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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.78(a) | At the time of the 05/27/26 inspection, Staff Person #1 made a bed out of blankets in the living room, between the couches, which prevented the Individuals that live in the home from accessing the space for their own use. | A home shall have living and dining areas that are separate from bedrooms. | Purpose of the requirement: Common living areas must remain available for the individuals' use and may not be converted into staff sleeping areas. This protects access, privacy, normal home life, supervision, and emergency egress.
Finding addressed: During the 05/27/2026 inspection, Staff Person #1 made a bed from blankets between the couches in the living room, preventing the individuals from using that portion of the common living space.
EIM status: The provider has already entered the event or events associated with this citation into EIM, and the related investigation or investigations are in process. The assigned Incident Management Representative/Certified Investigator will complete required notifications, interviews, record review, findings, and corrective-action recommendations within applicable timeframes. Final findings will be used to confirm or revise the preliminary root cause and to add any further individual-specific or systemic corrective action. The applicable EIM incident number(s) and actual entry date(s) will be included with the supporting evidence.
Preliminary root cause pending completion of the EIM investigation - confirm before submission: The apparent causes were failure to establish and enforce expectations for staff personal belongings and rest, insufficient overnight/early-morning supervisory checks, and scheduling practices that may not have adequately addressed staff fatigue.
Immediate and citation-specific corrective actions:
- 07/15/2026 - The bedding will be removed from the living room, the room will be inspected to confirm full access and unobstructed egress, and staff personal belongings will be stored only in the designated staff-storage area. No staff person may establish a bed or sleeping area in a living room, dining room, hallway, or other individual common area.
- 07/15/2026 - Staff Person #1 is no longer employed by the provider and will have no further assignment in the home. Human Resources and the Chief Executive Officer will document the separation and verify deactivation of all applicable schedule, electronic-record, medication, key, and building access. If Staff Person #1 is ever rehired, training on common-space access, awake/available supervision, and professional use of the individuals' home must be completed before assignment. The Chief Executive Officer will also review whether schedule length, overtime, or double shifts contributed and will adjust scheduling as needed to ensure alert and available staffing for current staff. |
07/31/2026
| Accepted |
| 6400.141(a) | Individual #1 had a physical on 1/16/25 and not again until 2/3/26. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Purpose of the requirement: Annual physical examinations identify changes in health, reconcile medication and treatment needs, update emergency information, and support timely preventive and specialty care.
Finding addressed: Individual #1 had a physical examination on 01/16/2025 and did not have the next physical examination until 02/03/2026, outside the annual interval.
EIM status: The provider has already entered the event or events associated with this citation into EIM, and the related investigation or investigations are in process. The assigned Incident Management Representative/Certified Investigator will complete required notifications, interviews, record review, findings, and corrective-action recommendations within applicable timeframes. Final findings will be used to confirm or revise the preliminary root cause and to add any further individual-specific or systemic corrective action. The applicable EIM incident number(s) and actual entry date(s) will be included with the supporting evidence.
Preliminary root cause pending completion of the EIM investigation - confirm before submission: The apparent cause was an ineffective due-date and appointment follow-up process. The annual physical was not scheduled with a sufficient advance window, and no manager-level report identified the approaching or missed due date.
Immediate and citation-specific corrective actions:
- 07/15/2026 - The Program Specialist will verify that the 02/03/2026 physical is complete, signed, dated, and filed and that all recommendations from that examination have been implemented or assigned for follow-up.
- 07/17/2026 - The Program Specialist will complete a 100% review of the last and next physical-examination due dates for all individuals in every agency Chapter 6400 home. Any overdue examination will be scheduled immediately, and the PCP will be asked to identify interim health instructions if the appointment cannot occur promptly. |
07/31/2026
| Accepted |
| 6400.141(c)(3) | Individual #1 had a TDAP immunization on 12/10/14 and not again until 9/22/25, outside of the 10-year recommended time period. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Purpose of the requirement: Review and timely completion of recommended immunizations reduce preventable illness and complications and ensure that the individual's annual physical and health record accurately address preventive health needs.
Finding addressed: Individual #1 received a Tdap immunization on 12/10/2014 and did not receive the next Tdap until 09/22/2025, outside the 10-year recommended interval.
EIM status: The citation-related event has been entered into EIM and is being investigated. The assigned Incident Management Representative/Certified Investigator will review the admission health documentation, subsequent physicals, immunization records, and the process used to identify preventive-health due dates. Final findings will be used to confirm the root cause and determine whether additional corrective action is required.
Preliminary root cause pending completion of the EIM investigation: Upon review, the provider identified that Individual #1 entered the program with a pre-existing lapse in Tdap compliance and that the admission review did not identify and resolve the overdue immunization before or immediately after admission. The admission and ongoing health-review processes did not contain a sufficiently reliable verification of required health documentation and immunization due dates.
Immediate and citation-specific corrective actions:
- Individual #1 received the Tdap immunization on 09/22/2025. The Program Specialist will verify the administration record, retain it in the health record, and obtain the PCP's written recommendation concerning the next due date or any additional follow-up.
- The provider reviewed the admission process and implemented additional safeguards so that required medical documentation, annual physical information, immunization history, and practitioner recommendations are reviewed before admission.
- The Admissions Team and designated supervisory/health-services staff will complete a thorough review of required medical documentation before accepting a new admission. The provider will not finalize an admission until all required regulatory health documentation has been received, reviewed, and confirmed as compliant.
- The Program Specialist will review the immunization record of every individual in agency Chapter 6400 homes against the most recent practitioner recommendations. Any overdue, missing, or unclear item will be referred promptly to the practitioner and tracked to completion. |
07/31/2026
| Accepted |
| 6400.141(c)(14) | The medical information pertinent to diagnosis and treatment in case of emergency section of Individual #2's 5/29/26 annual physical is blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Purpose of the requirement: Complete emergency medical information gives emergency responders and treating clinicians immediate access to facts that may affect diagnosis and treatment when delay or error could cause serious harm.
Finding addressed: The section for medical information pertinent to diagnosis and treatment in case of emergency was blank on Individual #2's 05/29/2026 annual physical examination.
Preliminary root cause: The apparent cause was failure to review the practitioner-completed physical for completeness before accepting and filing it. There was no second-level check for required fields or prompt return to the practitioner for a signed correction.
Immediate and citation-specific corrective actions:
- The provider will send the 05/29/2026 physical to the completing practitioner and request that the emergency-information section be completed, signed, and dated, or that the practitioner provide a signed addendum. Agency staff will not complete the medical section on the practitioner's behalf.
