| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | The Systemic abuse of individual #1 started on 7/14/2024 when police were called at around 4:30pm of an apparent obduction. Individual 1was seen on the ground with 3 women on top of her trying to restrain her feet with ropes and belts, and then shoved her in the back seat of a red SUV. These actions are prohibited under 6400.207(5) as a mechanical restraint. This systemic abuse continued on 7/29/2024 with staff restraining individual 1 and striking her in the eye causing a black eye and many bruises all over her body. The staff members brought Individual 1 to Staff Member 1's home; Individual 1 indicated during an interview with licensing staff that being taken to a staff member's home is a known trigger for their behaviors. They indicated staff brought them there because they had left something at the home they had to pick up. While Staff Member 1 was inside the house, the individual tried to leave the vehicle, and when Staff Member 1 returned to the car, the three staff members restrained her. The individual began to touch Staff Member 3 inappropriately, at which point Staff Member 2 struck her. They pulled over and all three exited the car. The individual began to hit all 3 staff members, who responded by restraining the individual's hands and ankles and holding them down and binding their ankles. Police came after being called by a passer-by who reported this as a possible kidnapping, but ultimately police left the individual in the staff members' care after a supervisor was called who helped the individual calm down. Afterwards, the staff members brought the individual home. The individual began to remove their clothing, and the individual stated that Staff Member 2 filmed them doing so. The individual asked them to stop filming but is unsure if they did, as they still held the phone's camera toward them. The individual tried to touch Staff Member 1 inappropriately, and the staff member responded by punching them in the eye and knocking them down. This sequence of events occurred twice in a row: the individual tried to touch a staff member and the staff responded by striking and knocking them down. During their interview with the individual, licensing staff noted that the individual had a black eye and light bruises on their arms, the shape of which is consistent with hands/fingers. | 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. | Upon discovery of the incident, Martha's Way took immediately action to protect the health, safety, and well-being of individual #1. Martha's Way conducted a certified investigation into the abuse allegations of individual #1. Martha's Way immediately removed the target staff members Staff 1, Staff 2, and Staff 3 from working with any other individuals receiving services from Martha's Way. Martha's Way's leadership team will conduct an in-depth analysis of the incident to reevaluate the agency's restrictive procedures & policies, incident management policies, crisis plans for individuals, and training policies to prevent future occurrences of abuse and/or rights violations. |
09/15/2024
| Not Accepted |
| 6400.43(b)(1) | Martha's Way has a policy that requires the restriction to be added to the behavior support plan, which individual #1's BSP does not have a restraint component to the plan. Also, the agency's policy around company van use limits the individual's access to safe transportation. Individual #1 requires being seated safely away from the driver to prevent the driver from being impacted by any of the individual's behaviors that might cause a distraction from the road. This space can be afforded by the agency's vans, but vans must be requested ahead of time and only certain drivers may use them. On the day of the individual's abuse in a public setting, no vans or alternate safe transportation were made available to the staff and individual, resulting in an off-duty staff member providing transport in their own car, which does not provide the individual the space they need to travel safely. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Martha's Way CEO met with individual #1 behavioral specialist, program specialist and house supervisor to review their individual support plan, behavioral support plan and crisis plan to determine all support needs required for the individual.
The CEO and leadership team conducted a review of Martha's Way transportation policy to revised and developed new transportation procedures to align with each residential program transportation needs.
The CEO audited individual #1s main file record to ensure that the behavioral support plan included the restrictive plan that was developed by the behavioral specialist.
Martha's Way DSP staff will be re-educated on Martha's Way transportation policy and procedures. |
09/26/2024
| Not Implemented |
| 6400.43(b)(3) | Martha's Way CEO did not protect individual #1 from systemic abuse from staff that occurred on 7/14/2024 and 7/29/2024. The individual was in psychological crisis and the agency provided inadequate support as her behaviors and support needs escalated. They did not follow their de-escalation plan from the individual's BSP and provided psychiatric hospitalization only after the second abuse incident. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | Martha's Way CEO met with individual #1 behavioral specialist, program specialist and house supervisor to review their individual support plan, behavioral support plan and crisis plan to determine all support needs required for the individual.
The CEO conducted an audit of each home's supervisory chain of command to ensure supervisor's phone number were posted in each residential site in the case of emergency. In addition, the CEO provide additional copies of the incident report forms to each home.
The CEO reeducated the supervisors and program specialist on their roles as point person for incident management.
