6400.45(d) | Based on Individual #1's ISP last updated 3/1/16, Individual #1 requires 1:1, staffing to individual ratio during the night due to heightened anxiety and Dysphagia diagnosis with dietary restrictions. Based on Individual #2's ISP, last updated 12/31/15 and Individual #3's ISP, last updated 1/12/16, Individual #2 and Individual #3 require 1:3 staffing to Individual ratio during the night. On 2/25/16 to 2/26/15, Direct Service Worker #1 and Direct Service Worker #2 were working the overnight awake shift from 11:00 PM to 9:00 AM. From 1:00 AM until to 3:30 AM on 2/26/16, Direct Service Worker #2 was asleep on the couch in the living room on the first floor of the home. | The staff qualifications and staff ratio as specified in the ISP shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c). | Direct Service Worker #2 was terminated as a result of sleeping on the job and failing to provide the necessary supervision to the individuals in her care.
Community Living & Learning, Inc. created a new Awake-Night Policy and Mandatory Reporter Form as a result of this violation. All staff in the agency were trained and required to sign the new Awake-night policy and mandatory reporter policy.
All of the staff at the 21 Coates Home where Individuals 1,2 and 3 live were trained on the Community Living and Learning's Grievance Policy, Incident Management, and the individual's ISPs
All awake-nights are required to complete hourly bed checks and indicate the checks in Quickmar which records the exact time of the bed check
Community Living and Learning, Inc. will do surprise inspections periodically between the hours of 1:00am and 6:00am to make sure that awake-night staff are not sleeping [Within 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current ISP to ensure staffing ratios are being implemented as written and discrepancy reported to the SC and plan team members as required. Documentation of "surprise inspections" shall be documented and reviewed by the CEO at least quarterly. (AS 8/16/16)] |
06/13/2016
| Implemented |