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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On the morning of 6/1/2026, Direct Service Worker #1 finished working the overnight shift and reportedly, at the conclusion of the shift had smoked marijuana at their personal residence. On 6/1/2026, at 11:45AM, Direct Service Worker #1, who apparently was "on call" was called to work at Individual #1's home due to another staff person "calling off" for their scheduled shift. Reportedly, Direct Service Worker #1 did not have time to change clothes or shower. Later that day, visitors to the home could smell marijuana inside the home. While the Agency's "Smoke Free Workplace" and "Use of Alcohol and Other Drugs" policies state that Agency is a "smoke-free workplace" and "use of alcohol and other drugs while on shift, before shift and while supporting a client is strictly prohibited," the policy does not address the procedures for "call offs" and "on call" staff coverage. The agency's "Use of Alcohol and Other Drugs" policies and procedures were not followed and/or implemented, as Direct Service Worker #1 reportedly "had to go" to work and provided supervision to Individual #1 having smoked marijuana before their unscheduled shift. | 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. | Direct Service Worker #1 was mandated to go on to shift because he accepted a leadership role that included on call. The shift was for an 11:45am-11pm shift, starting with picking the individual from school. Company policy mandates that on call personnel cover shifts that other employees call off for if other coverage is unable to be located. However, the policy was unclear on what to do when the on call personnel are mandated to come into shift, but they are under the influence. The policy has since been updated to provide direction to the on call staff to remain sober while active in the on call rotation. Though the policy was unclear for the on call team, company policy still states that employees must be free from drugs and alcohol while on shift. Through the investigation, it was determined that the Direct Service Worker #1 did not smoke on shift or otherwise neglect the individual. While the parents reported a strong odor, they did not have any immediate health and safety concerns for their child, nor did the investigators. The investigation concluded that there were no health and safety concerns for the individual. That being said, Direct Service Worker #1 was formally written up on 6.4.26 for smelling like marijuana and he agreed to follow company policies going forward. Direct Service Worker #1 was also demoted on 6.12.26 to a position that does not have on call responsibilities to prevent him from being mandated to respond to a call off. On 6.9.26, the Team Lead and Program Manager of the house reviewed expectations of staff, including our policy that we are a smoke free workplace. Additionally, the Program Managers increased their surprise pop ups to inspect the house/staff and to ensure the client was safe and free from abuse. |
08/15/2026
| Implemented |
| 6400.43(b)(1) | On the morning of 6/1/2026, Direct Service Worker #1 finished working the overnight shift and reportedly, at the conclusion of the shift had smoked marijuana at their personal residence. On 6/1/2026, at 11:45AM, Direct Service Worker #1, who apparently was "on call" was called to work at Individual #1's home due to another staff person "calling off" for their scheduled shift. Reportedly, Direct Service Worker #1 did not have time to change clothes or shower. Later that day, visitors to the home could smell marijuana inside the home. While the Agency's "Smoke Free Workplace" and "Use of Alcohol and Other Drugs" policies state that Agency is a "smoke-free workplace" and "use of alcohol and other drugs while on shift, before shift and while supporting a client is strictly prohibited," the policy does not address the procedures for "call offs" and "on call" staff coverage. The agency's "Use of Alcohol and Other Drugs" policies and procedures were not followed and/or implemented, as Direct Service Worker #1 reportedly "had to go" to work and provided supervision to Individual #1 having smoked marijuana before their unscheduled shift. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Direct Service Worker #1 was mandated to cover a call off because he accepted a leadership role with on call duties and he could not find suitable coverage. However, Direct Service Worker #1 violated our policy that states employees must be free from drugs/alcohol while working. The CEO updated the "Use of Alcohol and Other Drugs" policy to reflect processes for covering shifts while under the influence, or rather prohibiting employees from covering shifts while under the influence. The policy now states:
For employees with On Call responsibilities
1. Employees are prohibited from entering the worksites under the influence of alcohol and other drugs.
2. During periods of on call, employees should refrain from use of alcohol and other drugs to ensure they are able to respond to emergencies or staffing needs at any time.
3. If an on-call employee has consumed alcohol or is otherwise under the influence of drugs and is unable to respond to a staffing emergency, the employee must immediately notify the next level of on-call management or supervisor. The employee is prohibited from covering any shift or entering a worksite while under the influence.
4. The responsibility for obtaining alternate coverage will transfer to the next available member of the on-call chain. Under no circumstances may an employee work a shift or transport individuals while under the influence.