- Upon receipt, the provider will compare the completed information with Individual #2's emergency face sheet, diagnoses, allergies, medications, and ISP; correct any inconsistency through the appropriate source; and train staff on any new emergency instruction before their next shift.
- The provider will review every current annual physical in agency Chapter 6400 homes for all required elements, including emergency information, diet instructions, limitations, allergies, and health-maintenance recommendations. Incomplete documents will be returned to the practitioner within one business day. |
07/31/2026
| Accepted |
| 6400.144 | Individual #1 is prescribed the following medications: Nytsop, Celenium Sulfide, Ciproflax, Dexamethazone, Advil, and Lorazepam. None of these medications were available in the home at the time of the inspection on 5/27/26. On 2/5/26, the ENT ordered that Individual #1 have 2 drops of olive oil to be administered in each ear on Monday, Wednesday, and Friday. As of the 5/27/26 inspection, olive oil has not been administered to Individual #1. On 3/25/26, the doctor ordered Individual #1 to have a refit of their CPAP due to a recurrent scalp ulcer. As of the 5/27/26 inspection, this appointment has not been scheduled or completed. On 3/17/26, Individual #1's Weight Management physician recommended a diet of 1500-1600 calories per day, as well as 80 grams of lean protein daily and low calorie/high protein snacks 1-2 times per day. There is no tracking being completed by the provider agency to ensure that the individual is following this recommendation.
Individual #2 had a PCP appointment on 3/26/26 where it was noted that the individual had lower extremity edema for the past few days. The physician ordered a reduction in salt intake, elevation of legs, and compression stockings. If the edema worsened, the physician was to be notified. It was not documented that any of these recommendations were followed. On 4/30/26, the individual returned to the PCP for swollen ankles/edema. At this time, a new medication was prescribed. Individual #2 had an appointment with their kidney specialist on 12/18/25. It was recommended that follow up was to occur in 3 months. As of the 5/27/26 inspection, this follow-up appointment has not been completed. On 12/18/25, Individual #2's kidney specialist ordered twice daily blood pressure checks. If Individual #2's blood pressure was over 150/90, the physician was to be contacted. The individual's blood pressure was over the prescribed threshold on the following dates, and the physician was not contacted: · 12/31/25 6am -- 153/99 · 1/1/26 6am -- 151/99 · 1/2/26 6am -- 157/108 · 1/2/26 6pm -- 157/117 · 1/24/26 6pm -- 158/111 · 1/25/26 6pm -- 150/112 · 1/26/26 6pm -- 151/125 · 3/6/26 6pm -- 152/108 · 3/21/26 6pm -- 151/99 · 3/22/26 -- 156/98 · 4/6/26 730a -- 150/92 · 4/7/26 6pm -- 154/105 · 4/8/26 6pm -- 155/98 · 4/11/26 730am -- 150/112 · 4/11/26 6pm -- 182/125 · 4/12/26 730a -- 150/108 · 4/13/26 730a -- 153/99 · 4/17/26 6pm -- 152/94 · 4/18/26 6pm -- 150/92 · 5/1/26 6pm -- 152/103 · 5/13/26 6pm -- 160/96 · 5/15/26 730am -- 160/91 · 5/17/26 730am -- 160/100 · 5/29/26 730am -- 150/110 · 5/29/26 6pm -- 152/111 Additionally, blood pressure tracking was not completed from 6/1/26 through 6/6/26 in the morning, 6/8/26 in the evening, and 6/10/26 in the morning. On 10/18/24, Individual #2's physician recommended a 1400 calorie/day diet with no sweets permitted. On 5/29/25, the PCP recommended continuing this same diet. On 2/9/26, the PCP recommended limiting treats to once weekly and counting carbohydrates, not calories, limiting carbohydrates to 60 grams/day. This diet order was reaffirmed at Individual #2's 5/29/26 annual physical. There is no tracking in place to ensure that the individual has been following their diet recommendations. | 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.
| Purpose of the requirement: Prescribed medical, nursing, pharmaceutical, dietary, and specialty services must be carried out accurately and on time. Closed-loop implementation prevents untreated conditions, missed follow-up, worsening symptoms, and avoidable serious harm.
Finding addressed: Multiple prescribed or recommended services were not arranged, implemented, tracked, or documented: the 02/05/2026 ENT olive-oil ear treatment for Individual #1 was not administered; the 03/25/2026 CPAP refit for a recurrent scalp ulcer was not scheduled; the 03/17/2026 weight-management diet was not tracked; Individual #2's 03/26/2026 edema instructions were not documented as implemented and edema recurred; the 12/18/2025 kidney follow-up due in three months was not completed; ordered blood-pressure checks, threshold notifications, and multiple checks were missed; and Individual #2's diet recommendations were not tracked. The inspection narrative alternates between Individual #1 and Individual #2 when describing the 12/18/2025 blood-pressure order, so the original order must be verified before submission.
Preliminary root cause: The apparent systemic cause was the absence of a closed-loop medical-order and appointment-management process. Orders and recommendations were not consistently converted into the MARs, health plan, diet supports, staff training, and appointment calendar; completion was not verified; and supervisors did not audit open orders or unresolved appointments.
Immediate and citation-specific corrective actions:
- Ear treatment - The provider contacted the individual #1 physician to obtain clarification regarding the treatment instructions. A revised physician order was received from the doctor, dated 6/12/26, which states to administer 3 drops of olive oil in each ear daily for one week prior to the individual's next ENT appointment scheduled for August 12th.
- CPAP/scalp ulcer -- 6/16/2026 at 11:30AM Appointment -- Individual #1 attended appointment for fitting of new gear for CPAP.
- Individual #1 diet -- The provider created a new tracking form, and the form tracks the calories and lean protein. The provider obtained written diet recommendations from the weight-management practitioner addressing 1,500-1,600 calories, 80 grams of lean protein, and 1-2 low-calorie/high-protein snacks.
- Individual #2 edema -- The individual is wearing compression socks at nighttime. Staff will document edema observations, use of stockings/elevation, refusals, and any worsening and will notify the provider according to the written parameters.
- Kidney follow-up -- The provider spoke with the nurse at the kidney specialist and confirmed the notes from the 12/18/2025 appointment stated to follow up in 6 months. Appointment was completed on 6/18/2026 at 9:00AM.
- Blood pressure -- All applicable staff members have received training on blood pressure protocol and signed off on this training as of 6/19/2026. All applicable staff members have been retrained on the required blood pressure monitoring procedures, including obtaining readings as outlined in the individual's plan, documenting results accurately, and following established parameters for reporting abnormal readings. Blood pressure checks must be completed at the frequency and times specified within the individual's approved health care plan/protocol and that any missed readings, abnormal results, or concerns must be reported promptly to the appropriate supervisory personnel and healthcare provider as indicated.
