|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The provider agency completed a Licensing Inspection Tool on 11/23/2025. Regulation 6400.16 was documented as a violation. However, there was no plan of correction or documentation of corrective action completed. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Plan of Corrective action was completed for Valley Advantages Certified Investigation #9714002, 9718669, which investigated Violation Licensing Inspection tool 6400.16
Plan of Correction was completed prior to inspection, remediation was competed11/20/2025 |
01/05/2026
| Implemented |
| 6400.22(d)(1) | Individual #1 received funds from a rent rebate on an unknown date. The provider agency did not document the receipt of these funds on Individual #1's financial ledger. On 11/25/2025 at 12:01PM, there was $85.94 in an envelope that read, "Rent Rebate $." | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Individual #1 purchased items of his choice on 12/05/2025. 12/22/205. The remain $5.40 i was given directly to Individual #1, Documentation was completed that he funds in personal possession.
Verification Via email |
01/01/2026
| Implemented |
| 6400.22(d)(2) | Individual #1 received funds from a rent rebate on an unknown date. The provider agency did not document the disbursement of these funds made to or for Individual #1 on Individual #1's financial ledger. | (2) Disbursements made to or for the individual.
| Funds were dispersed to individual #1 on 11/26/2025. Individual #1 purchased items of his choice and retained the remainder of his funds |
01/01/2026
| Implemented |
| 6400.63(a) | On 11/25/2025 at 11:22AM, the hot water temperature measured 123.6F at the sink in the ensuite bathroom in Individual #1's bedroom. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | 68- Water Temperature exceeding 120 degrees in ensuite
Immediate Plan of Correction:
Valley Maintenance Department turned hot water tank down on 11/25/25.
Water testing thermometers put in all first aid/emergency kits at all locations on
11/26/25- Completed by: Residential Manager |
01/01/2026
| Implemented |
| 6400.68(b) | On 11/25/2025 at 11:36AM, the hot water temperature measured 123.2F at the bathtub in the bathroom along the hallway on the first floor of the home. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Immediate Plan of Correction:
Valley Maintenance Department turned hot water tank down on 11/25/25.
Water testing thermometers put in all first aid/emergency kits at all locations on
11/26/25- Completed by: Residential Manager |
12/31/2025
| Implemented |
| 6400.72(a) | On 11/25/2025 at 12:15PM, there was a one-quarter inch gap between the bottom of the screens and the window frames in the two operable windows in the basement allowing space for insects to enter the home. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | 72- Gap in screen in basement
Immediate Plan of Correction:
Maintenance adjusted the screen to be flush against the windowsill 11/26/25
Built new frame and screen for the window and installed it 12/10/25-
Photo of both in attachments |
01/01/2026
| Implemented |
| 6400.101 | On 11/25/2025 at 11:40AM, there was a turn lock with a dead bolt on the basement side and a key lock on the garage side of the door between the basement and the garage posing an obstructed egress from the garage when the locks are engaged. There was no swing door inside the garage of the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| 101- Lock on Breezway door into garage
Immediate Plan of Correction:
Valley Maintenance Department removed lock on 11/25/25. Photo Proof in attachments |
01/01/2026
| Implemented |
| 6400.104 | The provider agency sent a notification letter to the local fire department on 1/3/2019 indicating two individuals reside in the home, one is able to self-preserve in allotted time, and one is not able to preserve and needs assistance to evacuate. As of 10/15/2025, there is only one individual residing in the home. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| 104- Notification to fire department
Immediate Plan of Correction:
Resubmit updated Notification to Limestone fire hall for 148 Cannel Mine to show change in occupancy
Completion Date: 12/19/25 |
01/01/2026
| Implemented |
| 6400.141(c)(3) | Individual #1, date of admission 7/1/2021, had a Tetanus immunization on 1/23/2013 and then again on 8/29/2024. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual #1 Tetanus immunization on 8/24/29(prior to licensing inspection) which will set the time frame for the 10year compliance time frame. Indvidual #1 next tetnus appointment is scheduled for 08/29/34.
