| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 has a diagnosis of diabetes. The individual requires twice daily blood glucose checks, a fasting test in the morning and another test before bedtime, to ensure safe blood glucose levels. There was a protocol in place instructing staff what to do with each range of blood glucose. Individual #1 received multiple daily medications until 10/16/25 to control their blood glucose levels. At this time, Individual #1 became insulin dependent.
Individual #1 had a total of 24 staff work in their home between 5/1/25 and 10/21/25. Only 5 of these staff were trained in the individual's blood glucose protocol. 16 of these staff did not receive any training on Individual #1's plans and protocols.
As described in the Licensing Inspection Summary below, there were many dates where Individual #1's blood glucose levels were not tested and recorded properly. Additionally, there were 5 staff who administered medications to Individual #1 that were not medication administration trained.
On 10/11/25, Individual #1 had a blood glucose reading of over 600 that led to 911 being contacted and a short hospitalization. This is when Individual #1 was prescribed insulin, as further steps were needed to properly control the individual's blood glucose levels.
Failure to train staff and follow medical protocols led to conditions conducive to serious harm for Individual #1. | 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. | Although Individual #1 is no longer in our care, we have implemented agency-wide improvements to prevent similar issues when supporting individuals with complex medical needs. We identified that training documentation for staff was mishandled, so we are standardizing all training records through the Training and Development Coordinator and the agency Medication Administration Trainer. This includes creating a centralized tracking system for individualized protocol training, medication administration certification, and competency validations. Going forward, staff will not be scheduled to work with individuals requiring specialized health plans until training is documented and verified in this system. Additionally, we will conduct regular audits of training records and medication administration compliance to ensure accuracy and accountability. These measures strengthen our operational processes and guarantee that staff are properly trained and documented before providing care to individuals with complex health needs. |
12/22/2025
| Accepted |
| 6400.144 | Individual #1 has a blood glucose protocol in place. The individual's blood sugar is to be taken twice daily -- before breakfast (fasting) and at bedtime. If the individual's blood sugar was over 400, the PCP was to be contacted. If the individual's blood sugar was less than 70, the individual was to be given juice or glucose tabs. If the individual was unresponsive, 911 was to be called. From 5/1/25 through 10/21/25, Individual #1's blood glucose was rarely noted as taken while fasting. Additionally, there were 33 days when the individual's blood glucose was checked only once and 21 days when the individual's blood glucose was not checked at all. This does not include the dates where Individual #1 was out of program between 5/1/25 and 10/21/25. | 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.
| Although Individual #1 is no longer in our care, we identified that the greatest issue was inconsistent documentation of blood glucose checks, particularly when the individual was out of program for home visits, appointments, or hospitalization. Staff were also documenting in both paper and electronic records, which caused gaps and confusion. To correct this at the operational level, we have standardized documentation procedures so that all health data is recorded in one designated system, eliminating duplicate or conflicting entries. Supervisory staff now review documentation daily to ensure accuracy and timeliness, and any discrepancies are addressed immediately. Policies have been created to require clear notation when an individual is unavailable for scheduled checks, and staff have been retrained on these expectations. These changes ensure accurate health monitoring and documentation for any individual with medical protocols in the future. |
12/15/2025
| Accepted |
| 6400.52(c)(6) | Individual #1 has multiple plans and protocols that staff must be trained on before working with the individual. These include: Individual Support Plan (ISP), Behavior Support Plan (BSP), Blood Glucose protocol, Blood Pressure protocol, Crisis and Day Board protocol, Dental Hygiene plan, and a constipation protocol. There were 24 staff who worked with Individual #1 between 5/1/25 and 10/21/25. None of these staff were fully trained in working with Individual #1. The provider agency utilizes a "read and acknowledge" training system, which is not an approved method of training for Individual plans and protocols.
· Staff persons #1, 3, 4, 7, 8, 9, 12, 13, 15, 17, 18, 19, 20, 22, 23, and 24 were not trained in any plans and protocols.
· Staff persons #2 and #6 were only trained in the constipation protocol, crisis and day board protocol and blood glucose protocol.
· Staff persons #14, 16, and 21 were only trained in the crisis and day board protocol.