- Individual #2 diet -- The provider created a new tracking form where all staff members document. This tracking tracks the calories and lean protein. |
07/31/2026
| Accepted |
| 6400.216(a) | At the time of the 5/27/26 inspection, the closet in the living room that housed the records for Individual #1 and Individual #2 was unlocked. | An individual's records shall be kept locked when unattended.
| Purpose of the requirement: Locking records when unattended protects privacy, dignity, confidentiality, and the integrity of sensitive medical, behavioral, financial, and personal information.
Finding addressed: During the 05/27/2026 inspection, Individual #1's and Individual #2's records were located in an unlocked closet in the living room.
Immediate and citation-specific corrective actions:
- Individual #1's and Individual #2's paper records were secured in a locked file cabinet, locked records container, or other secure locked area. Records will remain locked whenever they are not in the direct use of authorized personnel.
- The provider reviewed with all applicable current staff the requirements for confidentiality, security, and protection of individual records. Staff were retrained that individual files, medical records, medication documentation, and other protected information must be stored in a secure locked location when not actively in use and may be accessed only by authorized personnel.
- Staff were instructed that confidential records may not be left unattended on desks, counters, common-area furniture, or in an unlocked closet. Lost keys, suspected unauthorized access, or suspected disclosure must be reported immediately.
- The Quality Management Director will inspect record-storage areas in every agency Chapter 6400 home and administrative location. Any unsecured record will be secured immediately, and the cause will be corrected. |
07/31/2026
| Accepted |
| 6400.18(b)(2) | The medication errors described in 6400.167a1, 6400.167a3, and 6400.167a4 were not reported in the department's incident management system. | 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. | Purpose of the requirement: Timely medication-error reporting allows the Department and the provider to protect the individual, complete required clinical follow-up, investigate contributing factors, identify patterns, and implement corrective action before another error occurs.
Finding addressed: The medication errors described under §§ 6400.167(a)(1), 6400.167(a)(3), and 6400.167(a)(4), including alleged omitted doses, a wrong dose, and medications administered on dates identified by licensing as incorrect, were not reported in the Department's incident management system within the required timeframe.
EIM and investigation status: The provider reports that citation-related medication incidents are represented in open EIM investigations. The 05/25/2026 medication omission is associated with EIM 9854572, identified by the provider as a medication-error report, and EIM 9856567, identified by the provider as a neglect report. The provider has also requested written clarification regarding whether separate EIM reports are required for cited entries that the provider's record review indicates may involve guardian or individual self-administration, a pharmacy supply issue, a late or missing MAR signature, or a three-times-weekly order that did not name specific days. Any additional report directed by the Department will be entered immediately and linked to the investigation.
Preliminary root cause: The apparent systemic cause was the absence of a closed-loop process connecting MAR exceptions, pharmacy or supply problems, guardian/self-administration documentation, supervisor notification, and EIM reporting. Staff and supervisors did not consistently recognize that a blank MAR entry, late signature, unavailable medication, disputed administration responsibility, or possible medication variance required immediate supervisory and incident-management review rather than waiting for later record reconciliation.
Immediate and citation-specific corrective actions:
- EIM 9854572 and EIM 9856567 remain open and under investigation. The Incident Management Representative/Certified Investigator will retain the original MARs, pharmacy records, progress notes, practitioner communications, self-administration documentation, staff schedules, and related records; complete required notifications and interviews; and document the reason for any delayed report before closure.
- By 07/31/2026, the Incident Management Representative and Program Specialist will create a citation-by-citation crosswalk showing each medication, date, alleged error type, applicable EIM number, date entered, investigation status, prescriber/pharmacy follow-up, and any item for which written reporting clarification has been requested. If an item is not separately reported, the file will contain the written basis and any Department response.
- As of 07/15/2026, all applicable currently employed medication-administration staff and supervisors have been retrained on the Six Rights of Medication Administration, documentation at the time of administration, immediate reporting of medication concerns and errors, notification of supervisory and health-care personnel, and the requirement to preserve rather than alter the original medication record. Staff were instructed that a later investigation does not delay the initial EIM reporting obligation when an event is reportable. |
07/31/2026
| Accepted |
| 6400.31(a) | This violation is a summation of rights the individual was deprived of, see 6400.32d, 6400.32g, and 6400.32t. | An individual may not be deprived of rights as provided under § 6400.32 (relating to rights of the individual.). | Finding addressed: This is a summary citation for the rights violations described under §§ 6400.32(d), 6400.32(g), and 6400.32(t). Staff Person #1 used language that Individual #2 could not understand, repeatedly used a profane or derogatory Spanish term, and prevented Individual #2 from preparing or obtaining breakfast until staff-selected times even though the ISP documented independent breakfast preparation.
EIM status: The cited rights events have been entered into EIM and are being investigated. The assigned Incident Management Representative/Certified Investigator will complete required notifications, interviews, record review, findings, and corrective-action recommendations. Final findings will be used to confirm or revise the preliminary root cause and to implement any additional individual-specific or systemic corrective action.
Preliminary root cause: The apparent causes were inadequate staff understanding of individual rights and self-determination, failure to implement Individual #2's ISP, staff convenience being allowed to override the individual's choices, and insufficient supervisory observation of early-morning practices.
Immediate and citation-specific corrective actions:
- Staff Person #1 is no longer employed by the provider and will have no further assignment or contact with Individual #2. Human Resources and the Chief Executive Officer will retain the separation documentation
- Effective 07/13/2026, the provider revised its new-hire orientation process to require completion of the ODP training "The Right to Eat Too Many Donuts and Take a Nap: Self-Determination for ID/DD" and all applicable provider policies concerning individual rights. New hires may not complete orientation or begin independent work until these requirements are successfully completed and documented.
- By 07/31/2026, all currently employed direct-support, supervisory, program, scheduling, and on-call staff will complete targeted retraining on individual rights, informed choice, personal preferences, self-determination, respectful communication, control of schedules and activities, access to food, the difference between health education and an unauthorized restriction, and the duty to implement the ISP. |
07/31/2026
| Accepted |
| 6400.32(c) | On 12/29/25, the provider agency sent a message to Individual #1's physician indicating that the individual had pain and drainage in their left ear since Christmas break. The physician did not respond until 1/4/26, and an ENT appointment was not conducted until 1/5/26, when an ear infection was diagnosed. An antibiotic was prescribed at this time. This delay in care created conditions conducive to serious harm for Individual #1. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Purpose of the requirement: Prompt assessment and treatment of acute health symptoms protects an individual from preventable pain, worsening infection, serious injury, hospitalization, or death.
