| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #1's individual support plan, last updated 2/21/2023, states "All poisonous substances are locked up". Individual #1's assessment completed 10/28/2023, states Individual #1 is unable to safely use or avoid poisonous materials. On 3/04/2024 the following poisonous materials, with instructions to contact poison control for treatment advice, were kept unlocked in a closet at the bottom of the second-floor staircase: Lysol Disinfecting Spray 19oz, Pine Sol 100fl oz, Disinfecting Wipes 1lb 4oz. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisons were locked upon discovery on 3/4/2024. |
04/08/2024
| Implemented |
| 6400.64(e) | On 3/04/2024 a 13-gallon trash receptacle, approximately 25 inches tall, was located in the basement without a lid. | Trash receptacles over 18 inches high shall have lids. | Program Specialist disposed on the trash receptacle and replaced with a smaller 15 inch trash bin. |
04/01/2024
| Implemented |
| 6400.76(a) | On 3/04/2024 Individual #1's chest of drawers, in her bedroom, was missing a drawer for the second shelf down from the top. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The chest of drawers was replaced on 03/08/2024. |
03/08/2024
| Implemented |
| 6400.81(i) | On 3/04/2024 Individual #1's bedroom windows did not have drapes, curtains, shades, blinds or shutters. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | Curtains were hung in individual #1's bedroom windows on 3/5/24. |
04/01/2024
| Implemented |
| 6400.82(f) | On 3/04/2024 the second-floor bathroom did not have individual clean paper or cloth towels. | 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. | Paper towels were placed in the bathroom upon discovery on 3/4/2024 |
04/01/2024
| Implemented |
| 6400.101 | On 3/04/2024 there was a deadbolt lock on the basement-side of the door leading to the garage and no exit from the garage. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The deadbolt was removed upon discovery on 3/4/2024. |
04/01/2024
| Implemented |
| 6400.105 | On 3/04/2024 a 13-gallon plastic trash receptacle was touching the furnace. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Trash receptacle was disposed of upon discovery on 3/4/2024. |
04/01/2024
| Implemented |
| 6400.111(e) | On 3/04/2024 the only fire extinguisher on the first-floor of the home, was located locked in the kitchen and was not easily accessible. | A fire extinguisher shall be accessible to staff persons and individuals. | Fire extinguisher was moved to the closet in the living room upon discovery on 3/4/2024. Another extinguisher was placed in the kitchen to ensure compliance. |
04/01/2024
| Implemented |
| 6400.18(b)(1) | On 3/04/2024 the following incidents were observed documented involving Individual #1 and were not reported through the Department's information management system within 72 hours of discovery: 2/05/2024 the individual was restrained twice from 2:30pm to 2:50pm, 2/13/2024 the individual was restrained multiple times from 8:00am to 9:00am, and 2/24/2024 the individual was restrained twice around 1:30pm. | 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:
Use of a restraint.
