation 6400.16, emphasizing the prohibition of abuse and neglect. The Training Specialist is working with scheduling to enroll all staff in Crisis and Critical Management (CCM) training, which includes suicide prevention and crisis intervention, ensuring staff can recognize early warning signs and respond appropriately in high-risk situations. Next CCM training is 9/9/24. Site supervisors will continue to conduct unannounced visits to homes to ensure compliance with supervision requirements. Regular feedback will be sought from individuals receiving care during site supervisor checks to ensure their needs are being met and they feel safe and supported. The effectiveness of the corrective actions will be reviewed monthly by the Residential Director and Program Director, with ongoing training sessions scheduled quarterly by the Training Specialist to reinforce compliance with individual plans and crisis management protocols. (AES,HSLS on 8/29/24)] |
08/27/2024
| Not Implemented |
| 6400.62(a) | On 7/24/24 at 11:02AM, the containers of Great Value disinfectant spray and a 15-ounce container of Spray Wax glass cleaner were unlocked and accessible in the cabinet under the kitchen sink. There was no locking mechanism for this cabinet. Individual #1's individual plan, last updated 6/14/24 reads, "It is unclear whether [Individual #1] understands the need to properly store poisonous materials for the safety of herself and others. [Individual #1] has threatened to ingest poisonous materials when she was upset. These materials are locked for this reason." | Poisonous materials shall be kept locked or made inaccessible to individuals. | 7/24/24 All cleaning supplies were moved to the closet that is locked and inaccessible to client. |
08/26/2024
| Not Implemented |
| 6400.64(a) | On 7/24/24 at 11:45AM, the windowsill, in the bathroom on the first floor of the home, had a multitude of dead insects. Inside the vanity in the bathroom on the first floor of the home, there was a multitude of dead insects and spider webs with suspended dead insects surrounding a bottle of mouth wash and a denture case. | Clean and sanitary conditions shall be maintained in the home. | Staff cleaned the bathroom area 7/24/24. Maintenance deep cleaned the site 8/16/24. |
08/05/2024
| Not Implemented |
| 6400.64(e) | On 7/24/24 at 11:49AM, the trash receptacle that was over 18 inches, containing discarded documents, file folders and a plastic bag, in the staff office of the home, did not have a lid. | Trash receptacles over 18 inches high shall have lids. | Site supervisor removed trash with no lid and replaced 7/24/24. |
08/26/2024
| Not Implemented |
| 6400.72(b) | On 7/24/24 at 11:46AM, the doorknob on the first-floor bathroom door was missing the screws and dangling. | Screens, windows and doors shall be in good repair. | Maintenance addressed bathroom door as of 8/16/24. |
08/16/2024
| Not Implemented |
| 6400.76(a) | On 7/24/24 at 11:02AM, the enamel coating inside of the microwave in the kitchen of the home, was delaminating and coated with a thick layer of what appeared to be grease. On 7/24/24 at 11:46AM, the toilet seat on the toilet in the first-floor bathroom was loose and moved approximately one inch from side to side. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Maintenance addressed the toilet seat 7/24/24. Microwave was replaced 8/23/24. |
08/23/2024
| Not Implemented |
| 6400.82(f) | On 7/24/24 at 11:46AM, the first-floor bathroom did not have individual clean paper or cloth towels. | 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. | Site supervisor brought clean paper towel from HR office 7/24/24. |
08/26/2024
| Not Implemented |
| 6400.110(a) | On 7/24/24 at 11:42AM, smoke detector in the basement of the home was inoperable. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Maintenance addressed the inoperable smoke detector on 7/24/24 so that it functions properly. |
08/26/2024
| Not Implemented |
| 6400.110(b) | On 7/24/24 at 11:51AM, the smoke detector on the first floor outside of Individual #1's bedroom was inoperable. At 11:52AM, an operable smoke detector on the first floor was 23 feet away from Individual #1's bedroom door. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | Maintenance addressed the inoperable smoke detector on 7/24/24 so that it functions properly. Maintenance added another smoke detector so that it is 15 feet from the individual bedroom door 8/23/24. |
08/23/2024
| Implemented |
| 6400.112(e) | A fire drill during sleeping hours was not held from 8/3/23 through 7/3/24. | A fire drill shall be held during sleeping hours at least every 6 months. | COO created a fire drill schedule for management team and team leads 7/24/24. August 14, 2024 fire drill was completed during sleeping hours. |
08/14/2024
| Not Implemented |
| 6400.112(f) | All monthly fire drills held from 8/3/23 through 7/3/24 used the front door as the exit route. | Alternate exit routes shall be used during fire drills. | COO created a fire drill schedule for management team and team leads 7/24/24. August 14, 2024 fire drill was completed during sleeping hours and residential director instructed staff to use different exit route. |
08/14/2024
| Not Implemented |
| 6400.141(c)(1) | Individual #1's physical examination, completed 7/16/24 did not include a review of previous medical history. | The physical examination shall include: A review of previous medical history. | 8/7/24 Program Director requested previous medical history to be completed by PCP. |
08/05/2024