Finding addressed: On 12/29/2025, the agency notified Individual #1's physician that the individual had left-ear pain and drainage present since Christmas break. The physician did not respond until 01/04/2026, and an ENT visit did not occur until 01/05/2026, when an ear infection was diagnosed and an antibiotic was prescribed. The delay created conditions conducive to serious harm.
Preliminary root cause: The apparent cause was reliance on a non-urgent message without a defined escalation pathway when the physician did not respond. Staff did not obtain same-day clinical triage, contact an alternate or on-call provider, or escalate the unresolved concern to supervisory and health-services staff. |
07/31/2026
| Accepted |
| 6400.32(d) | At the time of the 05/27/26 inspection, Staff Person #1 was speaking in English and Spanish throughout the inspection, so Individual #2 could not understand what was being said. Individual #2's 02/02/26 Individual Support Plan (ISP) states that Individual #2's Primary Language is "English". Additionally, while speaking in Spanish, Staff Person #1 repeatedly used the word "cabròn", which translates to "bastard" or "ass" in English (the direct translation is "male goat", however, there were no goats in the home at the time of the inspection). It is unclear if Staff Person #1 was referring to the Individual, Licensing Staff, or someone that was on the phone with Staff Person #1 during the inspection. | An individual shall be treated with dignity and respect. | Purpose of the requirement: Respectful and understandable communication protects the individual's dignity, emotional well-being, participation, and ability to know what is occurring in the individual's home.
Finding addressed: During the 05/27/2026 inspection, Staff Person #1 spoke in English and Spanish even though Individual #2's ISP identifies English as the primary language. While speaking Spanish, Staff Person #1 repeatedly used a profane or derogatory term. It was unclear whether the term referred to Individual #2, licensing staff, or a person on the telephone.
Preliminary root cause: The apparent causes were unacceptable staff conduct, failure to maintain communication understandable to the individual, inadequate understanding of dignity and self-determination, and insufficient supervisory oversight of staff professionalism and rights practices.
Immediate and citation-specific corrective actions:
- Staff Person #1 is no longer employed by the provider and will have no further assignment or contact with Individual #2.
- Effective 07/13/2026, new-hire orientation requires the ODP training "The Right to Eat Too Many Donuts and Take a Nap: Self-Determination for ID/DD" and all applicable provider policies concerning individual rights. New hires may not complete orientation or work independently until completion is verified.
- By 07/31/2026, all current direct-support and supervisory staff will complete retraining on dignity and respect, professional language, communication in the individual's preferred language, informed choice, personal preferences, confidentiality during telephone conversations, and the prohibition against humiliating, profane, insulting, or derogatory speech. |
07/31/2026
| Accepted |
| 6400.32(g) | At the time of the 05/27/26 inspection, Staff Person #1 told Individual #2 that Individual #2 "can't have breakfast until 6" at 5:35am and later stated that Individual #2 "can't have breakfast until 6:15 when staff arrive". Per Individual #2's 02/02/26 ISP, Individual #2 can prepare breakfast independently. | An individual has the right to control the individual's own schedule and activities. | Purpose of the requirement: An individual's control over daily routines promotes autonomy, independence, informed choice, and person-centered services. Staff schedules and convenience may not replace the individual's preferences or documented abilities.
Finding addressed: At 5:35 a.m. on 05/27/2026, Staff Person #1 told Individual #2 that breakfast could not be eaten until 6:00 a.m. and later stated that breakfast could not occur until 6:15 a.m. when other staff arrived. Individual #2's 02/02/2026 ISP documents the ability to prepare breakfast independently.
Preliminary root cause: The apparent causes were an informal staff-imposed morning schedule, inadequate understanding of self-determination and the ISP, and insufficient supervisory observation of early-morning practices. Staff convenience was allowed to override Individual #2's documented independence and preference.
Immediate and citation-specific corrective actions:
- Staff Person #1 is no longer employed by the provider and will have no further assignment or contact with Individual #2.
- On 07/15/2026, the Program Specialist and House Manager informed Individual #2, in plain English, that the individual may choose when to begin the morning routine and may prepare breakfast independently as documented in the ISP. Staff will provide assistance only when requested or required by the current plan.
- The House Manager verified that food, utensils, and appliances needed for breakfast are accessible and that no staff-created schedule prevents use. Any legitimate safety concern will be addressed through assessment and the individual-plan process rather than an informal restriction.
- Effective 07/13/2026, the provider's new-hire orientation requires the ODP training "The Right to Eat Too Many Donuts and Take a Nap: Self-Determination for ID/DD" and all applicable individual-rights policies.
- By 07/31/2026, all current direct-support, supervisory, scheduling, and on-call staff will complete retraining on informed choice, personal preferences, control of schedules and activities, implementation of documented independence, and the prohibition against staff-created routines that are not supported by the ISP. |
07/31/2026
| Accepted |
| 6400.32(t) | At the time of the 05/27/26 inspection, Staff Person #1 told Individual #2 that Individual #2 "can't have breakfast until 6" at 5:35am and later stated that Individual #2 "can't have breakfast until 6:15 when staff arrive". Per Individual #2's 02/02/26 ISP, Individual #2 can prepare breakfast independently. | An individual has the right to access food at any time. | Purpose of the requirement: Continuous access to food protects personal choice, dignity, comfort, and health. Medical or dietary recommendations must be supported in a person-centered manner and may not be converted into an unapproved denial of food.
Finding addressed: On 05/27/2026, Staff Person #1 told Individual #2 that breakfast was not permitted until 6:00 a.m. and later 6:15 a.m., although the ISP states that Individual #2 can prepare breakfast independently.
EIM status: The cited rights event has been entered into EIM and is being investigated. The assigned Incident Management Representative/Certified Investigator will complete required notifications, interviews, record review, findings, and corrective-action recommendations. Final findings will determine whether any other food-access restrictions occurred and whether additional corrective action is required.
Preliminary root cause pending completion of the EIM investigation: The apparent causes were an informal staff-controlled meal schedule, inadequate understanding of the right to access food at any time, failure to implement the ISP, and insufficient management verification that food and the kitchen remained available.
Immediate and citation-specific corrective actions:
- Staff Person #1 is no longer employed by the provider and will have no further assignment or contact with Individual #2. Separation and access-deactivation records will be retained.
- On 07/15/2026, the House Manager verified that Individual #1 and Individual #2 have access to food, beverages, the kitchen, and needed meal-preparation items at all times, subject only to individualized, approved, and documented health or safety supports. No staff person may deny food because of the time, staffing pattern, behavior, or staff convenience.
- The Program Specialist reviewed or will document reviewing the kitchen and food preferences with both individuals and will identify any needed assistance, adaptive equipment, or safety support. Any lock, blocked cabinet, withheld item, or staff-only rule that prevents access will be removed unless supported by an approved rights modification.
