| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The water temperature in the bathroom was 133°F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | On December 27, 2024, the Chief Operating Officer (COO) of Halia instructed the maintenance team to make adjustments to the water temperature in specific areas, including the kitchen sink, the 2nd-floor bathroom sink, and the hot water areas in the basement. This directive was aimed at ensuring compliance with regulatory standards by setting the water temperature at a permissible level of 120°F. Additionally, the COO, site manager, and maintenance personnel will conduct comprehensive checks on the water temperature at all residential sites to ensure full compliance with ODP regulations. |
12/27/2024
| Implemented |
| 6400.32(n) | There was no evidence of the right to be free from abuse form, provided by the supports coordinator, being retained and accessible at the home for individual #1. This form provides individual specific non-agency team contact information for individuals to contact someone if they feel they are being mistreated. | An individual has the right to unrestricted and private access to telecommunications. | The Program Specialist has addressed the violation by ensuring that copies of the "Right to Be Free from Abuse" form are now available. Moving forward, the Program Specialist will remind Service Coordinators (SCs) during their monitoring sessions to provide copies of this form. These copies will be posted on the bulletin board, and individuals will also be encouraged to keep their own copies. |
12/27/2024
| Implemented |
| 6400.34(a) | The agency provided copies of individual rights forms signed by each of the staff members, but no individual rights signed by Individual #1 or the individual's legal guardian. Individual #1's father, uncle and sister are his court-appointed legal guardians (as per guardianship papers provided for review). No individual rights forms were signed by any of the guardians. There was no evidence that the rights were reviewed with the individual and the guardians upon admission and annually. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The Program Specialist has addressed the violation by ensuring that each individual receives a copy of the "Individual Rights Forms," which are now available for review and signature. From now on, the Program Specialist will be responsible for informing individuals about their rights and explaining the process for reporting any rights violations. This information will be provided to each individual and any designated representative upon their admission to the home, and it will also be reviewed annually thereafter. |
12/27/2024
| Implemented |
| 6400.52(c)(5) | The behavior support plan for individual #1 is dated 11/15/23 and has not been updated annually. Training evidence provided by the agency was provided via a service/progress note by the behavior support specialist. It did not contain a sign-in sheet to document which staff attended. Also, this was completed on 1/11/24 and training in the behavior support plan has not been completed annually for staff working with the individual. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | The Behavioral Specialist, supervised by the Agency COO, has addressed the violation by updating the behavior support plan for Individual #1. |
01/05/2025
| Implemented |
| 6400.182(c) | The individual plan (ISP) has not been updated to reflect Individual #1's current behavioral support plan. The ISP states that the individual has a restrictive behavioral support plan. The BSP provided is not a restrictive plan. The BSP provided is dated 11/15/23 and has not been updated annually. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | 12/23/2024, The Program Specialist, under the supervision of the Agency COO, resolved the violation by printing the updated Individual Support Plan (ISP) and placing it both in the home and in the individual¿s folder. |
12/23/2024
| Implemented |
| 6400.207(4)(I) | Individual #1 is prescribed Desyrel 50mg (Dsp as Trazodone 50mg) PRN for Insomnia. Staff at the home were not able to provide evidence that there are written instructions and protocol in place for allowable administration of this specific PRN medication, as outlined in the ODP Regulatory Compliance Guide, so it is therefore considered a chemical restraint. The agency did provide a copy of their policy that met the guidelines when requested after the site inspection was completed. However, on the date of the inspection, the staff at the home when asked were not aware of such policy, being trained in the agency policy, nor was there a copy of the policy at the home. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | Individual #1 has been prescribed Desyrel 50mg (dispensed as Trazodone 50mg) to be used as needed (PRN) for managing insomnia effectively. To ensure the safe and appropriate administration of this medication, detailed written instructions and a clear protocol were meticulously developed by Halia Management on 12/26/2024. This initiative reflects a commitment to high standards of care and is being overseen by the COO and our agency nurse to guarantee proper implementation. |
12/26/2024
| Implemented |