| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(3) | Staff #4, also the Chief Executive Officer (CEO), failed to keep Individual 1 safe and protected. Individual #1 began to develop bruising on 12/5/24, by 12/8/24 the bruising became even more significant. The individual complained of pain on a few different occasions stating the leg was broken. On 12/12/24 staff reported more significant bruising to the left upper thigh and left lower leg. A few different examinations took place by agency nursing staff, but no physical examination took place from a physician or emergency room staff. By at least 12/17/24 a target was identified yet the target continued to work with Individuals in the home. No retraining of the target took place until 12-28-24. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | CEO updated Policy 215 - Abuse, Neglect and Exploitation on 12/27/2025. Policy 215 has been disseminated to all managers on 1/2/2025. Updated policy will be sent to Western Region Licensing Supervisor with updated sections highlighted in yellow. Per ODP's IM Bulletin it states if the incident is abuse, suspected abuse, or alleged abuse the target is separated from the victim. Additionally, on 4/2/2021 ODP confirmed that targets must be separated from the victim for incidents involving abuse and sexual abuse. The IM Bulletin does not require removal of targets for neglect incidents. MCAR filed two EIM's for abuse (9531956 & 9534238) and both do not have any targets listed. Both incidents were not confirmed. MCAR filed one EIM for neglect (9536910) which was confirmed for neglect. Staff was not required to be removed from duty due to ODP IM Bulletin. Staff was terminated on 01/08/2025 due to confirmed neglect. On 12/10/2024 individual's PCP was notified, lab and x-ray orders were given to provider on 12/11/2024 by PCP. Individual taken for lab and x-rays on 12/11/2024. X-rays of bilateral femurs, including hip and knee joints came back with no fractures. Bloodwork came back within normal range. PCP appointment was made for 12/13/2024. On 12/4/2024 staff was trained in the home by a manager. Training document will be sent to Western Region Licensing Supervisor. On 12/17/2024 the neglect of care was discovered, and at that point the individual was out of our care, therefore we could not retrain the staff to the individual's needs and care plan. MCAR will continue to follow revised Policy 215 for immediate medical attention at ER/hospital, ODP IM Bulletin, and MCAR training guidelines. |
02/01/2025
| Implemented |
| 6400.62(a) | On 12/23/24 at 12:25pm, poisons were unlocked and accessible in a utility room located directly in front of the front entrance. Poisons included 3 bottles of Clorox disinfecting cleaner, Pine-sol multi-surface cleaner, Great Value bleach concentrated, Resolve cleaning solutions, and Cascade dishwashing tablets. | Poisonous materials shall be kept locked or made inaccessible to individuals. | After becoming aware of this citation the House Manager went to the home and locked up all poisons in the home. The staff in the home were notified that the poisons need to remain locked at all time. |
12/23/2024
| Implemented |
| 6400.76(a) | The wheelchair utilized by Individual #1 located in the home was in disrepair. The right brake was loose and was not operable, the left brake was broken. There was no seatbelt on the wheelchair and a small piece of the material was ripped from the right armrest exposing the inner foam. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Agency owned wheelchair was immediately removed and discarded. |
12/26/2024
| Implemented |
| 6400.82(f) | On 12/23/24 at 12:06PM the bathroom located in the middle of the back hall was without toilet paper, hand soap or hand towels | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Toilet paper, hand soap, and hand towels were available in the home. All items were distributed to the restrooms immediately. |
12/23/2024
| Implemented |
| 6400.141(c)(12) | The assessment dated 12/29/23 and the ISP dated 10/18/24 both indicate adaptive equipment is to be used by Individual #1. The adaptive equipment mentioned is a wheelchair and gait belt. However, neither of this adaptive equipment was prescribed by a physician or addressed as a physical limitation on Individual #1's physical examination, dated 8/23/24. | The physical examination shall include: Physical limitations of the individual. | All residential individuals annual physicals are being reviewed to ensure all adaptive equipment is listed under physical limitations and addressed by their PCP. Any individuals physicals prior to this date that do not list adaptive equipment under their physical limitations section will have a PCP script identifying the adaptive equipment used. |
02/28/2025
| Implemented |
| 6400.141(c)(15) | Individual #1 current physical examination, dated 8/23/24 did not indicate "nectar thick liquids". The assessment dated 12/29/23 and ISP dated 10/18/24 indicates that the individual requires "nectar thick liquids". | The physical examination shall include:Special instructions for the individual's diet. | Residential Program Specialist will review their caseload to ensure that the individual's diet listed on the physical matches the assessment and matches the ISP. Any discrepancies found will be corrected so that the physical, assessment, and ISP reflect accurate and cohesive information. |
02/28/2025
| Implemented |
| 6400.144 | Individual #1 had bruising to their thigh and back area on 12/5/24, as reported by staff. On 12/6/24, staff #2 examined Individual #1 and reported, "Even though the bruises are very odd I do not feel like they are from sexual assault." On 12/8/24, staff observed more significant bruising, larger and darker in color. A complete body audit was completed on 12/9/24 by agency nursing staff. Significant bruising, larger in size and darker in color, was noted to both inner thighs, upper chest area, back of legs, and back. On 12/10/24 Individual #1's doctor ordered bloodwork and x-rays. On 12/12/24 more significant bruising to Individual #1's left upper thigh and left lower leg was observed. Despite Individual #1's reports of pain and progression in suspicious bruising the agency failed to seek an emergency medical evaluation and/or treatment for Individual #1. Individual #1 had advised staff on 12/8/24 and 12/10/24 that their leg hurt, even referencing the leg was broken. However, no PRN pain medication was provided to help eliminate the pain that Individual #1 was suffering, even though Individual #1 had a current PRN prescription for Acetaminophen 325mg tab. | 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.