- Effective 07/13/2026, the provider's new-hire orientation requires the ODP training "The Right to Eat Too Many Donuts and Take a Nap: Self-Determination for ID/DD" and all applicable provider policies concerning individual rights.
- By 07/31/2026, all current direct-support and supervisory staff will complete retraining on informed choice, personal preferences, access to food, person-centered support of medical diet recommendations, respectful documentation of choices or refusals, and the difference between offering health education and denying food. |
07/31/2026
| Accepted |
| 6400.44(b)(2) | The Program Specialist is responsible for the implementation of the Individual Support Plan (ISP) developed for Individual #2 on 02/02/26; see violations 6400.32d and 6400.32t. | 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. | Purpose of the requirement: The Program Specialist is a central safeguard for translating the ISP into daily services. Active participation in plan development, review, and implementation prevents staff from substituting personal practices for the individual's assessed needs, skills, and rights.
Finding addressed: The Program Specialist was responsible for implementation of Individual #2's 02/02/2026 ISP, but the practices cited under §§ 6400.32(d) and 6400.32(t) showed that staff did not implement the plan and rights requirements.
Immediate and citation-specific corrective actions:
- 07/15/2026 - The Program Specialist will complete a line-by-line implementation review of Individual #2's ISP, assessments, health plans, protocols, and rights information with Individual #2 and the House Manager. The review will identify the exact staff actions required for breakfast independence, food access, communication, health supports, and all other current outcomes and needs.
- As of 07/15/2026, the Program Specialist compared the current ISP and protocol requirements with the training records and work schedule. All currently employed staff assigned to or previously working at the cited home completed the required person-specific training, and the Program Specialist established an approved-to-work roster. Staff without current training may not be independently assigned. |
07/31/2026
| Accepted |
| 6400.52(c)(6) | Individual #1 and Individual #2 both have an Individual Support Plan (ISP) and plans and protocols that staff are to be trained in before working with the individuals. From 12/1/25 through 5/27/26, the only staff who were fully trained to work with both individuals in this home were Staff Persons #2, 3, and 7. The other 9 staff who worked in the home were only partially trained or not trained at all. | 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. | Purpose of the requirement: Person-specific training ensures that staff know how to safely and consistently implement each individual's ISP, Behavior Support Plan when applicable, medical orders, plans, protocols, communication needs, rights, and independence skills before providing unsupervised services.
Finding addressed: From 12/01/2025 through 05/27/2026, only Staff Persons #2, #3, and #7 were fully trained to work with both individuals. Staff Persons #1, #4, #5, #6, #8, #9, #10, #11, and #12 were partially trained or not trained but worked in the home. Staff Persons #1, #2, #5, #7, and #12 are no longer employed; their current employment status does not change the historical finding.
Immediate and citation-specific corrective actions:
- As of 07/15/2026, all currently employed staff who are assigned to, or who previously worked at, the cited home identified by the provider as "230" have completed training on each individual's current ISP, BSP when applicable, all required health and behavioral plans and protocols, communication and rights supports, emergency information, dietary and medication-related instructions, and any additional training necessary to support both individuals safely and effectively.
- The currently employed cited staff covered by this correction are Staff Persons #3, #4, #6, #8, #9, #10, and #11. Training records will identify the exact plans and protocols reviewed, the trainer, completion date, staff signature or electronic acknowledgement, and any competency or return demonstration required for hands-on tasks.
- Human Resources and management have documented that Staff Persons #1, #2, #5, #7, and #12 are no longer employed and have removed them from active schedules and access rosters. If any former employee is rehired, all current orientation and person-specific training must be completed before assignment or access is restored.
- The and Program Specialist reviewed the training records and established an approved-to-work roster for the home. Only staff whose required person-specific training is current may work independently or perform a task covered by a plan or protocol. |
07/15/2026
| Accepted |
| 6400.162(b)(2)(iii) | Staff persons #1, 2, 3, 4, 5, 6, 8, 9, and 10 were not trained in administering eye drop medications. These staff administered eye drops 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: Eye, nose and ear drop medications. | Purpose of the requirement: Route-specific medication training and competency protect the individual from contamination, injury, incorrect technique, missed treatment, and ineffective medication administration.
Finding addressed: Staff Persons #1, #2, #3, #4, #5, #6, #8, #9, and #10 administered eye-drop medications to Individual #1 without documented qualification in administering eye-drop medications. Staff Persons #1, #2, and #5 are no longer employed; their current employment status does not change the historical finding.
Immediate and citation-specific corrective actions:
- Currently employed Staff Persons #3, #4, #6, #8, #9, and #10 are not permitted to administer eye, nose, or ear drops until the approved training and competency are completed and documented. Coverage will be provided by a staff person whose route-specific qualification is current or by a licensed health professional.
- Human Resources, the House Manager, and the Medication Administration Trainer will retain documentation that Staff Persons #1, #2, and #5 are no longer employed and that their medication and other applicable access has been deactivated. If any is rehired, all current medication-administration and route-specific training requirements must be completed before medication access is restored.
- The provider contacted a doctor to obtain approved training on the proper administration of eye drops, ear drops, and nasal sprays. The provider will retain documentation of the training source, approval status, curriculum, and trainer qualifications.
- Within five business days after the approved training is received, and before any affected staff person resumes drop administration, all currently employed cited staff and all other medication-administration staff who may administer these routes in any agency home will complete the training and demonstrate competency in hand hygiene, correct individual/medication/site/dose, positioning, infection control, avoiding contact with the dropper, documentation, and response to refusal or adverse symptoms.
- The Medication Administration Trainer will complete an agency-wide route-qualification audit and will block each staff person from any medication route not supported by current training and competency.
- The Program Specialist will review Individual #1 for any current eye, ear, or nasal concern related to medication administration and will contact the practitioner if follow-up is indicated. |
07/31/2026
| Accepted |
| 6400.163(d) | At the time of the 5/27/26 inspection, the closet that held the medications was unlocked. The medications for Individual #1 were in a locked box. However, the controlled substances were not double locked. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Purpose of the requirement: Secure medication storage prevents unauthorized access, diversion, accidental ingestion, theft, and harm. Controlled substances require reliable access control, count verification, and staff accountability.
Finding addressed: During the 05/27/2026 inspection, Lorazepam, a controlled substance, was not double locked and was located in an unlocked living-room closet.
Immediate and citation-specific corrective actions:
- On 07/15/2026, the provider trained the House Manager on the required procedure for storing controlled substances. The House Manager then retrained all applicable currently employed medication-administration staff on locked storage, the provider's double-lock procedure for controlled substances, key control, count verification, and immediate reporting of a broken lock, missing key, or count discrepancy.
