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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 had a diagnosis of mild ID, spastic Cerebral Palsy, mood disorder, incontinence, oropharyngeal dysphagia, scoliosis, dislocated hips, constipation, short mal-formed legs, legs locked in extended position, lateral deviation both feet, and contractures of wrists and hands. Individual #1 was non-verbal, wheelchair dependent, and totally reliant on staff for all activities of daily living. Staff had to utilize a Hoyer lift system, or two persons lift to transfer Individual #1. Individual #1 also required a pureed diet with thin liquids until 9/3/24 due to their dysphagia. Beginning 9/3/24, Individual #1 required a pureed diet with nectar thick liquids.
Between 4/1/24 and 9/26/24, staff failed to adhere to care protocols. None of the 21 staff members working during this period were fully trained on Individual #1's support plans, including use of the Hoyer lift, dietary needs, and bowel protocol. Staff training for the ISP was limited to a "read and acknowledge format", which did not meet required standards. 8 of Individual #1's staff were not trained on the ISP.
Individual #1's SEEN plan identified behaviors such as screaming, crying, or wrist biting as potential indicators of pain, fatigue, frustration, or urinary tract infections. Between 4/1/24 and 9/6/24, staff documented 21 incidents of these behaviors, dismissing them as attention-seeking without seeking medical attention.
Signs of aspiration include gagging/choking during meals, persistent coughing during or after meals, drooling during meals, and wheezing or gurgling sounds from the throat. For individuals unable to self-report, staff should be on the lookout for the following behaviors during meals that could signal aspiration: eating slowly, fear or hesitancy to eat, refusing food and/or liquids, food and liquid falling out of the person's mouth, and refusing to eat except from "favorite" caregiver. Between 4/1/24 and 8/26/24, Individual #1 exhibited the above signs or behaviors at least 13 times and no medical attention was sought.
On 7/18/24, Individual #1 was treated in the ER for dehydration. On 7/19/24, their physician prescribed Thick-it fluids 4 times daily to address difficulties drinking through a straw, but this was not implemented until 7/24/24. On 8/7/24, the doctor ordered that free fluids could be offered through a straw, but some thick-it beverages should still be offered. On 8/26/24, worsening symptoms, including choking, drooling, and refusal to drink prompted a swallow study, which on 9/3/24 adjusted their fluid consistency to nectar thick.
On 9/18/24, Individual #1 was seen at the hospital for sweating, yelling, breathing difficulties, and dehydration, diagnosed with Constipation, and discharged. From 9/19/24 to 9/24/24, symptoms worsened, including gagging, refusing food, heavy breathing, and difficulty swallowing. On 9/24/24, speech therapy recommended honey thickened liquids, but staff were not trained. By 9/25/24, swallowing issues, coughing, and refusal to eat escalated. On 9/26/24 the physician advised immediate hospitalization. Individual #1 was admitted with acute respiratory failure, aspiration pneumonia, and severe swallowing issues. They passed away on 10/16/24, and the preliminary cause listed was aspiration pneumonia.
Failure to train staff, create protocols for health and safety, and delaying medical care created conditions conducive to serious harm for Individual #1. | 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. | Strawberry Fields is committed to supporting individuals with intellectual and developmental disabilities. We recognize the importance of adhering to medical guidelines and following physician recommendations to ensure the delivery of high-quality care for every individual.
It is essential to maintain comprehensive training records to verify all staff have been adequately trained in providing appropriate support and care.
Strawberry Fields acknowledges documentation related to staff training did not initially meet regulatory guidelines to confirm in-person training was completed. This oversight has been addressed, and the necessary training was completed to meet all regulatory standards. Additionally, the training process has been updated and includes a comprehensive training record, ensuring ongoing regulatory compliance.
It is the responsibility of the Program Specialist and SFI nurse to ensure all staff are trained on all new plans, protocols and health concerns as appropriate. The training will be facilitated by the SFI nurse, HCQU nurse or another appropriate trainer.
