|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.32(c) | Individual #1's Individual Support Plan (ISP) states that the home has 2 awake night staff to provide support. Agency witness statement from document that Staff #3 worked 9pm-11:45pm on 12/24/25 and received a text from Staff #1 that they were on their way and would be late. Staff #2's agency statement form documents that Staff #3 left the home around 11:40 pm on 12/24/25, and Staff #1 arrived at the home around 12:30 am on 12/25/25. Staff #1 stated during their interview with Licensing Representative (LR) on 1/15/26, that she was running late for their 11pm shift on 12/24/25 and arrived at approximately 12:30 am on 12/25/25. The agency failed to provide the 2 awake staff at the home on 12/24/25 from approximately 11:40-11:45pm until 12:30 am on 12/25/25, when the second staff member arrived at the home. As per the ISP, the supervision level was neglected to be provided by the agency at the home.
Emergency Medical Services (EMS) report on 12/25/25 stated that "staff reported that Individual #1 vomited a black and foul smelling Emese around 01:00 (1:00AM)." The coroner's report stated that Staff #1 stated that after arriving at work she went to Individual #1 room and she was vomiting a dark substance. Staff #1 contacted Staff #3, and they had a video call in the room with Individual 1, and she was not complaining of any pain and did not present with any symptoms that made them feel that she needed to go to the hospital. During the interview with LR on 1/15/26, Staff #1 stated, "that on 12/25/25 during the 1 AM check with Individual # 1 had vomited a brown, and light brown color, that kinda had a little smell." The brown vomit was on Individual #1's pillow, her mouth, teeth, clothes, and comforter. Staff #2 described it as a black outline of the vomit on Individual #1 mouth that had dried, and orange on her pillow during his interview with the LR on 1/15/26. Both Staff #1 and Staff #2 were unfamiliar with the vomit and contacted Staff #3. A photo of the vomit was exchanged with Staff #1 and Staff #3, and Individual #1 stated that they were not in any pain. Staff #1 And Staff #2 cleaned Individual #1 up and continued with normal duties. Staff #1 stated during their interview on 1/15/26 with the LR, that at approximately 6:00 am they entered Individual #1's bedroom and found her covered in a darker colored vomit, but the same odor when she vomited the first time, and Individual #1 was unresponsive. EMS was contacted, CPR was performed, but Individual #1 was pronounced deceased at the site. The agency failed to provide medical care/attention at 1:00 am when Individual #1 initially vomited a dark/substance; the agency neglected to provide immediate medical care for Individual #1.
Individual #1's Individual Support Plan (ISP) states under the Know and Do section states that Individual #1 is re-positioned in bed every 2 hours at night. According to the agencies task record for Individual #1 for repositioning in chair and bed documented that on 12/25/25, the 1 Am check was timestamped at 01:22 AM, the 3 AM check was timestamped at 04:27 AM, and the 5AM check was timestamped at 04:28AM. In addition, Individual #1's ISP also stated under the know and do section that Individual #1 wears disposable briefs and is checked every 2 hours. According to the agencies task record for Individual #1's incontinence check documented that on 12/25/25, the 1 Am check was timestamped at 01:21, the 3 AM check was timestamped at 04:27 AM, and the 5AM check was timestamped at 04:28AM. Both the repositioning in chair and bed and incontinence checks on 12/25/25 were documented by Staff #1. During the interview with the LR on 1/15/25 Staff #1 stated that she completed Individual #1's 1 AM check, but when Staff #1 was conducting the 3 am checks, "she stood in the hallway, just popped her head in the room, and didn't check Individual #1's brief or reposition her as she didn't want to bother Individual #1. Staff #1 did not enter Individual #1's bedroom, just looked from the hallway, and did not physically check on Individual #1. Also, according to the coroners' report Staff #1 also report/stated that she checked on Individual #1 was around 0300 hours, when she opened the door to the room and looked in. The light from the hallway illuminated the room and she did not turn the light on. Staff #1 said she observed Individual #1 sleeping. Staff#1 confirmed that she did not physically enter the room, she just looked in from the hallway. Staff # explained that her next check on Individual #1 was around 0600 hours. The agency staff neglected to reposition Individual #1 every 2 hours as well as check Individual #2 every 2 hours for incontinence care. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Staff #1 has been terminated following the investigation for failing to perform the essential duties of their position. All staff receive training on each individual's ISP, complete a shadowing period to become familiar with the residents and overnight responsibilities, and are expected to follow all plans as written. This employee disregarded those responsibilities and to follow organizational policies and procedures.
In addition, our agency has developed a Program Specialist responsibilities checklist. This includes a requirement that Program Specialists complete at least one monthly overnight check of awakenight staff in every home. The goal is to reinforce accountability and help identify gaps in timelines or patterns of incomplete tasks. The checklist also requires Program Specialists to review timestamps on completion records as another way to identify when expectations are not being met.
