| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On 1/13/25, an unannounced inspection was conducted at this property, and inspectors spoke with Individual 1 and their legal guardian parent. Individual 1 is diagnosed with Parkinson's and they report staff do not provide adequate support for their condition. Due to their mobility concerns, they sometimes must crawl and have great difficulty getting up, and they report that staff will often not help in this, leaving them to crawl on the floor for hours at a time. They indicate staff will threaten to leave them on the toilet in the morning. (The individual's ISP describes their need for morning support due to Parkinson's-related muscle weakness and dystonia.) The individual also reports being reprimanded by agency staff when they lodge complaints about their treatment, and that they fear retaliation when complaints are made. Agency staff were also observed providing dangerously inadequate support to Individual 1. Individual 1 was provided a bottle of water during the inspection, and the individual's parent reminded staff that the individual requires a straw to drink from a bottle. Staff dismissed the reminder and refused to provide the individual with a straw. The individual was then observed experiencing great difficulty when trying to drink directly from the bottle. This refusal to provide eating and drinking support constitutes a severe risk to the individual's health. Agency staff also did not demonstrate competency in performing a chair transfer. During the inspection, Individual 1 was observed requiring support as they transferred from a chair in the living room to a transfer wheelchair. Staff were observed lifting the individual in a bear hug and spinning them toward the wheelchair, almost dropping the individual and nearly falling over themselves. Staff had difficulty safely removing the individual from the home in the chair, encountering difficulty making it over the front door threshold; inspectors learned there is a foldable ramp in the home to assist with this, but it has so far been unused, and was found still contained in its original packaging. The individual reports there is routinely inadequate food in the home, and what food there is, is often spoiled or freezer-burnt. The individual's parent supplements the home's pantry with groceries they buy and often takes the individual out to eat to ensure they have food. When questioned about this, agency staff blamed the individual, indicating their handwriting is unclear and so they cannot provide grocery items she asks for via those lists. Individual 1 also reports a lack of support for community interaction. They do not get to go out into the community as often as they wish, and when staff do take them out, they rush them back home. They wish to engage in community activities like attending worship services but indicates staff have not addressed this need. | 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. | Importance of Regulation
o This regulation is important as it ensures the protection of individuals' rights, dignity, and well-being by prohibiting any form of abuse, neglect, exploitation, or harmful treatment.
Regulation Violated
o 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.
· Fix of Violation.
o Immediate corrective actions were taken to address the violations. Expired and spoiled food has been removed and replaced with fresh items, and we¿ve implemented a weekly food inventory check. Staff have been refreshed by the program specialist (staff member 2) on providing appropriate support for Parkinson¿s-related mobility issues, including safe chair transfers and the use of a foldable ramp. We¿ve reinforced the importance of accommodating Individual¿s needs for drinking and eating, such as providing a straw when requested. The Program specialist will put together a formal documented schedule for community activities upon her return, and we¿re ensuring consistent opportunities for social engagement. Additionally, we¿ve addressed concerns about retaliation and reprimands by reinforcing a zero-tolerance policy and establishing clear channels for reporting complaints. We are committed to improving the quality of care and ensuring the safety and well-being of individual.
· Responsible Person
o Program Specialist Staff member 2 and staff member 3 are responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/18/2025
| Implemented |
| 6400.62(a) | Cleaning supplies were left on back of toilet. | Poisonous materials shall be kept locked or made inaccessible to individuals. | · Importance of Regulation
o This regulation is critical for assuring safety and avoiding incidents or injuries
· Regulation Violated
o Poisonous materials shall be kept locked or made inaccessible to individuals
· Fix of Violation
o All cleaning materials were removed from the bathroom and placed in a lock closet
· Responsible Person
o Staff member 1 is responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25
o Based on analysis of other individuals, no similar violation occurred |
01/18/2025
| Implemented |
| 6400.62(d) | Bleach was stored in the same cabinet as food. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | Importance of Regulation
o This regulation is critical for assuring safety and avoiding incidents or injuries
· Regulation Violated
o Poisonous materials shall be kept separate from food, food preparation surfaces and dining surface
· Fix of Violation
o Bleach was removed from the cabinet and placed in a lock closet
· Responsible Person
o Staff member 1 is responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25
o Based on analysis of other individuals, no similar violation occurred |
01/17/2025
| Implemented |
| 6400.64(a) | There were multiple expired food items in the freezer. For Individual 1, the same med cup was being reused for med administration. Unused adult briefs were loosely thrown under bathroom sink with hair products and blow dryer. | Clean and sanitary conditions shall be maintained in the home. | · Importance of Regulation
o This regulation is critical to the health and wellbeing of the individual
· Regulation Violated
o Clean and sanitary conditions shall be maintained in the home.