The House Supervisor will re-educate all support staff on the agency's incident management and reporting requirements, on-call procedures, and supervisory chain of command for emergencies. |
09/26/2024
| Not Accepted |
| 6400.62(d) | Bleach and laundry soap were found stored in the pantry with food items. Staff removed the poisons at time of inspection. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | On 7/19/24 removed the bleach and laundry soap from the pantry area. The house supervisor conducted a safety check of the home to ensure no other chemicals were stored improperly in the home. |
07/19/2024
| Implemented |
| 6400.68(b) | The water temperature in the bathroom measured at 133.9 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | On 7/19/24, the House supervisor contacted the apartment maintenance department to lower the temperature of the water. The maintenance apartment adjusted the water temperature on the same date. The house supervisor re-check the water temperature which was 110 degrees. |
07/19/2024
| Implemented |
| 6400.24 | The 1970 Controlled Substances Act requires accurate counts be kept for controlled medications. The home was not keeping a controlled medication count for Individual #1's medication Lorazepam. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | On 7/19/24, individual #1 controlled substance count sheet was locked in the home's medication storage room in a locked file on the date of the inspection. A copy of the controlled substance count sheet was provided to the department after the inspection. |
07/19/2024
| Implemented |
| 6400.32(c) | The abuse described in the 6400.16 violation in this LIS also constitutes a violation of this regulation. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | The CEO conducted an audit of each individual's file to ensure that a copy of their signed individual rights were kept in the record.
The CEO met with the house supervisors to ensure all individuals were given a copy of Marthas Way's complaint policy and forms with a list of victim assistance resources.
The HR department will re-educate all staff on abuse and neglect and individual rights. |
09/26/2024
| Not Accepted |
| 6400.32(d) | Individual #1 has a written behavioral plan that indicates change in schedule, or plans can cause verbal and or physical aggression. On 7/14/2024, staff took her out and made a stop at staff's home, a change in plans that escalated Individual #1s behaviors quickly. In response, they restrained individual #1 by sitting on top of her and tying her feet with rope. This occurred in a public setting, further violating the individual's dignity. | An individual shall be treated with dignity and respect. | The CEO and program specialist completed an audit of all individual support plans to ensure each individual has a crisis plan component within their plan in place that addresses medical emergencies and behavioral health crisis.
Martha's Way's Program Specialist will re-educate all support staff working in the residential home on each individual's medical emergency and behavioral crisis plan.
In addition, Martha's Way HR department will re-educate all staff on the individual rights. |
09/26/2024
| Not Accepted |
| 6400.32(g) | The change in plan to take individual #1to a staff's house on 7/14/2024 did not allow individual #1 to have any choice of where she was interested in the activities for the day. | An individual has the right to control the individual's own schedule and activities. | The CEO has reeducated both the individuals and staff members that individual have the right to control their schedules and activities.
Program Specialist reviewed with each individual their individuals rights as outlined in the regulations.
Martha's Way has updated the electronic daily note template to reflect individual's preference in activities.
The HR department reeducated support staff on the agency's Home and Recreational Activities policy and procedures. |
09/26/2024
| Not Implemented |
| 6400.165(b) | Individual #1 had an ordered dosage increase beginning on the morning of 7/18/24 for two prescribed medications. The medications and new dosages were handwritten onto the MAR. However, the old dosages of the medications were not marked as discontinued. Med tech for the home stated a plan to implement a new MAR with the new dosages on it on the date of the inspection and showed the new MAR at the time of inspection. However, from 7/18/24 through 7/19/24, both the lower and higher dosages were both appearing on the MAR. The med tech for the home stated that the old/lower dosage was returned to the pharmacy. The correct current dose was in the home at the time of inspection.
Medications included:
Lamotrigine Tab BID,increased to 100mg on 7/18/24
Lorezepam Tab BID, increased to 1mg tab on 7/18/24 | A prescription order shall be kept current. | On 7/19/24 Martha's med tech discontinued the changed doses of Lamotrigine and Lorezapam BID medications on individual #1's MAR. |
07/19/2024
| Implemented |
| 6400.165(c) | Individual #1 did not receive her prescribed Fluticasone Spray 50mcg from the morning of 7/15/24 through the morning of 7/18/24. Staff stated that a new prescription had not yet been filled by the pharmacy. | A prescription medication shall be administered as prescribed. | Individual #1 was scheduled to meet with her new primary care physician on 7/18/24. The individual could not have her prescription refilled until the initial appointment. On 7/19/24, individual #1 medication was picked up from the pharmacy. |
07/19/2024
| Implemented |
| 6400.193(a) | On 7/14/2024, Individual #1's staff used prohibited restraints on her. They used a rope to tie up her feet to control her behavior in contradiction to her behavior support plan's de-escalation procedures. | A restrictive procedure may not be used as retribution, for the convenience of staff persons, as a substitute for the program or in a way that interferes with the individual's developmental program. | Upon discovery of the incident Martha's Way removed staff persons #1, #2 and #3 working with all individuals receiving services pending the outcome of an investigation.