- On 07/15/2026, the House Manager verified and documented that Lorazepam and all other controlled substances in the home were maintained in the required locked medication area or container and that access was limited to authorized medication staff.
- Lorazepam was discontinued on 06/23/2026. The Program Specialist will retain the signed discontinuation order and documentation showing that any remaining supply was returned to the pharmacy or destroyed in accordance with applicable requirements.
- Two authorized staff, or an authorized staff person and supervisor, reconciled or will document reconciliation of the Lorazepam quantity against the pharmacy record, controlled-substance count record, and MAR. Any unexplained discrepancy will be reported and investigated immediately.
- The Program Specialist and Quality Management Director will inspect medication storage, refrigerator storage, keys, controlled-substance security, and count records in every agency Chapter 6400 home. Any unsecured medication will be secured immediately and the contributing cause corrected. |
07/15/2026
| Accepted |
| 6400.165(c) | Individual #1 is prescribed Vitamin D2 that is to be administered twice a week. This medication was administered on 5/1/26, 5/3/26, 5/5/26, and 5/7/26; four times in one week. | A prescription medication shall be administered as prescribed. | Purpose of the requirement: Administering a prescription medication exactly as prescribed protects the individual from excessive dosing, adverse effects, toxicity, ineffective treatment, and avoidable medical complications. Non-daily medications require clear day-of-week scheduling and accurate medication-record documentation so that doses are neither omitted nor administered too often.
Finding addressed: Individual #1 is prescribed Vitamin D2 to be administered twice each week. Vitamin D2 was administered on 05/01/2026, 05/03/2026, 05/05/2026, and 05/07/2026, resulting in four administrations during one week instead of the prescribed twice-weekly schedule.
Immediate and citation-specific corrective actions:
- 07/15/2026 - The Program Specialist will notify Individual #1's prescribing practitioner and dispensing pharmacy of the exact Vitamin D2 administration dates and doses, obtain written direction regarding the current twice-weekly schedule, whether any upcoming dose is to be held or changed, and whether a clinical evaluation, laboratory work, or other follow-up is required. Staff will administer or withhold future doses only in accordance with the practitioner's written direction.
- 07/15/2026 - A qualified health professional will assess Individual #1 for any current symptoms or possible adverse effects and will arrange urgent or emergency evaluation when directed by the practitioner or when clinically indicated. The assessment, practitioner contact, instructions received, and completion of all follow-up will be documented in the health record.
- 07/15/2026 - The Program Specialist and House Manager will reconcile the current written Vitamin D2 order, pharmacy label, medication supply, and MAR. The MAR will be corrected prospectively to show the exact practitioner-approved days and administration time. Historical entries will not be erased, overwritten, or back-initialed.
- 07/17/2026 - The Program Specialist will complete a 100% review of Individual #1's Vitamin D2 administrations from the beginning of the current order through 07/15/2026 and will review all weekly, twice-weekly, monthly, alternating-day, and other non-daily medications for Individual #1 and Individual #2 from 12/01/2025 through 07/15/2026. A 90-day sample of non-daily medications will also be reviewed in every agency-operated Chapter 6400 home. Each additional variance will receive immediate clinical follow-up, medication-error reporting, and correction. |
07/31/2026
| Accepted |
| 6400.167(a)(1) | Individual #1 was not administered the following medications:
· 1/29/26 -- Zepbound
· 2/9/26 -- 7am Sertraline
· 5/15/26 -- 8am Folic Acid, Liothyronine Sodium
· 5/22/26 -- 8am Folic Acid, Liothyronine Sodium
· 5/25/26 -- 5pm Buspirone
· 5/28/26 -- Zepbound
Individual #1 is prescribed Ferrous Sulfate to be given 3 times weekly on Monday, Wednesday, and Friday. On the following dates, the prescribed dose was omitted:
· 5/11/26
· 5/15/26
· 5/20/26
· 5/22/26
· 5/25/26 | Medication errors include the following: Failure to administer a medication. | Purpose of the requirement: Administering each medication as prescribed is essential to maintain therapeutic benefit and prevent worsening psychiatric, endocrine, hematologic, metabolic, or other health conditions. Accurate contemporaneous documentation is necessary to establish whether a dose was administered and to identify an omission immediately.
Finding addressed: Licensing identified that Individual #1 did not receive Zepbound on 01/29/2026 and 05/28/2026; Sertraline at 7:00 a.m. on 02/09/2026; Folic Acid and Liothyronine Sodium at 8:00 a.m. on 05/15/2026 and 05/22/2026; Buspirone at 5:00 p.m. on 05/25/2026; and Ferrous Sulfate on 05/11/2026, 05/15/2026, 05/20/2026, 05/22/2026, and 05/25/2026.
EIM and investigation status: The 05/25/2026 medication omission is associated with EIM 9854572, identified by the provider as a medication-error report, and EIM 9856567, identified by the provider as a neglect report. Other citation-related medication matters are being reviewed through the open investigations. The provider emailed for written clarification regarding whether separate EIM reports are required for the cited entries that the provider's record review indicates may be guardian/self-administered doses, pharmacy-supply events, or documentation exceptions rather than confirmed omitted doses. The 05/28/2026 Zepbound event was not separately entered because Individual #1 self-administers the medication under practitioner authorization and administered the dose on 05/29/2026 after a pharmacy delay and practitioner approval to move the weekly date. Any additional EIM report directed by the Department will be entered immediately.
Preliminary root cause pending completion of the EIM investigation: The cited events appear to involve multiple contributing factors rather than one cause: unclear documentation of whether the guardian, Individual #1, or provider staff were responsible for Zepbound; a pharmacy-supply error; missing or late MAR signatures; weak end-of-shift review of MAR blanks; ambiguity between a three-times-weekly order and an assumed Monday/Wednesday/Friday schedule; and failure to escalate each discrepancy immediately for clinical and EIM review.
Provider record review and citation-specific response:
- 01/29/2026 Zepbound: The medication record states that the guardian administers this medication, and Staff Person #1 was working. The provider will retain the applicable order, self-administration/guardian-administration documentation, staff schedule, and guardian confirmation to establish responsibility and whether a provider-administered dose was due.
- 02/09/2026 7:00 a.m. Sertraline: The provider identified this as a missed dose related to a pharmacy error while Staff Person #2 was assigned. Staff Person #2 is no longer employed. The pharmacy was notified, and the provider will retain the pharmacy communication and any practitioner follow-up.