· Fix of Violation.
o Staff member 1 Immediately removed reusable all rubber med cup, all expired food were thrown in the trash and all hair products and blow dryer were placed in the lock closet for safety reasons.
· Responsible Person
o Staff member 1 is responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.67(a) | One of the floorboards in the living room had a gouge in it. Kitchen cabinet was missing a knob. | Floors, walls, ceilings and other surfaces shall be in good repair. | · Importance of Regulation
o This regulation is important because it ensure the safety and prevent accidents
· Regulation Violated
o Floors, walls, ceilings and other surfaces shall be in good repair.
· Fix of Violation.
o New Cabinet knobs were install on the cabinet doors and the floor gouge were filled to ensure a smooth surface.
· Responsible Person
o Staff member 2 is responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.71 | There were no emergency telephone numbers by the telephone in the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| · Importance of Regulation
o This regulation is important to ensure that the individual/staff has access to emergency services.
· Regulation Violated
o Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
· Fix of Violation.
o Program specialist immediately provided the list of all emergency contact and placed it on the wall next to the telephone.
· Responsible Person
o Staff member 2 is responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.76(a) | Laundry pad on chair in living room was visibly stained. | Furniture and equipment shall be nonhazardous, clean and sturdy. | · Importance of Regulation
o This regulation is important because hazardous, unclean, or unstable furniture and equipment can pose safety risks, compromise hygiene, and lead to accidents or injuries.
· Regulation Violated
o Furniture and equipment shall be nonhazardous, clean and sturdy.
· Fix of Violation.
o Laundry Pad on the chair in the living chair has been washed and cleaned.
· Responsible Person
o Staff member 4 is responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/16/25
o Violation was resolved on 1/16/25.
o Based on analysis of other individuals, no such violation occurred. |
01/16/2025
| Implemented |
| 6400.76(c) | A spare office chair in poor condition was being used as living room furniture. | Furniture shall be comfortable and home-like. | · Importance of Regulation
o This regulation is important because of the safety, comfort, and well-being of residents by preventing accidents and maintaining a hygienic living environment.
· Regulation Violated
o Furniture shall be comfortable and home-like.
· Fix of Violation.
o Spare office chair have been moved out of the living room.
· Responsible Person
o Staff member 1 is responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.77(b) | There were no tweezers or thermometer in the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | · Importance of Regulation
o This regulation ensures that essential first aid supplies are readily available to address injuries or emergencies promptly and effectively, especially for vulnerable individuals.
· Regulation Violated
o A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served.
· Fix of Violation.
o The tweezers and thermometer have been purchased and added to the first aid kit.
· Responsible Person
o Staff member 1 is responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.81(k)(6) | Individual 1's bedroom did not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | · Importance of Regulation
o This regulation promotes personal hygiene, grooming, and independence by ensuring individuals have access to a mirror in their bedrooms.
· Regulation Violated
o In bedrooms, each individual shall have the following: A mirror.
· Fix of Violation.
o A mirror has been purchased and placed in the individual¿s bedroom.
· Responsible Person
o Staff member 2 is responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.82(f) | There was no trash receptacle nor hand towels in the bathroom. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | · Importance of Regulation
o This regulation ensures hygiene, privacy, and sanitation by providing essential supplies and facilities in each bathroom and toilet area.
· Regulation Violated
o Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle.
· Fix of Violation.
o A trash receptacle and hand towel was placed in the bathroom .
· Responsible Person
o Staff member 1is responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.144 | Albuterol HFA 90 mcg PRN for individual 1 was on the MAR but was not with the individual's medications.
