| 6400.144 | Individual #1 has a bowel protocol that their bowel movements are to be tracked daily. From April 2025 to the present, Individual #1's bowel movements were not tracked a total of 9 times (04/12, 04/20, 05/21, 06/01, 070/5, 07/18, 10/30, 11/27, and 11/28). If Individual #1 goes three days with no bowel movement, they were to receive a dose of Milk of Magnesium on Day 3 and again on Day 4 if they still had no bowel movement. In August, the Milk of Mag was discontinued, and Lactulose was to be administered if Individual #1 went three days with no bowel movement and again on Day 4 with no bowel movement. The Milk of Mag was administered on 06/18/25 and 06/19/25 despite the Individual having had bowel movements in the previous days
Individual #1 has a prescription in the record dated 11/03/25 that Individual #1 should not consume any caffeine. Per Individual #1 financial record, Individual #1 purchased both a "Pepsi" and a "Mt Dew", two beverages that contain caffeine, on 11/13/25. | 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.
| The provider acknowledges the citation. Immediate corrective action was taken to ensure all prescribed health services are followed as ordered.,
Individual #1's bowel protocol, medication orders, and dietary restrictions were reviewed with all staff. Staff will be re-trained on daily bowel movement documentation, proper PRN medication administration per physician orders, and the discontinuation of Milk of Magnesia with appropriate use of Lactulose. The MAR and bowel tracking logs were reviewed for accuracy.
Staff will be also re-educated on Individual #1's no-caffeine medical restriction. Supervisory oversight by wellness coordinator will be increased to ensure compliance with health service plans and prescriptions |
01/28/2026
| Implemented |
| 6400.181(f) | Individual #1 ISP meeting was held on 10/23/25; the most recent Annual Assessment, completed 08/16/25 was sent to all members of Individual #1's Individual Support Plan (ISP) team, excluding Individual #1's mother. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The provider acknowledges the citation. the Program Specialist reviewed Individual #1's ISP records and confirmed that the Annual Assessment dated 08/16/25 was not provided to Individual #1's mother prior to the ISP meeting. The assessment was immediately provided to Individual #1's mother.
The Program Specialist was re-trained on ISP requirements, including ensuring that all ISP team members receive required assessments at least 30 calendar days prior to ISP meetings. |
01/28/2026
| Implemented |
| 6400.213(1)(i) | Individual #1's Guardian is listed as the next-of-kin; however, the Guardian is not a relative. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The provider acknowledges the citation. On 12/15/25 Individual #1's record was reviewed and corrected to accurately reflect the Guardian's role. The Guardian was removed from the "next-of-kin" section and properly identified as the legal Guardian. The individual's personal information record was updated to ensure accuracy and compliance with regulatory requirements.
Wellness coordinator and program specialist reviewed the corrected record to confirm accuracy |
01/28/2026
| Implemented |