The CEO reviewed the agency's restrictive policy to determine if the policy required revisions to capture language in regards to restrictive procedures and retribution.
Martha's Way conducted a certified investigation into the alleged incident that occurred on 7/14/24.
Martha's Way behavioral specialist retrained all staff working with individual #1 on the behavioral support plan and restrictive plan.
The HR department reeducated on support staff working in the home on Martha's Way restrictive procedures policy and individual rights policy. |
09/26/2024
| Not Accepted |
| 6400.194(a) | Individual #1's staff have used restricted procedures on her, and her plan dated 5/30/2024 has not been reviewed by a human rights team. | If a restrictive procedure is used, the home shall use a human rights team. The home may use a county mental health and intellectual disability program human rights team that meets the requirements of this section. | The behavioral specialist failed have individual #1 restrictive procedures did not provide the agency with a copy of the human rights team review and approval of the plan.
On 7/19/24, Martha's Way obtained a copy of the human rights team review . A copy of the restrictive plan HRT review was placed in the individual's record. |
09/18/2024
| Not Implemented |
| 6400.195(a) | Individual #1's staff have used restricted procedures on her as described in the violations listed in this LIS, and her BSP plan does not have a restrictive component in her plan. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | The behavioral specialist failed to provide Martha's Way with a copy of the human rights team review and approval of individual #1 restrictive procedures.
On 7/19/24, Martha's Way obtained a copy from the behavioral specialist of individual #1 behavioral support plan with the restrictive procedures. A copy of the review was placed an individual #1 main file record kept in the home. |
09/18/2024
| Not Implemented |
| 6400.207(5)(I) | On 7/14/2024 individual #1 was restrained by staff tying her feet with a rope, constituting a mechanical restraint. | 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: Post-surgical or wound care. | The support staff failed to follow individual #1 de-escalation techniques as outlined in her behavioral support.
Upon discovery of the incident the staff member was immediately removed from working with all individuals receiving services under Martha's Way pending the outcome of an investigation.
The CEO and CI met with individual #1 to reassure her health, safety and well-being and to offer victim assistance.
Martha's Way has reeducated all staff members on the agency's restrictive procedures policy and procedures. All staff members were retrained on the individual rights. |
09/18/2024
| Not Implemented |
| 6400.208(d) | Staff 1, 2 and 3 used unauthorized restraints several times during the incident described in the 16a citation in this LIS. One instance of this occurred on the street in public where it was observed by a passer-by who reported it to the police. The use of this restraint caused bruises to individual and its occurrence in public was embarrassing and humiliating for the individual. | A physical restraint that inhibits digestion or respiration, inflicts pain, causes embarrassment or humiliation, causes hyperextension of joints, applies pressure on the chest or joints or allows for a free fall to the floor is prohibited. | Martha's Way immediately removed staff 1, 2 and 3 from working with individual #1 pending the outcome of a certified investigation.
Martha's Way CEO offered individual #1 medical attention and formal supports. Individual #1 was taken to emergency room for a medical evaluation. Martha's Way review again with individual #1 their individual rights to be free abuse, neglect and to be treated with dignity and respect at all times.
Martha's Way leadership provided reeducate to support staff on individual rights and restrictive procedures. Also, support staff was reeducated by the program specialist on the individual's support plan and restrictive procedures. |
09/18/2024
| Not Implemented |
| 6400.209 | Individual #1 has had more than two physical restraints in the past 6 months and does not have a plan in place to address the use of physical restraints. | If a physical restraint is used on an unanticipated, emergency basis, §§ 6400.194 and 6400.195 (relating to human rights team; and behavior support component of the individual plan) do not apply until after the restraint is used for the same individual twice in a 6-month period. | Martha Way reviewed the agency restrictive procedures policy and procedures to ensure measures were put into place for two or more physical restraints used during an emeregency.
Individual #1 behavioral specialist was consulted on developing a plan to address her target behaviors and to develop nonphysical intervention strategies to support them at home and while in the community.
Martha's Way risk and incident manager conducted a review all of incidents for any trends in physical restraints. |
09/18/2024
| Not Implemented |