| Not Implemented |
| 6400.142(g) | Individual #1's dental hygiene plan was dated 2020. | A dental hygiene plan shall be rewritten at least annually. | Program specialist developed dental hygiene plan for the individual 8/9/2024 |
08/09/2024
| Not Implemented |
| 6400.20(b) | The agency completed a review and analysis of incidents for the first and second quarters of 2024; prior to these, a reviews and analysis of incidents has not been complete since March 31, 2021. | The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months. | COO has developed a team to work on EIMs 8/16/24. A quarterly review and analysis of incidents have been conducted since first two quarters and will continue each quarter moving forward. |
08/16/2024
| Not Implemented |
| 6400.44(b)(2) | The fire safety section of Individual #1's individual plan, last updated 6/14/24 does not include the individual's ability to evacuate in a fire. The individual #1's ability to evacuate in a fire has not been included in the individual plan for at least the last 3 years. | The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter. | Training specialist requested SC to update ISP 7.24.24. The ISP has been updated to include individuals ability to evacuate in a fire. |
08/27/2024
| Not Implemented |
| 6400.163(d) | On 7/24/24 at 11:02AM, the closet located in the living room of the home contains medications, records, cleaning supplies, and sharp items. The key to this closet was hanging on a hook directly next to this closet door. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Maintenance removed the keys from being hung up near the med closet 7.24.24 |
08/26/2024
| Implemented |
| 6400.163(f) | On 7/24/24 at 11:03AM, a box of Ozempic Inj 2mg/3ml was unlocked and accessible in the refrigerator in the kitchen of the home. | Prescription medications stored in a refrigerator shall be kept in an area or container that is locked. | Med box for fridge was ordered by COO 7/24/24. Ozempic is now in lock box in fridge. |
08/26/2024
| Implemented |
| 6400.165(c) | Ozempic Inj 2mg/3ml prescribed to Individual #1 on 1/29/24 has not been administered. Chief Executive Officer #3 revealed that the agency has not been able to hire a nurse to administer the medication. | A prescription medication shall be administered as prescribed. | Agency contracted nurse and medication will be given starting 8/27/24. |
08/27/2024
| Implemented |
| 6400.165(g) | The only psychiatric medication review completed for Individual #1, date of admission 2/18/19, was completed on 12/22/23. This medication review did not include the reason for prescribing the medications, the need to continue the medications and the necessary dosage. [Repeated violation-8/7/23, et al] | 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. | The individual has had a review of medication every 3 months as required. This is how the agency is able to renew prescriptions. The psychiatrist has not completed the documentation to show medication reviews have been completed. Program Director and Program Specialist have been contacting the psychiatrist to obtain information needed for medication review documentation. |
08/05/2024
| Not Implemented |
| 6400.186 | On 7/24/24 at 11:00AM, Direct Service Worker #1 was the only staff person providing supervision to Individual #1. In the outcome action plan section of Individual #1's individual plan, last updated 6/14/24, reads "One staff will maintain a line-of-sight distance from [Individual #1] and the other staff must maintain a line of hearing distance at which they can immediately respond in the event of a crisis situation, and both staff must always be on the property. In the supervision care needs section of this individual plan reads, "Two to one supervision is necessary to ensure [Individual #1]'s safety". | The home shall implement the individual plan, including revisions. | Training specialist requested SC to update ISP 7.24.24. The ISP has been updated to match appropriate staffing levels. |
08/27/2024
| Not Implemented |
| 6400.192 | On 7/24/24 at 11:36AM, the closet in the living room of the home contains scissors and knives which are being locked due to behavioral concerns for Individual #1. The home does not have a restrictive procedure plan for Individual #1. | The home shall develop and implement a written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the staff persons who may authorize the use of restrictive procedures and a mechanism to monitor and control the use of restrictive procedures. | Program director requested RPP from BSC for sharps for the individual 7/24/24. Until then the sharps are not locked away. |
08/23/2024
| Not Implemented |
| 6400.207(5)(III) | On 7/24/24 at 11:50AM, Individual #1's bed was equipped with half bed rails. Individual #1 was prescribed a hospital bed on 2/19/24; however, bedrails were not included in this order. Individual #1's assessment, dated 4/13/24 does not address if Individual #1 can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #1's individual plan, updated 6/14/24 does not include periodic relief of the device to allow freedom of movement. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | The individual has a prescription for the hospital bed. The physician has stated they will send a note about the bed rails being used by the individual. The individual uses the bed rails to assist her in the bed. The individual has signed a note stating she will not allow the agency to remove her bed rails. |
08/26/2024
| Not Implemented |