| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual # 1 and Individual # 2 require 1:2 staffing in the home at all times to ensure safety in the home. On 04/05/24 sometime between 8AM and 9:47 AM staff # 1 overdosed on drugs and left both individual # 1 and # 2 unsupervised. Staff # 1 was found on the living room floor unconscious at approximately 9:47 when 911 was called while Individual # 1 and Individual # 2 were found unsupervised waiting to leave for their day programs. Individual # 1's 01/08/24 Assessment reads "Individual # 1 requires assistance and supervision in all areas of their daily life···They relies on staff to ensure his health and safety needs are met." Individual # 2's 09/26/23 Assessment reads "1:2 staffing at all times for their health and safety." It is reported that Staff # 1 overdosed on drugs caused them to lose consciousness leaving both individuals neglected of supervision. | 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. | Crossroads Services Inc. has been in contact with individual #1 and Individual #2 adult day programming, their respective program should alert Crossroads Services Inc. Director, if the individuals have not arrived at their day program by 8:30 a.m. This plan went into effect for individual #1 and individual #2 on 4/8/2024.
Crossroads Services Inc. will contact all day program providers for our individuals who reside in single- staff homes to implement this updated policy.
Crossroads Services Inc. will implement a chart for unannounced checks on our residential properties. The unannounced checks will help ensure that residences are within compliance. It will also help ensure the health and safety of individuals and staff. The checks will be completed by members of management. Management members include, Director, , LPN , Medical Coordinator, and Residential Program Specialist.
The staff working in the homes will be made aware of this new policy but will not know when the checks will occur in advance. |
07/01/2024
| Implemented |
| 6400.144 | Individual # 2 has a bowel protocol due to a diagnosis of constipation. The bowel protocol is included in their 01/08/24 Annual Assessment. The bowel protocol indicates an increase in MiraLAX to three times per day if they do not have a bowel movement within 24 hours, administration of Dulcolax if no bowel movement within 48 hours, an enema if no bowel movement within 72 hours and contact the physician if no bowel movement within 96 hours.
Individual # 2 had a bowel movement on 03/27/24 at 6:45 am. Individual # 2 did not receive an increase in MiraLAX to three times per day on 03/28/24 when they did not have a bowel movement 24 hours after the 6:45 am bowel movement on 03/27/24. They had their next bowel movement at 6:12 am on 03/29/24.
Additionally Individual # 2's bowel tracking did not include the time of bowel movements on 03/11, 17/24. The bowel protocol requires knowledge of the time of bowel movements to ensure the chronologically dependent nature of the medicine interventions as specified. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Individual #2 did not receive Miralax when it should have been given in accordance with his bowel protocol.
Crossroads Services, Inc. (CSI) Residential Director, and CSI LPN, updated and implemented a new bowel chart on May 1, 2024. The new chart has a designated spot to document time of bowel movement. Staff have always been required to document time; the old charts were just blank boxes that staff were expected to document the times. The new chart has designated time slots under every type of bowel movement the individual may have. Khala Vines updated the chart again to be implemented on July 1, 2024. The new updated charts will still have the designated time slots, but each chart will be unique to the individual. Each person's bowel protocol will be listed at the top of the form. This will give clear instructions on what medication needs to be administered and in what time frame.
Individual #2 had a bowel protocol that started at the 24-hour mark with no bowel movement, which was to increase his Miralax, then followed with additional medications at 48 hours, 72 hours, etc. Individual #2 has since had their annual gastro appointment, the physicians changed the protocol to now start after 48 hours of no bowel movement. The new protocol will be on Individual #2's bowel chart for implementation on July 1, 2024.
For individuals who do not have a specific bowel protocol in place, staff will alert LPN, Medical Coordinator and Director at the 48-hour mark.
If staff start a bowel protocol. they must notify CSI LPN, CSI Medical Coordinator, and CSI Residential Director. |
07/01/2024
| Implemented |
| 6400.62(b) | Disinfecting wipes (poison) were found unlocked in the upstairs bathroom cabinet under the sink during the physical site walk through on 04/19/24. | Poisonous materials may be kept unlocked if all individuals living in the home are able to safely use or avoid poisonous materials. Documentation of each individual's ability to safely use or avoid poisonous materials shall be in each individual's assessment. | Crossroads Services Inc. Residential Director will implement a shift checklist for staff to verify all items are locked in accordance with their ISPs. This will include, but not limited, to medications, cleaning products, personal hygiene products and identifying documentation. Some individuals are poison aware, but their medications and identifying documentations are to be locked at all times. |
07/01/2024
| Implemented |
| 6400.45(c) | Individual # 1's 01/08/24 Assessment reads "Individual # 1 requires assistance and supervision in all areas of their daily life···They relies on staff to ensure his health and safety needs are met." Individual # 2's 09/26/23 Assessment reads "1:2 staffing at all times for their health and safety." On 04/05/24 sometime between 8AM and 9:47 AM staff # 1 overdosed on drugs and left both individual # 1 and # 2 unsupervised. Staff # 1 was found on the living room floor unconscious at approximately 9:47 when 911 was called. Supervision of individuals as indicated in their Assessments was not maintained placing both individuals at risk. Individual # 1 is in a wheelchair and "If going out of the house, uses a wheelchair pushed by staff". It is reported that Staff # 1 overdosed on drugs which caused them to lose consciousness. | An individual may be left unsupervised for specified periods of time if the absence of direct supervision is consistent with the individual's assessment and is part of the individual plan, as an outcome which requires the achievement of a higher level of independence. | All residential staff will be required to review and sign that they understand the individual's supervision levels and needs quarterly. This will be in addition to annual/ bi-annual ISP or BSP training. |
07/01/2024
| Implemented |
| 6400.52(c)(6) | Individual # 1 and Individual # 2 require 1:2 staffing in the home at all times to ensure safety in the home. On 04/05/24 sometime between 8AM and 9:47 AM staff # 1 overdosed on drugs and left both individual # 1 and # 2 unsupervised. Staff # 1 was found on the living room floor unconscious at approximately 9:47 when 911 was called. It is reported that Staff # 1 overdosed on drugs which caused them to lose consciousness. Implementation of the Individual Supervision plans by Staff of both Individuals was not maintained as required to ensure their health and safety. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | All residential staff will be required to review and sign that they understand the individual's supervision levels and needs quarterly. This will be in addition to when staff receive a new ISP or BSP training. A individual specific will be sent to the homes every quarter and will be turned in once all staff working in the home or trained on the individual have reviewed and signed. |
07/01/2024
| Implemented |