| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(a) | On 12/23/24 Licensing Representative arrived at the home at 3:15pm at the request of the provider due to Individual #1 and staff being out of the home to attend an appointment. Upon arrival no appliances were in use. Licensing Representative spoke to Individual #1 for approximately 30 minutes. Individual #1 reported the hot water in the home to be too cool and was not comfortable for bathing, describing the water as starting okay but quickly becoming cold and that they were unable to take a bath or long shower as desired. Licensing Representative tested the water in the only bathtub of the home. The hot water initially measured 103°. The tub was filled to the level desired as stated by Individual #1. The hot water coming from the faucet measured 71° when the tub reached the desired depth, approximately ¾ full. The water in the tub was then mixed by hand and measured. The reading of the water mixed in the tub was 91°. As reported by Individual #1 the hot water was not found to be comfortable for bathing at 91° and was not sufficient to meet the Individual's needs for hygiene and comfort. | A home shall have hot and cold running water under pressure. | QLHS called the landlord to inform him that the water in the home is not staying hot after running for more than 5 mins. After the landlord checked and adjusted the water temperature, he informed QLHS Director Wanda that he has to change the hot water tank. At that time individual #1 was moved to a hotel for a few days until that landlord replaced the hot water tank. |
01/24/2025
| Implemented |
| 6400.70 | At time of inspection Individual #1 reported that the two phone lines and phones in the home were not easily accessible to them. Both phones and phone lines were kept in the locked staff office of the home. Individual #1 reported to not be allowed in the staff office and the office was kept locked when not in use. Individual #1 would need to ask to access either phone when desired. The phone/phones would be provided but no other phones nor phone lines were available to Individual #1 with easy access and access without permission. Individual #1 also reported that the phones would sometimes go dead due to battery use and they would then have no phone if their personal cell phone was also not available due to payment and carrier issues. Individuals shall have a phone that is easily accessible in their home. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| QLHS purchased a new phone with 2 receivers and placed one receiver and the base in the office to ensure the phone is charged at all times, and the other receiver was given to individual #1 to ensure access to the phone at all times as required by ODP. |
01/13/2025
| Implemented |
| 6400.144 | Per Provider team members Individual #1's diabetic management is completed by both their primary care physician group (PCP) and their Endocrinologist. As stated by team members on 1/7/25 staff at the home follow protocols set forth by the Endocrinologist, noting that the Endocrinologist is the only one that is notified for blood sugars over 400.
The most recent documentation for treatment of high blood sugar found was dated 2/6/24. A letter from Individual #1's PCP noted that "If [their] blood sugar is 300 or higher then please call the office."
Blood sugar records covering 10/14/24-12/23/24 noted readings above 300 three times on 10/25/24, 10/28/24, 10/29/24, two times on 10/30/2411/4/24, two times on 11/5/24, 11/6/24, two times on 11/7/24, 11/10/24, three times on 11/11/24, 11/13/24, two times on 11/15/24, 11/17/24, three times on 11/18/24, three times on 11/19/24, 11/20/24, two times on 11/21/24, two times on 11/22/24, two times on 11/24/24, six times on 11/25/24, 11/26/24, 11/29/24, two times on 12/1/24, 12/2/24, two times on 12/5/24, two times on 12/6/24, seven times on 12/7/24, two times on 12/8/24, four times on 12/9/24, two times on 12/10/24, 12/12/24, 12/13/24, two times on 12/14/24, 12/15/24, three times on 12/16/24, 12/17/24, three times on 12/18/24, two times on 12/19/24, two times on 12/20/24 and 12/21/24.
The PCP directives were not being followed as there was no documentation of notification to the PCP when blood sugars were over 300 as directed in the letter dated 2/6/24 and per team statement on 1/7/25 that no notification to the PCP is made at a blood sugar of 300 or above. Notification is made only to the Endocrinologist when blood sugars of over 400 are recorded.
(REPEAT VIOLATION 5/22/24) | 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.
| QLHS supervisor and designated person scheduled a virtual appointment for individual #1 Endocrinology on February 10th at 1:30 pm to discuss her diabetes and their recommendations to ensure her health and safety as required by ODP. |
01/21/2025
| Implemented |
| 6400.181(a) | The current assessment for Individual #1 was requested. The annual assessment received on 12/30/24 was dated as being completed on 12/1/23. The annual assessment was not updated annually as required.
(REPEAT VIOLATION 5/22/24) | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | QLHS program specialist will update and complete a new assessment for individual #1 to ensure that the individual will have an updated assessment as required by ODP regulation. |
01/17/2025
| Implemented |
| 6400.18(a)(11) | On 12/30/24 the unplanned move of Individual #1 to a hotel room was necessitated by the ongoing lack of adequate hot water in the home. The home was vacated from 12/20/24 until 1/2/25 when the hot water system in the home had been repaired. As of 1/15/25 the unplanned move and emergency closure of the home was not reported as required. | 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 24 hours of discovery by a staff person:
Emergency closure.