- 05/15/2026 Folic Acid and Liothyronine Sodium: Staff Person #4 was assigned. The provider located documentation indicating the medications were given, but the MAR signature was missing. The original MAR and supporting contemporaneous documentation will be preserved for the investigation. This will be treated as a medication-documentation exception unless and until the investigation confirms an omitted dose.
- 05/22/2026 Folic Acid and Liothyronine Sodium: Staff Person #1 was assigned. The MAR was signed after the missing entry was identified. The later signature will be identified as a late entry and will not be used by itself as proof of timely administration. The investigation will review contemporaneous records and interviews to determine whether the doses were administered.
- 05/25/2026 5:00 p.m. Buspirone: The missed dose is included in EIM 9854572 and EIM 9856567 and remains under investigation.
- 05/28/2026 Zepbound: The pharmacy was out of stock until the following day, and the guardian who typically administered the medication was hospitalized and unavailable. The practitioner approved moving the weekly administration date, and Individual #1 self-administered the medication on 05/29/2026. Melinda Jimenze, NP, signed documentation authorizing Individual #1 to self-administer Zepbound. The provider will retain the pharmacy record, practitioner direction, self-administration authorization, guardian-administration information, and 05/29/2026 administration documentation.
- Ferrous Sulfate: The signed order directs administration three times weekly and does not identify specific days. For the weeks containing 05/20/2026 and 05/22/2026, the provider's review indicates that the medication was administered three times during the week in accordance with the written frequency. Health Direct prepared the medication packs and selected the administration days. The provider has communicated with Health Direct, which now packages Ferrous Sulfate for Monday, Wednesday, and Friday to eliminate ambiguity. The 05/11/2026, 05/15/2026, and 05/25/2026 entries will remain under record and EIM review; the 05/25/2026 omission is included in EIM 9854572 and EIM 9856567.
Immediate and citation-specific corrective actions:
- The Program Specialist will reconcile all current Zepbound, Sertraline, Folic Acid, Liothyronine Sodium, Buspirone, and Ferrous Sulfate orders with the pharmacy profile, medication supply, self-administration assessment, and MAR. Any current ambiguity concerning who administers a medication or the exact days/times will be clarified in writing before the next dose.
- The provider will submit the cited dates and supporting records to the applicable practitioners and pharmacy and will complete any clinical, laboratory, or treatment follow-up directed.
- As of 07/15/2026, all applicable currently employed medication-administration staff have been retrained on the Six Rights of Medication Administration, following practitioner orders and MARs, documentation at the time of administration, non-daily medications, self-administration documentation, supply problems, and immediate reporting of medication concerns and errors.
- Staff were specifically instructed that original MAR entries may not be erased, overwritten, or back-initialed to conceal a blank. A late entry must be clearly identified as late and supported by contemporaneous documentation.
- The provider established pharmacy-supply escalation: staff will notify the supervisor and pharmacy immediately when a medication is unavailable; the supervisor will seek emergency supply or practitioner direction before the dose is due; and the response will be documented. |
07/31/2026
| Accepted |
| 6400.167(a)(3) | Individual #1 was prescribed an extra 50mcg dose of Synthroid to be administered on Mondays only with their regular daily 200mcg dose. Beginning 3/1/26, this Monday dose was no longer administered. There is no doctor's order discontinuing this supplemental dose.
Individual #1 is prescribed Ferrous Sulfate to be given 3 times weekly on Monday, Wednesday, and Friday. On the following dates, the wrong dose was administered:
· 5/5/26 -- Extra dose given | Medication errors include the following: Administration of the wrong dose of medication. | Purpose of the requirement: Accurate dosing prevents under-treatment, toxicity, abnormal laboratory values, adverse effects, and avoidable medical emergencies. Supplemental and non-daily medications require exact reconciliation of the written order, pharmacy packaging, and MAR.
Finding addressed: Individual #1's extra 50 mcg Monday dose of Synthroid was no longer administered beginning 03/01/2026 even though there was no discontinuation order. Individual #1 was also cited as receiving an extra dose of Ferrous Sulfate on 05/05/2026.
EIM status: The cited medication matters are represented in open EIM review and investigation. The Incident Management Representative/Certified Investigator will preserve the original orders, MARs, pharmacy profiles, laboratory and practitioner information, and will complete required notifications, findings, and corrective actions. Any additional report directed by the Department will be entered immediately.
Preliminary root cause pending completion of the EIM investigation: The apparent causes were failure to reconcile a supplemental Monday Synthroid order during MAR changes, acceptance of an undocumented change to the medication schedule, ambiguity in a Ferrous Sulfate order written only as three times weekly, and absence of a second check for complex or non-daily dosing.
Immediate and citation-specific corrective actions:
- The Program Specialist will obtain a current signed Synthroid order clarifying the daily 200 mcg dose and whether the supplemental 50 mcg Monday dose remains active. The practitioner will receive the dates of missed supplemental doses and will direct any laboratory, monitoring, or treatment follow-up. Staff will not resume, discontinue, or alter the supplemental dose without written direction.
- The original Ferrous Sulfate order dated 04/09/2025, states that the medication is to be given three times weekly and does not name specific days. The Program Specialist will review the total number of Ferrous Sulfate doses administered during the week containing 05/05/2026 to determine whether the cited dose resulted in more than three doses that week. If the weekly frequency was exceeded, the practitioner will be notified, and the error will be reported and investigated.
- The provider has communicated with Health Direct, which now packages Ferrous Sulfate for Monday, Wednesday, and Friday. The current written order, pharmacy profile, medication pack, and MAR will be made consistent so staff have one clear schedule.
- As of 07/15/2026, all applicable currently employed medication staff have been retrained on the Six Rights of Medication Administration, complex and supplemental dosing, written-order requirements, documentation at the time of administration, and immediate reporting of any wrong or questioned dose.
- The Program Specialist will review every supplemental, taper, alternating, weekly, and other non-daily medication order for Individual #1 and Individual #2 and will complete an agency-wide sample. Any mismatch will be clarified before the next dose. |
07/31/2026
| Accepted |
| 6400.167(a)(4) | Individual #1 is prescribed Ferrous Sulfate to be given 3 times weekly on Monday, Wednesday, and Friday. On the following dates, the medication was administered on the wrong date:
· 5/14/26
· 5/21/26
· 5/23/26
· 5/26/26 | 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. | Purpose of the requirement: Medication must be administered according to the prescribed frequency and schedule so that the intended therapeutic interval is maintained and duplicate, omitted, or mistimed doses are prevented.
Finding addressed: Licensing identified that Individual #1's Ferrous Sulfate was administered on the wrong dates of 05/14/2026, 05/21/2026, 05/23/2026, and 05/26/2026 based on an expected Monday/Wednesday/Friday schedule.