Verification via email |
11/26/2025
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On 10/26/2024, Individual #1 had a Percutaneous Endoscopic Gastrostomy Tube placed and was ordered by a physician to ingest nothing by mouth due to the risk of choking. Individual #1's Restrictive Procedure Plan, last updated 5/19/2025, indicates that Individual #1 requires the supervision of two staff at all times at home and in the community due to behavioral and safety concerns. Individual #1's Restrictive Procedure Plan, last updated 5/19/2025 reads "[Individual #1] does require supervision at all times, but [Individual #1] is allowed alone time in [Individual #1] bedroom to provide [them] space with 15 minute checks. DSP needs to ensure both [Individual #1] and the community safety at all times." The Restrictive Procedure Plan also reads, "[Individual #1] has begun to collect feces and put it in [Individual #1] dresser drawers with [their] clothes. For health and safety reasons, [Individual #1's] dresser will be moved from [Individual #1's] bedroom to the office," and "since [Individual #1] is a risk for swallowing inedible objects, DSPs will do bedroom sweeps every shift and upon return from an outing as well as check [Individual #1's] pockets after returning from an outing to ensure [Individual #1] did not pick up any object in the community." In addition, the Restrictive Procedure Plan indicates Individual #1 requires supervision within visual range in the home and that the supervision within auditory range is required when sleeping. On 10/2/2025 at 9:55AM, Nurse #1 contacted Individual #1's medical provider. Documentation from the medical provider regarding this conversation reads , "just need to report that staff walked in this AM and [Individual #1] had mitts on and still had stool in [Individual #1's] mouth. The staff does not believe [Individual #1] swallowed any. They got it cleaned out. Wondering if there is anything in particular that [Individual #1's] workers should be looking for?" On 10/8/2025, Program Specialist #2 visited Individual #1 at the home and observed Individual #1 eating feces. Individual #1 later had breathing issues and was taken to the hospital and was diagnosed with pneumonia. On 10/8/2025 at 6:46PM, Program Specialist #2 sent a message on the provider agency's "GroupMe" communication application that read, "until further notice [Individual #1] must be in visual range at all times!!! [Individual #1] can not be left alone in [their] bedroom!!" On 10/15/2025 at approximately 5:55PM, Direct Service Worker #3 found Individual #1 lying on Individual #1's bedroom floor. Individual #1 was unresponsive with feces in Individual #1's mouth. Prior to being found, Individual #1 was in their bedroom with the door closed for approximately thirty minutes and reportedly, was periodically checked. During this time, Direct Service Worker #3 went to the bathroom and then to the living room and Direct Service Worker #4 went to the basement of the home to do laundry leaving only Direct Service Worker #3 in auditory range of Individual #1. Once Individual #1 was found, Direct Service Worker #3 called Direct Service Worker #5 who told them to call 911. Direct Service Worker #3 yelled for Direct Service Worker #4 to come upstairs from the basement to help. Direct Service Worker #3 attempted to remove the feces from Individual #1's mouth and throat with paper towels. Direct Service Worker #4 then began doing chest compressions on Individual #1 until the Emergency Responders arrived and provided emergency medical care. Individual #1 was unable to be revived and was pronounced dead at the home. The provider was aware of Individual #1's risk of choking and prior attempts to ingest feces. The provider failed to support Individual #1 to ensure Individual #1's health and safety. The provider failed to provide Direct Service Workers with adequate training regarding Individual #1's supervision and care needs including supervision changes to ensure Individual #1's health and safety. Individual #1 was left unsupervised and died of asphyxiation due to choking at 6:30PM on 10/15/2025. | 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. | Valley Advantages response to Violation 6400.16. 6400.43(b)(C), will be sent in separate attachment:Response to Allegation: Failure to Provide Adequate Training to Direct Service Workers Regarding Individual #1's Supervision and Care Needs
Valley Advantages respectfully disagrees with the assertion that the Chief Executive Officer failed to ensure adequate training or communication to Direct Service Workers (DSWs) regarding Individual #1's supervision and care needs.