1/27/2025 All Program Managers, working managers, and SFI nurse were trained on the new training process. Training for all staff regarding individuals will be an in-person training, person specific, and based on the most current Assessment and Individual Plan. It will include, but not limited to the following areas: knowledge about the needs of the individual and practices necessary to assure their health, safety and welfare, the individual's mode of communication, what is important to the individual, preferred activities, foods, relationships, safe eating/feeding procedures, respiratory maintenance and treatments, positioning and transferring procedures, skin integrity protocols, individual-specific emergency procedures, safe and appropriate use of trauma-informed behavior support, and an understanding of age-related factors such as interests ,preferred activities and stamina as specified in the Individual Plan. All Plans and protocols will be included in the training process. (Attachment #1)
1/27/2025 All Program Managers, working managers, and the SFI Nurse signed a training record indicating their training, knowledge and understanding of their responsibilities as trainers.
(Attachment #1)
1/27/2025 Program specialists, working managers, and SFI nurse were trained on their responsibilities including 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. (Attachment #1)
1/27/2025 A training record was signed indicating their attendance and understanding. All program specialists, working managers, and SFI nurse will continue to ensure 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. (Attachment #1)
1/30/2025, a new tracking process was implemented to address specific medical concerns that may require follow-up or could lead to further complications. The process includes the identification of the medical issue and the development of an action plan by the Strawberry Fields Nurse and Program Specialist. The process also includes training for all staff as appropriate. The medical issue will be monitored and tracked on the Medical Issue Tracking Documentation until it is fully resolved. |
01/30/2025
| Implemented |
| 6400.32(c) | Individual #1 was seen by the physician on 7/25/24 for blood pressure and heart rate concerns. The physician ordered that the Individual's heart rate should be checked daily and as needed. The provider agency only checked the individual's pulse on Mondays after this appointment, and no protocol was written to clarify when the physician should be notified. This created conditions conducive to serious harm for Individual #1. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Strawberry Fields is dedicated to supporting individuals with Intellectual and Developmental disabilities. We recognize the importance of following through with medical issues and doctor recommendations. It is crucial in providing quality care.
In regard to the physician recommendation to check Individual #1's heart rate daily and as needed on 7/25/24, it is unclear why our staff did not document this properly. There is no documentation to suggest the recommendation had changed to weekly and no further protocol was written to determine when the physician should be notified. Our internal protocol includes both the Program Specialist and SFI nurse reviewing the appointment information and following up as needed. This did not occur. This was a protocol failure on the part of Strawberry Fields.
1/27/2025 Program specialists, working managers, and SFI nurse were trained on their responsibilities including: An individual will not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.
(Attachment #1)
1/27/2025 A training record was signed indicating their attendance and understanding. All program specialists, working managers, and SFI nurse will continue to confirm an individual will not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.
(Attachment #1)
1/28/2025 & 1/31/2025 A review of the documentation and failure to follow protocols was completed for the Program Specialist and SFI nurse who failed to follow through on the doctor recommendation for Individual #1 on 7/25/2025 (Attachment #3)
1/30/2025, a new tracking process was implemented to address specific medical concerns that may require follow-up or could lead to further complications. The process includes the identification of the medical issue and the development of an action plan by the Strawberry Fields Nurse and Program Specialist. The process also includes training for all staff as appropriate. The medical issue will be monitored and tracked on the Medical Issue Tracking Documentation until it is fully resolved. |
02/06/2025
| Implemented |
| 6400.32(g) | On 6/8/24, staff noted the following in daily logs about Individual #1:
· "[Individual #1] was awake when staff clocked in. [They] then had [their] morning meds. Staff told [them] to go back to sleep. [They] did not listen and just screamed. Staff let [them] be on bed. [They] did not go back to sleep. [They] were then attended by staff and got [them] out of bed by 11am."
On 7/31/24, staff noted the following in daily logs about Individual #1:
· "Staff knocked and entered [Individual #1's] room around 8am for morning meds and 8oz of fluid. After receiving all AM meds, [Individual #1] fell back to sleep for a short bit. Shortly after [Individual #1] began to yell. Staff told [Individual #1] it was too early and to try to go back to sleep. [Individual #1] was quiet for a little then began to yell again. Staff entered [Individual #1's] room around 10am and gave [Individual #1] 8oz of fluid. "
Individual #1 has the right to control their schedule and should not be left in bed until a certain time for staff convenience. | An individual has the right to control the individual's own schedule and activities. | Strawberry Fields recognizes the importance of respecting each individual's right to manage their schedule and activities. We are committed to empowering all individuals to make their own informed choices. To ensure all staff understand and support our mission, additional training will be provided to the staff where Individual #1 lived.