5. Employees who are unable to fulfill their on-call responsibilities due to alcohol or drug use will be subject to the disciplinary process for failing to meet on-call responsibilities."
The Program Director will train On Call personnel (Team Leads and Program Managers) on the new policy by 8.15.26. |
08/15/2026
| Implemented |
| 6400.62(a) | On 7/7/2026 at 10:36 AM, the following cleaning products with instructions to contact a physician or poison control if ingested were unlocked and accessible in the cabinet under the upper-level bathroom sink: two 24-fluid ounce bottles of Clorox Toilet Bowl Cleaner with Bleach, one 32-fluid ounce spray bottle of Clorox Clean-Up Multi-Surface Cleaner + Bleach. Individual #1's support plan, last updated 6/24/2026, states "[Individual #1] will ingest poisons or harmful materials that will damage his body, such as poisons, plastics or sharps." | Poisonous materials shall be kept locked or made inaccessible to individuals. | The employee on shift was in the process of cleaning when the individual required his immediate attention, leaving the cleaning supplies/poisons accessible. On 7.7.26, the poisons were immediately moved from the bathroom to the basement to be inaccessible. The place the poisons are usually locked is the office, but due to an aggressive incident, the door was broken, removing the lock for the poisons. The employee on shift followed protocol by posting a picture to the maintenance team. As an alternative, a coded key pad lock was placed on a spare bedroom to immediately lock up materials. By the end of the day 7.7.26, the poisons were locked up by the Maintenance Director. The office door was broken in half and could not be fixed immediately. The Maintenance team followed protocol by making this a priority and the door was fixed on 7.8.26 by the maintenance team. |
08/31/2026
| Implemented |
| 6400.216(a) | On 7/7/2026 at 10:32 AM, Individual #1's records, to include but not limited to, Individual #1's individual plan were unlocked and accessible in the staff office that did not have a door. | An individual's records shall be kept locked when unattended.
| Due to the aggressive behavior by the individual, the office door was broken. The individual does not have a history of breaking down doors. The staff on duty ran away from the individual and the individual was trying to follow him. The behavior plan for the individual does not list hiding from the individual as an acceptable course of action. When the individual is upset, the staff are supposed to keep their distance but maintain supervision. Additionally, there are blocking pads at the house per the UKERU training that all staff complete in orientation. The staff on duty has been terminated as of 7.30.26. The current staff working in the home will receive a retraining of the de-escalation process on 8.5.26, though none of the other staff have reported having this issue. The de-escalation process includes:
1. Remain neutral, keep a calm tone of voice.
2. Limit language. Less if more when individual is escalated.
3. Model desired behaviors for individual.
4. State replacement behaviors you would like individual to engage in instead of telling him what not to do or to "stop".
5. Provide space.
6. If he is aggressing towards you, move away or block yourself with a soft item to create a barrier (Ukeru blocking pads, pillows)
7. Direct individual to engage in replacement behavior: "Safe body" and "Safe hands"- This is the ONLY talking you should do during this time
8. Praise individual for successes or attempts at safe choices
9. Compliance lets you know he is ready to move on and has de-escalated
The staff on duty did follow the procedure process of reporting the broken door to the maintenance team. Additionally, the Maintenance Director put a lock on a different door to ensure the individual's records were locked up. The Maintenance Director moved the records to this room on 7.7.26. |
08/15/2026
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(b) | On 9/4/25 at 11:28AM signs of rodent infestation were discovered in the basement of the home. A large quantity of rodent feces was in the left and right corners of the basement, once you exited the stairwell. | There may not be evidence of infestation of insects or rodents in the home. | The Maintenance Director cleaned the mouse feces. |
09/06/2025
| Implemented |
| 6400.141(c)(11) | Individual#1's physical dated 2/26/25 indicated the medication regimen was attached to the physical examination form; however, nothing was attached. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The Program Specialist stapled the med list to the physical. |
09/25/2025
| Implemented |
| 6400.165(g) | Individual #1 is prescribed psychotropic medication. Individual #1had a psychotropic medication review on 10/16/24, and then again on 1/23/24. This exceeds the every 3-months requirement. [Repeat violation 9/17/24, et. al.] | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The psych form was updated to include a section "next appointment is due by", and all managers will be trained to ensure an appointment is scheduled within the timeframe. If the client is unable to make the appointment, the Program Manager will change the appointment to be virtually. |
10/06/2025
| Implemented |
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