| QLHS designated person will contact the Administrative Entity to request that she put the emergency closure evacuation from individual #1 home in EIM to ensure that we are incompliance with ODP regulation. |
02/04/2025
| Implemented |
| 6400.32(d) | Initial report received on 12/23/24 noted that the water temperature in the one bathroom of the home was below the desired temperature of Individual #1 as it would start warm then quickly fade to cold. Staff #1 stated that the water temperature had been reported "about a week ago" but no one had been at the home to assess and rectify the issue. On 12/23/24 Licensing Representative measured the water temperature in the bathtub of the home. Individual #1 stated that they liked to take a bath. The tub was filled to the level that Individual #1 noted where they would fill the tub. The hot water was measured to have a temperature of 103° when first turned on. The temperature of the water coming out of the faucet when Individual #1 reported the tub to be at the fill level they desired was measured at 76°. Once the tub was at the desired level, the water in the tub was mixed by hand and measured to be 91°. Individual #1 reported this temperature to not be comfortable for bathing. As indicated in the 6400 Regulatory Compliance Guide (RCG) the water in the home must be warm enough for comfortable bathing without exceeding the maximum allowable water temperature. Licensing Representative spoke to Staff #2 on 12/23/24 and informed them of the urgency to rectify the water temperature. Staff #2 noted that they were not aware that the landlord had previously been informed of the water temperature issue. Staff #2 noted the urgency to be understood and that the water temperature would be addressed. Licensing Representative spoke to Staff #2 again on 12/24/24 and 12/26/24 with Staff #2 expressing that they felt the issue to be hot water usage prior to Individual #1 attempting to use the water and the length of time that Individual #1 used the water and that they would attempt to contact the landlord again. Urgency was explained again. Licensing Representative spoke to Staff #2 again on 12/30/24 with Staff #2 reporting that they were still working on the issue. According to timeline provided by Staff #1, Individual #1 had now been without water comfortable for bathing from approximately 12/16/24 through 12/30/24 with the Provider having knowledge of the issue. | An individual shall be treated with dignity and respect. | QLHS called the landlord to inform him that the water in the home is not staying hot after running for more than 5 mins. After the landlord checked and adjusted the water temperature, he informed QLHS Director that he has to change the hot water tank. At that time individual #1 was moved to a hotel for a few days until that landlord replaced the hot water tank. |
02/04/2025
| Implemented |
| 6400.32(n) | At the time of inspection Individual #1 did not have unrestricted access to the phones in the home. Licensing Representative noted that Individual #1 was speaking on one of the two phones in the home at time of arrival. Individual #1 reported that they do not have access to the phones as they are maintained in the staff office which they "are not allowed" to enter and is locked when not in use. Staff #1 reported that there are two lines in the home. Staff #1 reported that the two lines were necessary as Individual #1 would use the phone designated for the home excessively and important calls would be missed. There was no functioning input for either line in the main living or private areas for Individual #1 in the home. Staff #1 reported that there had been a line in the main living area of the home, but that line was not working and reported that it could not be fixed. Additionally, there were no charging bases for either phone line in the main living, unrestricted areas of the home and private bedroom of Individual #1. Individual #1 reported that they needed to ask for the phone and that once the battery was drained, they were not able to use the phone. The phone would be returned to the office where it was kept until charged. Individual #1 did not have unrestricted access to either phone required by 6100.684(d)(II). | An individual has the right to unrestricted and private access to telecommunications. | QLHS purchased a new phone with 2 receivers and placed one receiver and the base in the office to ensure the phone is charged at all times, and the other receiver was given to individual #1 to ensure access to the phone at all times as required by ODP. |
01/13/2025
| Implemented |
| 6400.193(a) | At time of inspection on 12/23/24 Individual #1 reported feeling "like a prisoner" in their own home due to a restrictive procedure plan (RPP) in place and dated 9/6/24.
The RPP limits Individual #1 to their home when their blood sugar is "180 or higher" as outlined by their primary care physician (PCP) and author of the document. Noting that "Patient is not safe for transport out of [their] home if [their] blood sugar is 180 or higher."
A blood sugar of 180 is also reported to be in an acceptable range according to the Individual Support Plan (ISP) for Individual #1 last updated on 11/8/24 which indicates that "Recommendations from [Individual #1's] PCP: [Individual #1's] fasting blood sugar is recommended to be between 80-120 mg/dl, and 180-200mg/dl after meals."
Due to conflicting and absence of supporting information it could not be determined that the RPP in place was not 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.
As outlined in 6400.32(e) and 6400.32(u) Individual #1 has the right to make choices and accept risks as well as make health care choices.
In accordance with 6400.32(v) The Individual's rights may only be modified to the extent necessary to mitigate a significant health and safety risk to the individual or others.
The RPP in use as of 12/23/24 did not illustrate that the Provider utilized risk mitigation factors in the development of the RPP to ensure compliance with associated regulations.
The RPP did not illustrate that less restrictive techniques and resources appropriate to the behavior have been tried but have failed and that the RPP is a last resort to address challenging behaviors.
The RPP in place for Individual #1 does not list a target date to achieve the outcome. The plan notes that "The follow criteria is will be used by [Individual #1] and [their] team to make the decision to change and eventually fade this plan:" No target date is listed for the expected achievement of the outcome.
Providers are equally obligated to protect individuals' right to self-direction, choice, and control and to protect individuals' health and safety. | 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. | QLHS called individual #1's behavior specialist to request that she make all necessary changes to individual #1 RPP to reflect the individuals' rights and responsibilities as required by ODP regulation. |
01/17/2025
| Implemented |