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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.32(r)(1) | On 5/20/2026 at 12:11pm, Individual #3's bedroom door was observed with a straightedge locking mechanism that does not have a unique locking mechanism to lock and unlock their door. On 5/25/2023, Individual #3 signed the agency's door lock declination form and indicated that they were "choosing to have a lock on [their] bedroom door." The agency violated Individual #3's right to lock their bedroom door by not providing them with a unique locking mechanism.
On 5/20/2026 at 12:14pm, Individual #4's bedroom door was observed with a straightedge locking mechanism that does not have a unique locking mechanism to lock and unlock their door. On 12/10/2024, Individual #4 signed the agency's door lock declination form and indicated that they were "choosing to have a lock on [their] bedroom door." The agency violated Individual #4's right to lock their bedroom door by not providing them with a unique locking mechanism. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | Program Specialist or designee will meet with all individuals who reside in the home. For those individuals who choose to have a lock on their door a knob with a unique key will be installed and the individual and staff will be given a key. For those who indicate that they do not want a lock on their door a passage door knob will be installed in accordance with their rights and personal choice as documented on their signed locked doors form. Staff to be retrained by July 1, 2026 on client lock preferences. |
07/01/2026
| Implemented |
| 6400.32(r)(4) | On 5/20/2026 at 12:06pm, Individual #1's bedroom door equipped with a straightedge locking mechanism. Staff and Individual #1 did not have the designated straightedge to unlock the mechanism to provide easy and immediate access to the room in the event of an emergency.
On 5/20/2026 at 12:07pm, Individual #2's bedroom door equipped with a straightedge locking mechanism. Staff and Individual #2 did not have the designated straightedge to unlock the mechanism to provide easy and immediate access to the room in the event of an emergency.
On 5/20/2026 at 12:11pm, Individual #3's bedroom door equipped with a straightedge locking mechanism. Staff and Individual #3 did not have the designated straightedge to unlock the mechanism to provide easy and immediate access to the room in the event of an emergency.
On 5/20/2026 at 12:14pm, Individual #4's bedroom door equipped with a straightedge locking mechanism. Staff and Individual #4 did not have the designated straightedge to unlock the mechanism to provide easy and immediate access to the room in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | Program Director or designee to meet with all individuals who reside in the home and complete updated door lock forms. Door knobs will then be assessed to ensure that the accurate locking mechanisms are in place. For those who report they would like a lock on their door a knob will be installed with a unique key to that knob and the individual and staff will have corresponding keys. For those who decline to have a lock on their door a passage knob will be installed. To be completed by 7/1/2026. Requests to ISP's will be made if needed. |
07/01/2026
| Implemented |
| 6400.207(5)(II) | On 5/20/2026 at 12:09pm, Individual #2's hospital bed was equipped with partial, bilateral bed rails at its head and bilateral medical assist bars at its foot that restricted the movement or function of the individual's body. The agency obtained a prescription for the medical assist bars on 5/7/2026, indicating that the assist bars were to aid in mobility and independence due to Individual #2's diagnoses of Ambulatory Dysfunction, Bilateral Leg Weakness, and Physical Deconditioning. Although the medical assist bars are prescribed by the medical practitioner, the order did not include the need for the bilateral upper bedrails that were observed on Individual #2's bed. Individual #2's assessment, last updated 8/29/2025, did not indicate if the individual can easily remove the bedrails or if the bedrails are removed by a staff person immediately upon the request or indication by the individual. Individual #2's Support Plan, last updated 5/14/2026, did not include periodic relief of the bedrails to allow freedom of movement. Both Individual #2's current assessment and support plan only indicated that Individual #2 required the use of a medical assist bar.
On 5/20/2026 at 12:12pm, Individual #3's hospital bed was equipped with a half bed rail at its head on the left side, while the bed's right side was positioned directly against the wall. The bedrail had the potential to restrict the movement or function of the individual's body. The agency obtained a prescription for the bedrail on 5/7/2026, indicating that the device was to aid in safety and Individual #3's ability to adjust themself in bed due to their diagnoses of Cerebral Palsy, cognitive impairment, and Frederich's Ataxia. Although the device is prescribed by the medical practitioner, Individual 3's Support Plan, last updated 5/13/2026, did not include periodic relief of the device to allow freedom of movement. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | The Program Specialist or designee will send ISP change form by 6/15/2025 indicating that individuals #3 is able to verbally request period relief of the device to allow freedom of movement. Individual #2's medical orders were reviewed and by order is required to have assist bars only. On 5/21/2026, bilateral bed rails were removed based on the current order of necessity of assist bars only. |
06/15/2026
| Implemented |
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