1/27/2025 Program specialists, working managers, and SFI nurse were trained on their responsibilities including: An individual has the right to control the individual's own schedule and activities.
(Attachment #1)
1/27/2025 A training record was signed indicating their attendance and understanding. All program specialists, working managers and SFI nurse will continue to confirm an individual has the right to control the individual's own schedule and activities. (Attachment #1)
1/29/2025 An Individual Rights training was completed with the staff where Individual #1 lived. The training included a comprehensive review of all individual rights, with a focused discussion on the right of each individual to plan and control their own schedule and activities. (Attachment #4) |
01/29/2025
| Implemented |
| 6400.166(a)(14) | The duration of treatment was not listed for Nitrofurantoin on Individual #1's May 2024 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Duration of treatment, if applicable. | Strawberry Fields recognizes the importance of having all information on the medication record as required for regulatory compliance, including a prescription medication must have the duration of treatment indicated.
1/27/2025 Program specialists, working managers, and SFI nurse were trained on their responsibilities including: a medication record shall be kept, including the following for each individual for whom a prescription medication is administered: duration of treatment, if applicable.
(Attachment #1)
1/27/2025 A training record was signed indicating their attendance and understanding. All program specialists, working managers, and SFI nurse will verify a medication record shall be kept, including the following for each individual for whom a prescription medication is administered: duration of treatment, if applicable (Attachment #1)
1/27/2025 A Medication Verification section was added to medical, dental, and psychiatric appointment forms. The verification section includes confirmation the prescription is correct, and duration of treatment is listed.
1/27/2025 The Monthly Supervisory Documentation form was updated to include a review of all medications to confirm the medication record indicates the duration of treatment, if applicable. |
01/29/2025
| Implemented |
| 6400.166(b) | Individual #1's 8pm Mirtazapine administration was not documented at the time of administration on 5/14/24. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Strawberry Fields recognizes the importance of having all information on the medication record as required for regulatory compliance, including having the medication recorded at the time the med is administered.
Strawberry Fields was transitioning pharmacies in May. One pharmacy ended on the 13th and the new pharmacy began on the 14th on the eMAR. The medication was not documented on the MAR on the 14th. It's unclear why the medication was not documented when all other 8pm medications were, and other documentation indicated it was given as prescribed.
1/27/2025 Program specialists, working managers, and SFI nurse were trained on their responsibilities including: the information in subsection (a)(12) and (13) will be recorded in the medication record at the time the medication is administered.
(Attachment #1)
1/27/2025 A training record was signed indicating their attendance and understanding. All program specialists, working managers and SFI nurse will verify information in subsection (a)(12) and (13) will be recorded in the medication record at the time the medication is administered.
(Attachment #1)
1/27/2025 The Monthly Supervisory Documentation form was updated to include a review of all medications to confirm they were recorded at the time the med was administered. . Medications not recorded as administered on the MAR will follow appropriate reporting procedures per ODP. |
01/28/2025
| Implemented |
| 6400.167(a)(3) | Individual #1's Divalproex was increased from 500mg in the morning and 625mg in the evening to 625mg in both the morning and evening on 6/27/24. This increase did not begin in the home until 7/4/24. | Medication errors include the following: Administration of the wrong dose of medication. | Strawberry Fields recognizes the importance of obtaining medications as quickly as possible. Psychiatric appointment forms were updated to include a medication verification section.
Strawberry Fields did not contact the pharmacy and doctor regarding the medication until four days had passed. Faster follow up needs to occur when a medication is prescribed or changed.
1/27/2025 Program specialists, working managers, and SFI nurse were trained on their responsibilities including medication errors include the following: administration of the wrong dose of medication.
(Attachment #1)
1/27/2025 A training record was signed indicating their attendance and understanding. All program specialists, working managers and SFI nurse will continue to verify medication errors include the following: administration of the wrong dose of medication.
Verifying new medications or med changes with the pharmacy in a reasonable amount of time is also vital in the process. A verification process was established to ensure medications are obtained and those staff were trained on the process.
(Attachment #1)
1/27/2025 The psychiatric consult/medication review form was updated to include a Medication Verification section. Medication Verification will be done with the pharmacy when a medication is prescribed or changed to confirm the medication will be received in a timely manner. If there are problems/issues, it will be documented on the medical correspondence form. |
01/31/2025
| Implemented |
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