· Staff persons #5, 10, and 11 were only trained in the constipation protocol and blood glucose protocol. | 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. | Although Individual #1 is no longer in our care, we have identified that our previous approach of "read and acknowledge" for individual plans and protocols was not compliant and did not ensure staff competency. Lead Program Specialist and Training and Development Coordinator will identify any other such inadequate trainings and correct the documentation and re-train on said policies per our new process. |
12/22/2025
| Accepted |
| 6400.162(b)(2)(ii) | Staff persons #6, 8, and 24 have not been trained in administering topical medication. These staff persons administered topical medication to Individual #1. | A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Topical medications. | Although Individual #1 is no longer in our care, we identified that poor record-keeping contributed to staff administering topical medication without documented training. To correct this, the Training and Development Coordinator and the agency Medication Administration Trainer will pull all medication administration training records and confirm accurate completion and remedy any deficient training packets through correcting the documentation or re-training. |
12/22/2025
| Accepted |
| 6400.165(c) | Individual #1's prescription for Rybelsus indicates that the medication is to be given "30 minutes before first food, beverages, or other oral medications." On the following dates, this medication was administered at the same time as Individual #1's 8am medications:
· 5/2/25
· 5/16/25
· 6/15/25
· 6/27/25
· 7/1/25
· 7/19/25 | A prescription medication shall be administered as prescribed. | Although Individual #1 is no longer in our care, we recognize the importance of following specific medication administration instructions. Operationally, if we support an individual with a prescription that requires timing adjustments---such as Rybelsus, which must be given 30 minutes before food or other medications---we will request clarification from the prescribing provider to ensure exact timing requirements are documented. Our Medication Administration Trainer will update the MAR and staff instructions to reflect these requirements, and staff will be trained on the adjusted schedule before administering the medication. These steps will ensure compliance with prescription directions and prevent timing errors in the future. |
12/22/2025
| Accepted |
| 6400.167(a)(4) | The following medications were administered to Individual #1 more than one hour before or after the prescribed time:
· 5/17/25 -- 730am meds given at 221pm
· 5/24/25 -- 730am meds given at 1107am
· 6/30/25 -- 8am meds given at 210pm
· 7/28/25 -- 8am meds given at 1146am | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | Although Individual #1 is no longer in our care, we identified that the issue was late documentation during the transition to an electronic MAR, not late medication administration. To correct this operationally, we have implemented a policy requiring that if medication is signed off outside the prescribed time window, a supervisory note must confirm whether it was a documentation error versus an administration error. Additionally, the agency will maintain a record of these identified documentation errors and notify staff via email or Therap message to make the correction only after confirming that the medication was administered at the correct time. Staff have been retrained on timely documentation expectations, and supervisors will review these notes daily to ensure accuracy and accountability. These steps ensure medication records accurately reflect administration times and prevent similar discrepancies in the future. |
12/15/2025
| Accepted |
| 6400.169(a) | There is no documentation verifying that Staff Persons #1, 2, 7, 9, and 12 have completed the Medication Administration Training Course. These staff persons have administered medications to Individual #1. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | To correct this operationally, the Training and Development Coordinator and the agency Medication Administration Trainer have implemented a centralized system to track all medication administration certifications and competency validations. Staff who do not have verified documentation will be scheduled for retraining and competency validation to ensure compliance. |
12/22/2025
| Accepted |
| 6400.207(4)(I) | Individual #1 was administered PRN Trazodone 50mg for agitation on 10/15/25, 10/16/25, 10/24/25, and 10/25/25 with no written protocol in place from the physician or CEO approval for the administration. This constitutes a chemical restraint. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | Although Individual #1 is no longer in our care, we identified that PRN Trazodone was administered without a written protocol from the prescribing physician or CEO approval, which constitutes a chemical restraint. To prevent this in the future, the Director of Operations will be responsible for verifying all prescriptions during intake to ensure that any PRN medication includes a physician-approved protocol. For psychotropic PRN medications specifically, the Executive Director and agency nursing team will reconcile the prescription and confirm that all required documentation and approvals are in place before administration. These steps will be documented in the individual's record and reviewed by supervisory staff prior to implementation. This process ensures that PRN medications are administered only in accordance with regulatory requirements and approved protocols. |
12/15/2025
| Accepted |