| Provider entered incidents in EIM. Provider will also include a corrective action for late entering in the final section. (9400321, 9400473, 9400485) |
04/08/2024
| Implemented |
| 6400.32(e) | On 3/04/2024 sharps were locked in the home and inaccessible to Individual #1. Individual #1 does not have a restrictive procedure for sharps being locked. | An individual has the right to make choices and accept risks. | Sharps were unlocked pending the approval of the updated RPP. This information was communicated to BSC on 3/20/2024 and RPP is currently being updated. |
03/20/2024
| Implemented |
| 6400.32(h) | On 11/26/2023 incident #9319770, reported in the Department's information management system, involving Individual #1 was documented that the provider reviewed video footage from the outside camera and the footage was provided to the police for an investigation. On 8/28/2023 Individual #1 signed an acknowledgement of camera use consent form, which does not disclose the cameras will record video footage. | An individual has the right to privacy of person and possessions. | Provider has switched camera providers on 3-1-2024 to ensure that they were in compliance with all regulatory requirements. |
03/01/2024
| Implemented |
| 6400.32(n) | On 3/04/2024 a note in the staff office was observed stating "If the individual has a behavior before program and stays home, No phone! No exceptions". The note documented the following times on when Individual #1 could have access to the phone: Monday thru Friday from 10:00am to 2:00pm and 4:00pm to 8:00pm, and Saturday thru Sunday 9:00am to 2:00pm and 4:00pm to 9:00pm. The note documented the following: "[Individual #1] is not allowed to have her phone to sleep with. The phone needs to charge at night in the staff office. The only people to make exceptions to these rules are the team lead and supervisor". Individual #1 had a documented incident on 2/24/2024 stating Individual #1 had a behavior because she did not want to follow the phone schedule. On 3/04/2024 the only telephones in the home were kept locked in the kitchen and staff office. | An individual has the right to unrestricted and private access to telecommunications. | The note was taken down from the staff office. The telephone was moved into the living room providing the individual access to it at all times. |
04/01/2024
| Implemented |
| 6400.166(b) | Individual #1's March 2024 medication administration record did not include initials of the person who administered the following medications: 3/03/2024 5:00pm for Gabapentin 400mg and Clonazepam 1mg, and 3/01/2023-3/03/2023 8:00pm for Trazadone 100mg and Retin-A Cream 0.25%. Individual #1's March 2024 medication administration record documented staff initials for Chlorhex Glucose Solution 0.12% at 8:00pm from 3/01/24 through 3/03/24, but the medication was discontinued 2/23/2024 and was no longer in the home. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Program Specialist ensured that the medication that needed to be discontinued was properly discontinued and documented. Program Specialist ensured that the staff that passed the medications initialed the MAR in the proper place. All MAR corrections were completed by 3/6/2024. |
04/08/2024
| Implemented |
| 6400.186 | On 3/04/2024 from 10:10am to 10:47am the kitchen was observed to be unlocked. Direct Service Worker #1 was in the staff office on the second floor, while Individual #1 was on the living room couch. Individual #1's restrictive procedure plan, last updated 11/08/2023, states "the kitchen door in the individual's home is a door that remains locked in order to assure the absolute food security that is necessary to maintain the individual's safety due to her diagnosis of Prader Willi". | The home shall implement the individual plan, including revisions. | The door was locked upon discovery on 3/4/2024 |
04/08/2024
| Implemented |
| 6400.193(a) | On 2/05/2024 an incident was documented from 2:30pm to 2:50pm, involving Individual #1 where the individual "began to get upset when she was told that she could not go out due to behavior form the morning time" and was then restrained due to the individual's escalation. Individual #1's restrictive procedure plan, last updated 11/08/2023, states the individual "should remain at home until she is safe and calm. The individual should be allowed the opportunity to resume regular activities and go out in the community". On 3/04/2024 a note in the staff office was observed stating "If the individual has a behavior before program and stays home, No phone! No exceptions". The note documented the following times on when Individual #1 could have access to the phone: Monday thru Friday from 10:00am to 2:00pm and 4:00pm to 8:00pm, and Saturday thru Sunday 9:00am to 2:00pm and 4:00pm to 9:00pm. The note documented the following: "[Individual #1] is not allowed to have her phone to sleep with. The phone needs to charge at night in the staff office. The only people to make exceptions to these rules are the team lead and supervisor". Individual #1 had a documented incident on 2/24/2024 stating Individual #1 had a behavior because she did not want to follow the phone schedule. On 3/04/2024 the only telephones in the home were kept locked in the kitchen and staff office. | 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. | The telephone was moved to the living room to be accessible to all staff. Staff were retrained on individual's restrictive procedure plan on 4/8/2024. The sign was removed from the staff office. The individual has access to the phone at all times. |
04/08/2024
| Implemented |
| 6400.213(1)(i) | On 3/04/2024 Individual #1's record included a photograph which was not dated. Upon meeting with the individual, the appearance is significantly different than the picture provided. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.; (vi) a current, dated photograph. | Individuals photograph was replaced with a current photo on 3/5/2024. |
03/05/2024
| Implemented |