| Policy 215 - Abuse, Neglect, and Exploitation has been updated to include directives that all unknown bruising is to be evaluated at a hospital. Update to the policy includes procedures that all directives by APS, ODP, the individual's guardian, individual's family, and/or PCP are to be followed explicitly. Policy was sent to all management. Policy with updates highlighted will be sent to Western Region Licensing Supervisor. Daily MAR in Therap implemented that includes the ability to schedule PRN's for DSP's disbursement. At January 2025 inservice training a review of PRN procedures was completed. |
01/02/2025
| Implemented |
| 6400.214(b) | Individual #1's most current Individual Service Plan, (ISP) available in the home was last updated on 5/31/24; however, the most current ISP was last updated on 10/18/24. | The most current copies of record information required in § 6400.213(2)-(14) shall be kept at the residential home. | Reviewed all current ISP's of individuals in all group homes. All current ISP's have been verified and uploaded in Therap (EHR) for each individual in all group homes. Staff have access to each individual's ISP through Therap (EHR). |
01/02/2025
| Implemented |
| 6400.32(d) | On 12/23/24 at 12:31 PM, located hanging on a wall in the living room is a large bulletin board. Hanging on the bulletin board was specific identifying information for all three individuals living in the home. On a piece of printer paper Individual #1's medication times were listed, 8am, 4pm and 8pm. It also gives medication instructions, "Meds must be crushed and put in applesauce, yogurt, pudding and spoon fed!!!*" Individual #1 had a change in medication posted from 8/30/24. "Lorazepam tab 0.5mg-take one tablet by mouth every morning-anxiety." It has a handwritten note, "Higher fall risk with med be aware." Individual #1 schedule is posted, "attends the day program at MCAR Inc. 8:30am-12:pm on Monday, Tuesday, Thursday. Individual #2 also had a medication change posted, 8/30/24. "Escitalopram tab 20 mg-take one tablet by mouth once daily-depression. Individual #2 also had the following information posted on a printed paper, which hung on the bulletin board," Gluten free diet and needs to be kept in line of sight because they do tend to go into cabinets and refrigerator without permission to get food, they know they can't have." CPS from 12:30pm-3pm on Tuesday's Wednesday's and Thursdays. Individual #3 also had a printed paper on the bulletin board indicating, "Goes to day program Monday-Friday 8:30-3:30pm. Is to be showered, clean clothes, shaved every morning and looking presentable daily." | An individual shall be treated with dignity and respect. | The House Manager removed all individual personal information from the bulletin board in the home. Photo will be sent to Western Region Licensing Supervisor of bulletin board. |
12/23/2024
| Implemented |
| 6400.165(c) | On 12/23/24, at 12:31PM, On a bulletin board, located on a piece of printer paper Individual #1's medication times, 8am, 4pm and 8pm were listed. It also gives medication instructions, "Meds must be crushed and put in applesauce, yogurt, pudding and spoon fed!!!" The agency failed to consult with the physician prior to altering the form of prescribed medications for administration. | A prescription medication shall be administered as prescribed. | All prescriptions for all individuals in group homes are having a review of the administration procedures to ensure that prescriptions are clear in administration method. Provider is contacting PCP's to update administration methods as necessary. Ongoing all prescriptions will be administered as prescribed. |
02/28/2025
| Implemented |
| 6400.186 | Individual #1's Individual Support Plan (ISP) dated 10/18/24, under "General Health and Safety Risk" it indicates, Per HRST 1/16/23, while walking individual should be wearing a gait belt for staff to assist individual walking, staff should be within arm's reach when the individual is ambulating. The ISP was not implemented as written, as evidenced by the videos dated 12/5/24 at 4:52pm and video dated 12/5/24 at 7:04pm which individual #1 was observed being ambulatory without staff present, which resulted in Individual #1 falling both times. | The home shall implement the individual plan, including revisions. | Provider was made aware of individual ambulating without gait belt on 12/17/2024. Provider immediately started neglect investigation with target identified. Provider identified that target was trained on gait belt procedures on 12/4/2024 for individual. Provider terminated staff for neglect on 1/8/2025. All staff are trained in the home on each individual's ISP, which includes ambulation, diet, care, needs, etc.. |
02/28/2025
| Implemented |