| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Based upon the violations listed below the department has shown evidence of abuse. | 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. | 1. All individuals shall be free from abuse.
2. Individual received immediate medical attention as 911 was called and he was transported to the hospital.
3. Staff involved were immediately suspended pending investigation.
4. An investigation was conducted beginning on 7/1/2025 and completed on 7/29/2025.
5. Existing staff were trained on "What is Abuse?" on 7/7/2025
6. Existing staff were trained on De-Escalation 7/8/2025
7. Existing staff were trained on Incident Management 7/7/2025
8. Existing staff were trained on the BSP including antecedents/triggers/interventions on 7/7/2025
9. Monthly team meetings are held including Next Step Care, Cornerstone, Parents, Advocate and Job Coach. Individual attends if he is agreeable.
10. Existing staff received a Crisis Prevention Intervention refresher course focusing on hands-on training using real life examples and least restrictive alternatives 7/8/2025 |
01/30/2026
| Implemented |
| 6400.32(d) | The incident that occurred on 6/30/2025 of a non-sanctioned restraint took away individual #1's dignity and respect. | An individual shall be treated with dignity and respect. | 1. An individual shall be treated with dignity and respect.
2. All physical restraints are reviewed by Incident Management Representative when entered (within 72 hours of the incident) and reviewed on monthly and quarterly basis on monthly and quarterly reports.
3. Individual received immediate medical attention as 911 was called and he was transported to the hospital.
4. Staff involved were immediately suspended pending investigation.
5. An investigation was conducted beginning on 7/1/2025 and completed on 7/29/2025.
6. Existing staff were trained on "What is Abuse?" 7/7/2025
7. Existing staff were trained on De-Escalation 7/8/2025
8. Existing staff were trained on Incident Management 7/7/2025
9. Existing staff were trained on the BSP including antecedents/triggers/interventions 7/7/2025
10. Monthly team meetings are held including Next Step Care, Cornerstone, Parents, Advocate and Job Coach. Individual attends if he is agreeable. |
01/30/2026
| Implemented |
| 6400.186 | Individual #1's ISP/BSP dated 8/27/2025 was not properly implemented during the restraint on 6/30/2025. | The home shall implement the individual plan, including revisions. | 1. The home shall implement the individual plan, including revisions.
2. Berkshire staff were re-trained on current BSP dated 4/30/2025
3. BSP was reviewed and revised on 8/27/2025 to reflect and focus on least restrictive interventions/antecedents/triggers
4. Existing staff were trained on BSP revisions dated 8/27/2025
5. Existing staff were trained on "What is Abuse?" 7/7/2025
6. Existing staff were trained on De-Escalation 7/8/2025
7. staff were trained on Incident Management 7/7/2025
8. staff received a Crisis Prevention Intervention refresher course focusing on hands-on training using real life examples and least restrictive alternatives on 7/8/2025 |
01/30/2026
| Implemented |
| 6400.208(d) | The unauthorized restraint that occurred on 6/30/2025 inflicted pain on individual #1. | A physical restraint that inhibits digestion or respiration, inflicts pain, causes embarrassment or humiliation, causes hyperextension of joints, applies pressure on the chest or joints or allows for a free fall to the floor is prohibited. | 1. A physical restraint that inhibits digestion or respiration, inflicts pain, causes embarrassment or humiliation, causes hyperextension of joints, applies pressure on the chest or joints or allows for a free fall to the floor is prohibited.
2. Individual received immediate medical attention as 911 was called and he was transported to the hospital.
3. Staff involved were immediately suspended pending investigation.
4. An investigation was conducted beginning on 7/1/2025 and completed on 7/29/2025.
5. All physical restraints are reviewed by Incident Management Representative when entered (within 72 hours of the incident) and reviewed on monthly and quarterly basis on monthly and quarterly reports.
6. Existing staff were trained on "What is Abuse?" 7/7/2025
7. Existing staff were trained on De-Escalation 7/8/2025
8. Existing staff were trained on Incident Management 7/7/2025
9. Existing staff were trained on the BSP including antecedents/triggers/interventions
10. Monthly team meetings are held including Next Step Care, Cornerstone, Parents, Advocate and Job Coach. Individual attends if he is agreeable. 7/7/2025
11. staff received a Crisis Prevention Intervention refresher course focusing on hands-on training using real life examples and least restrictive alternatives 7/8/2025 |
01/30/2026
| Implemented |