Diclofenac Sodium 1% gel PRN for individual 1 was on the MAR but was not with the individual's medications.
Guaifenesin SF/AF 100 MG/5ml PRN for individual 1 was on the MAR but was not with the individual's medications.
Melatonin 3 mg PRN for individual 1 was on the MAR but was not with the individual's medications.
Rizatriptan 10 mg PRN for individual 1 was on the MAR but was not with the individual's medications.
Triamcinolone 0.1% cream PRN for individual 1 was on the MAR but was not with the individual's medications. | 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.
| · Importance of Regulation
o This regulation is important because it ensures individuals receive essential health services tailored to their specific needs, promoting their overall well-being and preventing potential health complications.
· Regulation Violated
o 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.
· Fix of Violation.
o Triamcinolone 0.1%, Rizatriptan 10 mg, and Melatonin 5 mg were immediately ordered and delivered. Melatonin 3mg was discontinued. Guaifenesin SF/AF 100 MG/5ml, Diclofenac Sodium 1% gel, and Albuterol HFA 90 mcg were ordered and pending delivery. Expected delivery date is 1/21/25.
· Responsible Person
o Program Specialist (staff member 2) and staff member 1 are responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/21/25
o Violation was partly resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.171 | A dirty broom was stored in the same cabinet as food. Mayonnaise was kept in cupboard after opening. | Food shall be protected from contamination while being stored, prepared, transported and served.
| · Importance of Regulation
o This regulation is important because it ensures the individual health and also ensures proper nutrition.
Regulation Violated
o Food shall be protected from contamination while being stored, prepared, transported and served.
· Fix of Violation.
o The food was removed from the closet, separating food from chemical and other cleaning products. The food was moved to the kitchen cabinet where it is easily accessible by the individual
· Responsible Person
o Staff Youngor Gayflor is responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.31(c) | The conditions described in 6400.16 in this LIS also constitute a violation of Individual 1's right to seek remediation for complaints without reprimand or retaliation. | An individual man not be reprimanded, punished or retaliated against for exercising the individual's rights. | · Importance of Regulation
o This regulation is important to protect individuals from unfair treatment or harm, ensuring they can exercise their rights without fear of retribution or discrimination.
Regulation Violated
o An individual may not be reprimanded, punished or retaliated against for exercising the individual's rights.
· Fix of Violation.
o Staff members were trained on individual rights policies and non-discriminatory policy that safeguard individuals from retaliation and establish consequences or any punitive actions taken against them for exercising their rights.
· Responsible Person
o Program Specialist staff member 2 and staff member 3 are responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.32(c) | The conditions described in the 6400.16 violation in this LIS also constitute a violation of Individual 1's right to be free from abuse, neglect, and mistreatment. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | · Importance of Regulation
o This regulation is crucial because it ensures the protection of human dignity, promotes physical and emotional well-being, and upholds basic human rights, safeguarding individuals from harm and creating a society based on respect, fairness, and justice.
Regulation Violated
o An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.
· Fix of Violation.
o Staff members were trained on individual rights policies, non-discriminatory policy abused, neglected, mistreated, exploited, and abandoned policies. Staff were granted a clear, protected process for seeking remediation for complaints without fear of reprimand or retaliation, in accordance with human rights.
· Responsible Person
o Program Specialist staff member 2 and staff member 3 are responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.32(d) | The conditions described in the 6400.16 violation in this LIS also constitute a violation of Individual 1's right to be treated with dignity and respect. | An individual shall be treated with dignity and respect. | · Importance of Regulation
o This regulation is important because it ensures that individuals are valued, promoting fairness, equality, and a positive environment for all.
Regulation Violated
o An individual shall be treated with dignity and respect.
· Fix of Violation.
o Staff members received training on established policies, with clear emphasis on their responsibility to uphold dignity and respect in all interactions.
· Responsible Person
o Program Specialist staff member 2 and staff member 3 are responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.32(h) | Individual 1's bedroom lamp was being used in the living room instead of next to her bed in her room. | An individual has the right to privacy of person and possessions. | · Importance of Regulation
o This regulation is important because it protects individuals' autonomy and dignity by ensuring their personal space and belongings are free from unwarranted intrusion.