Valley Advantages had successfully supported Individual #1 for five years prior to the incident, during which time there were no reports of swallowing or ingestion incidents. At that time, Individual #1 no longer required G-tube feeding and was safely consuming food orally. The residential environment at 148 Cannel Mine was closely monitored and maintained as a secure setting, with all potential hazards (e.g., keys, nails, screws, personal belongings, and other small objects) removed from access.
During a brief period in which Individual #1 developed a behavioral compulsion involving ingestion of feces, the treatment team promptly engaged with Supports Coordination and Person Driven Clinical Solutions (PCDS) to reassess and increase supervision and clinical supports. These interventions were designed to ensure safety while maintaining dignity and respect consistent with individual rights and regulatory expectations.
In 2025, Valley Advantages provided more than 200 hours of training to, Staff #3 and #4. The approved Valley Advantages Annual Training Plan (2025--2026), validated by the Office of Developmental Programs (ODP) under the Performance-Based Contract framework, included general and specialized training through ODP, Relias, NADD-Dual Diagnosis Specialist, HWC, Ukeru Trauma-Informed Care Curriculum, and Person Driven Clinical Solutions. All DSWs assigned to Individual #1 were certified in First Aid/CPR, Incident Management, and Emergency Medical Procedures in accordance with ODP requirements.
Following the initial ingestive incident, Program Specialist #2 issued immediate supervision change directives to all DSWs via in-person communication, written notice, and the Valley "GroupMe" communication system. The instructions clearly specified:
· When supervision changes were to begin
· What supervision entailed ("eyes-on supervision at all times, including in bedroom areas")
· Where supervision was required
· When supervision modifications could be reconsidered
Direct Support Professionals acknowledged receipt of this information via verification in communication logs and Critical Incident (CI) statements.
Although there were administrative delays in the formal documentation and distribution of updated Residential Protective Planning (RPP) documents due to ongoing interdisciplinary team revision processes, staff were verbally and electronically informed of all required supervision changes to ensure immediate compliance.
Tragically, on October 15, 2025, Individual #1 was left unsupervised, resulting in choking and death by asphyxiation. Internal investigations confirmed neglect on the part of Staff #3 and Staff #4, who failed to follow Program Specialist directives and previously completed emergency medical training.
Valley Advantages maintains that appropriate training, supervision directives, and communication systems were in place and verified. The organization continues to enhance staff accountability, retraining protocols, and interdisciplinary communication processes to further strengthen the safeguards that protect all individuals in its care. |
01/08/2026
| Implemented |
| 6400.43(b)(3) | The provider was aware of Individual #1's risk of choking and prior attempts to ingest feces. The provider failed to support Individual #1 to ensure Individual #1's health and safety. Chief Executive Officer #6 failed to provide Direct Service Workers with adequate training regarding Individual #1's supervision and care needs including supervision changes to ensure Individual #1's health and safety. Individual #1 was left unsupervised and died of asphyxiation due to choking at 6:30PM on 10/15/2025. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | Response to Allegation: Failure to Provide Adequate Training to Direct Service Workers Regarding Individual #1's Supervision and Care Needs
Valley Advantages respectfully disagrees with the assertion that the Chief Executive Officer failed to ensure adequate training or communication to Direct Service Workers (DSWs) regarding Individual #1's supervision and care needs.
Valley Advantages had successfully supported Individual #1 for five years prior to the incident, during which time there were no reports of swallowing or ingestion incidents. At that time, Individual #1 no longer required G-tube feeding and was safely consuming food orally. The residential environment at 148 Cannel Mine was closely monitored and maintained as a secure setting, with all potential hazards (e.g., keys, nails, screws, personal belongings, and other small objects) removed from access.
During a brief period in which Individual #1 developed a behavioral compulsion involving ingestion of feces, the treatment team promptly engaged with Supports Coordination and Person Driven Clinical Solutions (PCDS) to reassess and increase supervision and clinical supports. These interventions were designed to ensure safety while maintaining dignity and respect consistent with individual rights and regulatory expectations.
