| 6400.33(a) | Individual #1's plan team members met on 7/5/16. Individual #1's current ISP reads "The team determined there is a continued need for 1:1 supports...it's necessary to provide [him/her] with 1:1 care 24 hours/day...[Individual #1] is diagnosed with a seizure disorder and osteoporosis. [S/he] requires 1:1 support due to these health issues...[S/he] required full staff assistance with bathing, toileting and all other activities of daily living. The home utilizes a "care tracker" system that staff are to complete every 30 minutes after monitoring Individual #1. On 9/20/16, entries were made in the care tracking system at 1:31AM and then again at 5:30AM. On 9/20/16, upon arrival to the home at 7:57AM, Program Specialist #3 found the front door of the home to be locked and knocked for a few minutes before Direct Service Worker #1 answered the door. Upon entering Individual #1's bedroom, Program Specialist #3 found Individual #1 awake in bed and noticed a strong odor of feces. Upon checking Individual #1, the Program Specialist #3 found him/her to be wearing a soiled adult diaper containing dry, flaky fecal matter. Direct Service Worker #1 and Direct Service Worker #2 were not aware of how long Individual #1 had been soiled or that s/he needed to be changed. | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | The Program Specialist of the home reported the case of neglect immediately. Actions were taken to protect the health, safety, and welfare of the individuals. The allegation was reported on EIM. A certified investigator initiated the investigation the same day. The 2 Direct Support Professionals involved were suspended immediately pending the results of the investigation. Based on the findings of the investigation, the Direct Support Professionals that were the targets in this investigation were terminated. The Program Specialist has completed training on Abuse/Neglect, including reporting guidelines with all DSP's that work at this location. The incident has been closed on EIM.
All new hire employees are trained on Abuse/Neglect and Reporting of Incidents in a timely manner (on 09/26/2016). [At least annually, all direct service workers working in community homes shall be trained in abuse and neglect including types of abuse and neglect, prevention and reporting requirements. (AS 12/8/16)] |
11/12/2016
| Implemented |
| 6400.216(a) | Two boxes containing Individual #1's and Individual #2's records were unlocked and unattended in the closet in the room to the left at the top of the stairway on the second floor of the home. | An individual's records shall be kept locked when unattended. | All Program Specialists will be trained on regulation 6400.216(a) on 11/18/. The door to the office area of the home had a lock installed on the door to secure the records on 10/25/2016. All other houses have locked areas for records.[Immediately, the CEO shall develop and implement policies and procedures to ensure all individuals' records are kept licked when unattended. Within 60 days of receipt of the plan of correction, all staff shall be trained on the policies and procedures to ensure all individuals' records are kept locked when unattended. (AS 11/30/16)] |
11/12/2016
| Implemented |