| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | On 4/23/24, the Department requested two years of staff schedules and payroll records for all agency staff. This material was requested again on or around 5/2/24. Incomplete and partial records were provided: a few months of schedules ranging from September to December 2023, and partial payroll records that did not detail where staff were working during the pay periods listed. Agency staff indicated that full records were not available because the external drive on which they were stored was damaged. After Individual 1's baby was born, she was to have 24-hour staffing per her ISP. Agency staff indicated Staff Member 1's mother served as a PRN DSP during this period to meet that staffing need. Payroll and staff schedule records for this staff member were requested on or around 5/17/24 but were never provided. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | CEO of Self Sufficient for Successful Living LLC (SS4L) entered into contract with ADP Payroll system on May 30, 2024. All employees are now utilizing ADP to clock in and clock out effective Monday, June 24, 2024. ADP manages payroll including timekeeping, paystubs and tax records. CEO edited the Employee Records policy to include new payroll and time keeping systems. The Employee Records policy also indicates process for maintaining employee records and claims documentation. (see attached Employee Records Policy and ADP contract) to ensure the department has full access to SS4L records during unannounced and announced visits. |
07/05/2024
| Not Accepted |
| 6400.16 | Between 8/30/20 and 4/12/24, Individual 1 was repeatedly abused by the provider. The individual transferred to a home operated by the provider on 7/29/19. Staff Member 1 was hired by the agency on 8/30/20 to work as a DSP and was assigned to work in Individual 1's home. Staff Member 1 began sexually abusing this individual during their residency at this property, and also misled the individual into believing theirs was a consensual sexual relationship. On or around 7/5/22, the individual moved to another home operated by the agency while Staff Member 1 remained assigned to the individual's previous home. The DSP continued sexually abusing the individual in the individual's new home and the DSP's private residence, causing the individual to become pregnant. On or around the week of 8/20/23, the individual informed the CEO that Staff Member 1 is the baby's father and was instructed by the CEO to not to reveal this information to others because doing so could result in the DSP being criminally charged, the agency being shut down, and the individual losing custody of their baby. About a week later, the baby was born on 8/29/23. On 1/1/24, the individual applied for court-ordered child support, naming Staff Member 1 as the father, and on or about 1/23/24, Staff Member 1 verbally abused the individual, stating that she was trying to take his money by applying for the support. On 1/31/24, Staff Member 1's mother, herself a DSP employed by the agency, persuaded the individual to withdraw her petition for child support and guided her through the withdrawal process. The individual withdrew their petition on 2/1/24. In February 2024, the agency proceeded to establish an informal child support system in which they made two $100 payments to the individual and told her that Staff Member 1 would become more involved in the baby's care, an outcome the individual desired as she was misled into believing that she and the DSP were in a consensual relationship. This system was facilitated by the Residential Director, with whom the individual shared the paternity of her baby, also in February 2024. On or about 4/11/24, the individual made a post on Instagram that named Staff Member 1 as the baby's father, after which the CEO and Residential Director came to her home and removed a cell phone and laptop from her possession. These items have not been returned to the individual. Also on or around 4/11/24, the CEO notified the police and county AE, sharing with them what the individual had shared online. On 4/12/24, the individual transitioned to another provider on an emergency basis. In addition to sexual abuse in the form of sexual contact between a staff person and an individual, Individual 1 also suffered emotional harm, being misled to believe that she was romantically involved with Staff Member 1, who also verbally abused her when she sought child support. The individual was told by the CEO that naming Staff Member 1 as the father could result in the loss of custody of her child and result in criminal charges against the DSP, and she was persuaded to withdraw her child support petition even though it was her right to seek it. | 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. | CEO has made edits to the Individual Property policy on June 28, 2024. CEO made edits to the Restrictive Intervention policy ¿ specifically the Access to or use of Individual Personal property policy on June 28, 0224 to ensure compliance with ODP¿s regulations on Abuse and the use of individual property. The CEO also made edits to the Incident Management Policy ¿ sections pertaining to Abuse categories, reporting procedures and notifying appropriate authorities, and Protective Services to ensure we comply with the regulatory standard as it relates to the prohibition of Abuse. (see attached the Individual Property Policy, Restrictive Procedures Policy and Incident Management Policy). |
07/11/2024
| Not Accepted |
| 6400.43(b)(1) | The provider obtained criminal history clearance results for Staff Member 1 on 12/3/21 and 7/12/23. The agency provides the Residential Habilitation HCBS Waiver service. One of the requirements to provide this service is that if the criminal history clearance results identify a criminal record, providers must make a case-by-case decision about whether to hire the person that includes consideration of the following factors: the nature of the crime; facts surrounding the conviction; time elapsed since the conviction; the evidence of the individual's rehabilitation; and the nature and requirements of the job. Staff Member 1's clearance results returned a criminal record but the agency did not perform the required screening at any time, demonstrating the CEO's failure to implement policies and procedures. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | In order to ensure that the CEO is responsible for the administration, general management of the home, and the health, safety, protection of individuals supported by our organization the following has been updated by the CEO Criminal history Review Policy (6/28/24), Employee Background Authorization Form (6/28/24), provisional employment form (6/27/24), Criminal Background Review Form (6/28/24) and updated the Chief Executive Officers Job Description (6/27/24). (see attached all documents) |
07/05/2024
| Not Accepted |
| 6400.43(b)(3) | As described in this LIS under the 6400.16 violation, on or around 8/20/23, Individual 1 told the CEO that Staff Member 1 is the baby's father. The CEO's actions between the individual's disclosure on 8/20/23 and the individual's removal from the agency on an emergency basis on 4/12/24 demonstrate repeated failures to protect her health and safety. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | The CEO developed an Employee Relationship/Nepotism Policy on June 28, 2024. The CEO developed an Employee Relationship Disclosure Form on June 27, 2024 . The CEO edited the job description for the Chief Executive Officer to ensure with the requirements of the positions to ensure responsibility of administration, general management of the home and the health safety, protection of individuals supported by our organization. The CEO developed and Employee Professional Conduct Acknowledgement to be utilized effective Monday, July 1, 2024. |
07/11/2024
| Not Accepted |
| 6400.18(a)(3) | Individual 1's hospitalization on 8/29/23 for the birth of her baby has not been reported by the agency. | 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: Inpatient admission to a hospital.