In 2025, Valley Advantages provided more than 200 hours of training to, Staff #3 and #4. The approved Valley Advantages Annual Training Plan (2025--2026), validated by the Office of Developmental Programs (ODP) under the Performance-Based Contract framework, included general and specialized training through ODP, Relias, NADD-Dual Diagnosis Specialist, HWC, Ukeru Trauma-Informed Care Curriculum, and Person Driven Clinical Solutions. All DSWs assigned to Individual #1 were certified in First Aid/CPR, Incident Management, and Emergency Medical Procedures in accordance with ODP requirements.
Following the initial ingestive incident, Program Specialist #2 issued immediate supervision change directives to all DSWs via in-person communication, written notice, and the Valley "GroupMe" communication system. The instructions clearly specified:
· When supervision changes were to begin
· What supervision entailed ("eyes-on supervision at all times, including in bedroom areas")
· Where supervision was required
· When supervision modifications could be reconsidered
Direct Support Professionals acknowledged receipt of this information via verification in communication logs and Critical Incident (CI) statements.
Although there were administrative delays in the formal documentation and distribution of updated Residential Protective Planning (RPP) documents due to ongoing interdisciplinary team revision processes, staff were verbally and electronically informed of all required supervision changes to ensure immediate compliance.
Tragically, on October 15, 2025, Individual #1 was left unsupervised, resulting in choking and death by asphyxiation. Internal investigations confirmed neglect on the part of Staff #3 and Staff #4, who failed to follow Program Specialist directives and previously completed emergency medical training.
Valley Advantages maintains that appropriate training, supervision directives, and communication systems were in place and verified. The organization continues to enhance staff accountability, retraining protocols, and interdisciplinary communication processes to further strengthen the safeguards that protect all individuals in its care. |
12/31/2025
| Implemented |
| 6400.64(b) | On 10/23/2025 at 10:10AM, there were an inordinate amount of dead flies on the window and on the floor under the window in Individual #1's bedroom. At 10:32AM, there were an inordinate amount of fruit flies surrounding the apples and potatoes on shelves in the kitchen of the home. | There may not be evidence of infestation of insects or rodents in the home. | On 10/23/2025 during the unaccounted inspection, Individual #1 had already passed away, his items and belongings had been removed from the room, Valley Operations department was in the process of removing the closed in air conditioner. The flies that were, in this bedroom, had fallen from behind the air-conditioning unit when it had been removed, Due to bedroom being unoccupied, instructions were given to completely clean bedroom #1(walls, floors, windows, closets, etc) once all belongings were removed, bedroom was no longer secured for Certified Investigation. it was sanitized and cleaned by GM.
The Produce was removed from shelve in the kitchen area, where they were stored) on 10/23/2025 |
02/01/2026
| Implemented |
| 6400.181(e)(4) | Individual #1's assessment, completed 10/25/2024, states that Individual #1 requires one on one supervision at all times. Individual #1's Restrictive Procedure Plan, last updated 5/19/2025, states that Individual #1 requires two on one supervision at all times. | The assessment must include the following information: The individual's need for supervision.
| Immediate corrective action could not be completed for Individual #1 assessment (as he had passed away on 10/15/2025). The Program Department reviewed all assessments to assure supervision needs were reflective of the individuals current needs. Corrections were made, those corrections to all designated team members. |
11/26/2025
| Implemented |
| 6400.45(e) | Individual #1's Restrictive Procedure Plan, last updated 5/19/2025, states that the individual requires two staff within auditory range while alone in the bedroom. On 10/8/2025 at 6:46PM, Program Specialist #2 sent a message on the provider agency's "GroupMe" communication application that read, "until further notice [Individual #1] must be in visual range at all times!!! [Individual #1] can not be left alone in [their] bedroom!!" On 10/15/2025 at approximately 5:30PM, Individual #1 was alone in Individual #1's bedroom with the door closed. Direct Service Worker #4 went to the basement of the home to do laundry leaving only Direct Service Worker #3 in auditory range of Individual #1. | An individual may not be left unsupervised solely for the convenience of the home or the direct service worker. | Direct Service worker #3, Direct Service Worker #4 were placed on suspension on 10/23/2025(currently still suspended, pending file review of all investigations. Suspension is for violation of multiple regulations, along with failure to follow verbal and written communication by Program Specialist #2 |
11/26/2025
| Implemented |
|
|