Regulation Violated
o An individual has the right to privacy of person and possessions.
· Fix of Violation.
o Staff members were educated on the significance of individual privacy and property rights. The administration will uphold privacy laws rigorously and hold accountable those who violate individuals' personal space and belongings.
· Responsible Person
o Program Specialist staff member 2 and staff member 3 are responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.32(j) | The conditions described in the 6400.16 violation in this LIS also constitute a violation of Individual 1's right to voice concerns about their services. They reported to licensing staff that they are reprimanded when they voice their concerns. | An individual has the right to voice concerns about the services the individual receives. | · Importance of Regulation
o This regulation ensures that individuals can express concerns about the services they receive, promoting accountability and improving service quality.
Regulation Violated
o An individual has the right to voice concerns about the services the individual receives.
· Fix of Violation.
o Acute educated staff members on individual rights when it comes to voicing out their concerns. Acute will continue to implement a clear process for individuals to easily voice concerns and ensure these are addressed promptly and effectively.
· Responsible Person
o Program Specialist staff member 2 and staff member 3 are responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.32(r) | There were no locks on indiviidual 1's bedroom door. | An individual has the right to lock the individual's bedroom door. | · Importance of Regulation
o The importance of this regulation lies in ensuring an individual's right to privacy and security within their personal living space.
Regulation Violated
o An individual has the right to lock the individual's bedroom door.
· Fix of Violation.
o The individual door locking mechanism was changed to clocked.
· Responsible Person
o Program Specialist staff member 2 and staff member 3 are responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.163(d) | Medication for Individual 1 was found in an unlocked kitchen cupboard. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | · Importance of Regulation
o This regulation is important to ensure the safe storage of prescription medications and syringes, preventing unauthorized access and misuse, while maintaining proper control over potentially harmful substances.
Regulation Violated
o Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.
· Fix of Violation.
o The medication was disposed.
· Responsible Person
o Program Specialist (staff member 2) and staff member 1 are responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.166(b) | Chlorhexidine Oral Rinse for 01/13/25 at 8 AM staff member 1 states that the medication was administered, but it was not signed off on either electronic or paper MAR for individual 1.
Ketoconazole 2% cream for 01/13/25 at 8 AM, staff member 1 states that the medication was administered, but it was not signed off on either electronic or paper MAR for individual 1. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | · Importance of Regulation
o This regulation is important because it ensures accurate and timely documentation of medication administration, which helps maintain patient safety and compliance with healthcare standards.
Regulation Violated
o The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.
· Fix of Violation.
o Staff members have been retrained on the correct procedures for administering medications and recording them on both the paper MAR and the electronic MAR.
· Responsible Person
o Program Specialist (staff member 2) and staff member 1are responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |
| 6400.167(a)(1) | Individual 1 - Mupirocin Ointment USP 2% for 8 AM, 4 PM and 8 PM tube was empty and was not administered on 01/13/25 at 8 AM; staff member 1 stated that it was ordered from the pharmacy on 01/10/25 and expected to arrive on 01/15/25.
Individual 1 - Triamcinolone 0.1% cream for 8 AM tube was empty and was not administered on 01/13/25 at 8 AM; staff member 1 stated that it was ordered from the pharmacy on 01/10/25 and expected to arrive on 01/15/25. | Medication errors include the following: Failure to administer a medication. | · Importance of Regulation
o This regulation is important because it ensures patient safety by preventing medication errors, such as failing to administer prescribed medications, which could lead to adverse health outcomes.
Regulation Violated
o Medication errors include the following: Failure to administer a medication.
· Fix of Violation.
o Both medications Mupirocin Ointment USP 2% and Triamcinolone 0.1% have been delivered.
· Responsible Person
o Program Specialist Lavina Gould and Youngor Gayflor are responsible for preventing future violations.
o Acute anticipated the resolution of this violation by 1/17/25
o Violation was resolved on 1/17/25.
o Based on analysis of other individuals, no such violation occurred. |
01/17/2025
| Implemented |