EIM status: The cited medication dates are under EIM and record review. The provider has requested clarification because the underlying signed order states three times weekly and did not identify Monday, Wednesday, and Friday.
Preliminary root cause: The apparent causes were an ambiguous non-daily order, reliance on the dispensing pharmacy's blister-pack dates without a documented provider verification, and inconsistent assumptions that three times weekly meant Monday/Wednesday/Friday even though those days were not stated in the signed order.
Immediate and citation-specific corrective actions:
- The provider reviewed the initial Ferrous Sulfate order from the 04/09/2025 appointment. The order states that the medication is to be administered three times weekly and does not specify particular days.
- Health Direct prepared the medication packs and selected the administration days. The provider has communicated with Health Direct, and the pharmacy now packages Ferrous Sulfate for Monday, Wednesday, and Friday to create a consistent schedule.
- The Program Specialist will obtain or retain a current signed order that clearly states the intended frequency and, when the practitioner agrees, the specific Monday/Wednesday/Friday schedule. The pharmacy profile, medication packs, and MAR will match the signed order before further administration.
- The Program Specialist will review each cited week to determine the total number of Ferrous Sulfate doses administered. If more or fewer than three doses were given during any week, the practitioner will be notified and the variance will be reported and investigated as required.
- As of 07/15/2026, all applicable currently employed medication staff have been retrained on the Six Rights of Medication Administration, checking the current signed order, reviewing the date and prior doses before administering a non-daily medication, and immediately reporting any discrepancy.
- The provider will retain the written request for clarification concerning whether the cited dates constitute wrong-date errors under the order as written. Regardless of the final citation determination, the provider has eliminated future ambiguity by aligning the practitioner order, Health Direct packaging, and MAR. |
07/31/2026
| Accepted |
| 6400.186 | Staff person #1 did not implement Individual #2's 02/02/26 Individual Support Plan; see violations 6400.32d, 6400.32g, and 6400.32t. | The home shall implement the individual plan, including revisions. | Purpose of the requirement: The ISP is the authorized, person-centered direction for services. Consistent implementation protects the individual's health, safety, rights, choices, and progress toward outcomes.
Finding addressed: Staff Person #1 did not implement Individual #2's 02/02/2026 ISP, as shown by the use of language the individual could not understand and the restrictions on breakfast timing and food access described under §§ 6400.32(d), 6400.32(g), and 6400.32(t).
EIM status: The provider has already entered the event or events associated with this citation into EIM, and the related investigation or investigations are in process. The assigned Incident Management Representative/Certified Investigator will complete required notifications, interviews, record review, findings, and corrective-action recommendations within applicable timeframes. Final findings will be used to confirm or revise the preliminary root cause and to add any further individual-specific or systemic corrective action. The applicable EIM incident number(s) and actual entry date(s) will be included with the supporting evidence.
Preliminary root cause pending completion of the EIM investigation - confirm before submission: The apparent causes were incomplete or ineffective person-specific training for Staff Person #1, lack of competency verification, and insufficient Program Specialist observation of ISP implementation on the early-morning shift.
Immediate and citation-specific corrective actions:
- 07/15/2026 - Staff Person #1 is no longer employed by the provider and will have no further assignment or contact with Individual #2. Human Resources and the Chief Executive Officer will document the employment separation, remove the former staff person from all schedules and authorization rosters, and verify deactivation of electronic-record, medication, key, building, and other agency access, as applicable. The associated event was entered into EIM and is being investigated using available records and interviews. If Staff Person #1 is ever rehired, complete current ISP, rights, communication, breakfast-independence, food-access, health-and-safety training, competency, and written authorization will be required before assignment.
- 07/15/2026 - The Program Specialist will review the ISP with Individual #2 and document whether the plan accurately reflects the individual's current skills and preferences. Any needed revision will be requested through the plan team; current supports and rights will remain in effect while revisions are pending.
- As of 07/15/2026, all currently employed staff assigned to or previously working at the cited home completed training on every current ISP, BSP when applicable, plan, and protocol element for both individuals, with competency documented as required under the corrective action for § 6400.52(c)(6). |
07/31/2026
| Accepted |
| 6400.207(4)(I) | On 12/11/25 at 7:00, Individual #1 was administered a PRN Lorazepam for "difficulty sleeping." This medication is to be utilized PRN for anxiety or agitation. The administration of this PRN medication for an unprescribed reason constitutes a chemical restraint. Additionally, there is no protocol in place for this medication that describes Individual #1's "signs and symptoms" that permit the administration of the PRN medication. | 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. | Purpose of the requirement: A medication may be used only for its prescribed clinical purpose and under clear practitioner direction. Using a PRN medication for an unprescribed reason can suppress behavior, mask an unmet need, cause adverse effects, and constitute a prohibited chemical restraint.
Finding addressed: On 12/11/2025 at 7:00, Individual #1 received PRN Lorazepam for "difficulty sleeping," although the medication was prescribed PRN for anxiety or agitation. There was no protocol defining the observable signs and symptoms that permitted administration.
EIM status: The Lorazepam event has been entered into EIM and is being investigated. The Incident Management Representative/Certified Investigator will complete required notifications, interviews, record review, findings, and corrective-action recommendations and will determine whether any other PRN administration was outside the prescribed indication.
Preliminary root cause pending completion of the EIM investigation: The apparent causes were an incomplete PRN protocol, failure to translate the prescribed indication into observable criteria and staff steps, use of the medication for an unprescribed reason, and failure to identify the variance through prompt PRN review.
Immediate and citation-specific corrective actions:
- On 06/23/2026 at 12:30 p.m., Individual #1 attended an appointment to clarify the signs and symptoms that would permit PRN Lorazepam administration.
- The practitioner reviewed that Individual #1 did not typically use Lorazepam and had not received it since 12/11/2025. The doctor discontinued the Lorazepam on 06/23/2026.
- The Program Specialist will retain the signed discontinuation order, remove the medication from the current MAR and pharmacy profile, notify all assigned staff, and retain documentation that any remaining supply was returned to the pharmacy or destroyed in accordance with applicable requirements.
- The Program Specialist and Program Specialist will review all PRN Lorazepam documentation for the preceding 12 months to confirm that no additional dose was administered after 12/11/2025 and to identify any other use outside the prescribed indication. Any additional variance will receive clinical follow-up and incident reporting.
- Because the medication was discontinued, a new Individual #1 Lorazepam protocol is no longer required. The provider will nevertheless complete an agency-wide review of active PRN psychotropic medications to ensure that each has a current written order, a person-centered protocol when required, observable signs and symptoms, permitted indications, dose/frequency/maximum, monitoring, and documentation instructions before staff may administer it. |
06/23/2026
| Accepted |
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