| CEO reported the incident for Individual 1 in EIM/HCSIS on June 28, 2024. Incident ID 9440791. The CEO also made edits to the Incident Management Policy to ensure accurate and timely reporting on June 28, 2024. (see attached Incident management policy and Certified Investigator certificates) |
07/11/2024
| Not Accepted |
| 6400.18(a)(4) | Providers are required to report abuse to the Department within 24 hours of discovery. Although the CEO and other staff persons knew that Individual 1 had been sexually abused by Staff Member 1 as early as, or around, the week of 8/20/23, the provider did not report the incident until 4/12/24. When the Residential Director was asked why she did not report sexual abuse when the individual told her that the staff member was the baby's father, the Residential Director stated that she did not make the report because she did not think it was sexual abuse. | 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:
Abuse, including abuse to a individual by another client.
| The CEO for Self Sufficient for Successful Living made edits to the Incident Management Policy on June 28, 2024 pertaining to Abuse Categories and Reporting Procedures to ensure accurate and timely reporting as per the Office of Developmental Programs. See Attached Incident Management Policy. |
07/11/2024
| Not Accepted |
| 6400.31(a) | The provider's conduct as described in this LIS demonstrates repeated deprivation of individual rights. | An individual may not be deprived of rights as provided under § 6400.32 (relating to rights of the individual.). | In order to ensure that Self Sufficient for Successful living does not deprive individual of their rights as per 6400.31 (a) the CEO has updated the Individual Rights policy, specifically as it relates to the Exercise of Rights on June 28, 2024. |
07/11/2024
| Not Accepted |
| 6400.31(b) | When Individual 1 expressed a desire to obtain child support and disclose the identity of her child's father, the provider was responsible to support the individual in making those decisions; instead, the provider persuaded her to make other choices that were in the provider's best interests. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | In order to ensure that Self Sufficient for Successful living educates, assist and provides the accommodations necessary for the individual to make choices and understand the rights of the individual the CEO has updated the Individual Rights policy , specifically as it relates to the Exercise of Rights on June 28, 2024. (see attached policy) |
07/11/2024
| Not Accepted |
| 6400.31(c) | Individual 1 was reprimanded by the CEO when she sought to exercise her right to choose to disclose the father of her baby. The individual was also verbally abused and reprimanded by Staff Member 1 after she sought child support through the court. These incidents constitute a violation of this right. | An individual man not be reprimanded, punished or retaliated against for exercising the individual's rights. | In order to ensure that Self Sufficient for Successful living does not reprimand, punish or retaliate against an individual for exercising their rights the CEO updated our Individual Rights (exercise of rights) policy pertaining to this specific regulation on June 28, 2024. (see attached policy) |
07/11/2024
| Not Accepted |
| 6400.32(b) | Agency staff reprimanded Individual 1 for seeking child support that would be afforded to her by law, persuaded her to withdraw the application, and guided her through the process of withdrawing her petition. | An individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of the individual's choice and practice no religion. | In order to ensure Self Sufficient for Successful living does not violate or restrict an individual rights to civil and legal rights afforded by the law including the right to vote, speak freely, practice the religion of the individuals choice and practice no religion the CEO updated our Individual Rights (Rights of Individuals) policy pertaining to this specific regulation on June 28, 2024. (see attached policy).The CEO also met with an consultant on June 27, 2024 to discuss the issues surrounding effective service delivery and plan to increase compliance. (see attached meting agenda memo) |
07/11/2024
| Not Accepted |
| 6400.32(c) | The events described in 6400.16, above, also constitute a violation of this regulation. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | To ensure all individuals will be treated with dignity and respect the CEO updated the Individual Rights (Rights of Individuals) policy pertaining to this specific regulation on June 28, 2024. (see attached) |
07/11/2024
| Not Accepted |
| 6400.32(d) | The events described in 6400.16, above, also constitute a violation of this regulation. | An individual shall be treated with dignity and respect. | To ensure all individuals are treated with dignity and respect the CEO updated the Individual Rights (Rights of Individuals) policy pertaining to this specific regulation on June 28, 2024. (see attached) |
07/11/2024
| Not Accepted |
| 6400.32(e) | As described in the violation under 6400.16, Individual 1 was deprived of the right to make choices about disclosing the identity of her child's father and obtaining child support. | An individual has the right to make choices and accept risks. | To ensure all individuals has the right to make choices and accept risk the CEO updated the Individual Rights (Rights of Individuals) policy pertaining to this specific regulation on June 28, 2024. (see attached) |
07/11/2024
| Not Accepted |
| 6400.32(i) | As described in the violation under 6400.16, the provider removed Individual 1's cell phone and laptop computer from her home without her permission. | An individual has the right of access to and security of the individual's possessions. | To ensure all individuals has the right to access to and security of their individuals possessions the CEO for Self Sufficient for Successful living update the Individual Rights policy on 6/28/24 ; CEO updated the Individual Property Policy on 6/28/24 ; CEO updated the Restrictive Procedure Policy and Restrictive Procedure Record on 6/28/24 and the Incident Management Policy on 6/28/24 (see attached all policies and documents). |
07/11/2024
| Not Accepted |