Lastly, our organization is in the process of adopting a new EHR system with more robust features that will alert management when required responsibilities are not completed. This will provide an additional safeguard to ensure timely follow through and direct support staff in meeting expectations. |
01/26/2026
| Implemented |
| 6400.45(e) | Agency witness statement form document that Staff #3 worked 9pm-11:45pm on 12/24/25 and received a text from Staff #1 that they were on their way and would be late. Staff #2's agency statement form documents that Staff #3 left the home around 11:40 pm on 12/24/25, and Staff #1 arrived at the home around 12:30 am on 12/25/25. Staff #1 stated during their interview with Licensing Representative (LR) on 1/15/26, that she was running late for their 11pm shift on 12/24/25 and arrived at approximately 12:30 am on 12/25/25. The home was left with 1 night staff at the home on 12/24/25 from approximately 11:40-11:45pm until 12:30 am on 12/25/25, when the second staff member arrived at the home. | An individual may not be left unsupervised solely for the convenience of the home or the direct service worker. | Program Specialists have been retrained on the critical nature of maintaining the staff to individual ratios outlined in each person's ISP---even when the timeframe is limited. It was also reinforced that if a situation arises where staffing levels do not meet required ratios, Program Specialists or Supervisors must contact the overnight/weekend on call specialist so that appropriate coverage can be secured. |
01/29/2026
| Implemented |
| 6400.51(b)(5) | Staff #1's record documented that they received Individual Support Plan (ISP) training on 12/20/25, however during their interview on 1/15/26 with the licensing representative (LR) Staff #1 stated "nobody sat down with me, it was a packet left here to fill out, she read it, but I did not retain it." Therefore, Staff #1 did not receive adequate/appropriate training on Individual #1's ISP. There is no record or documentation that Staff #2 received training on Individual #1's Individual Support Plan. | The orientation must encompass the following areas: Job-related knowledge and skills. | All job-related knowledge and skills training will be done face-to-face by Program Specialists or Supervisors. Program Specialists and Supervisors will be expected to hold conversations staff to evaluate the retention and understanding of the information covered in the ISPs. |
01/29/2026
| Implemented |
| 6400.186 | Individual #1's Individual Support Plan (ISP) states that the home has 2 awake night staff to provide support. Agency witness statement from document that Staff #3 worked 9pm-11:45pm on 12/24/25 and received a text from Staff #1 that they were on their way and would be late. Staff #2's agency statement form documents that Staff #3 left the home around 11:40 pm on 12/24/25, and Staff #1 arrived at home around 12:30 am on 12/25/25. Staff #1 stated during their interview with Licensing Representative (LR) on 1/15/26, that she was running late for their 11pm shift on 12/24/25 and arrived at approximately 12:30 am on 12/25/25. The agency was not implementing Individual #1's plan as they did not provide 2 awake staff at the home on 12/24/25 from approximately 11:40-11:45pm until 12:30 am on 12/25/25, when the second staff member arrived at the home.
Individual #1's Individual Support Plan (ISP) states under the Know and Do section states that Individual #1 is re-positioned in bed every 2 hours at night. According to the agencies task record for Individual #1 for repositioning in chair and bed documented that on 12/25/25, the 1 Am check was timestamped at 01:22 AM, the 3 AM check was timestamped at 04:27 AM, and the 5AM check was timestamped at 04:28AM. In addition, Individual #1's ISP also stated under the know and do section that Individual #1 wears disposable briefs and is checked every 2 hours. According to the agencies task record for Individual #1's incontinence check documented that on 12/25/25, the 1 Am check was timestamped at 01:21, the 3 AM check was timestamped at 04:27 AM, and the 5AM check was timestamped at 04: 28AM.Both the repositioning in chair and bed and incontinence checks on 12/25/25 were documented by Staff #1. During the interview with the LR on 1/15/26 Staff #1 stated that She completed Individual #1's 1 AM check, but when Staff #1 was conducting the 3 am checks, "she stood in the hallway, just popped her head in the room, and didn't check Individual #1's brief or reposition her as she didn't want to bother Individual #1. Staff #1 did not enter Individual #1's bedroom, just looked from the hallway, and did not physically check on Individual #1. Agency staff were not implementing Individual #1's plan as they were not documenting that they were repositioning Individual #1 every 2 hours as well as not documenting that they were not conducting an incontinence check on Individual #1 every 2 hours according to the timestamps on the task record for Individual #1, and the interview with the LR by Staff #1 stating that they did not physically re-position or complete incontinence check for Individual #1 at the 3:00 am check. | The home shall implement the individual plan, including revisions. | Program Specialists have been instructed to perform unannounced overnight checks to ensure that staff are implementing each individual's plan. These checks will be done monthly. Additionally, Program Specialists and Supervisors will be expected to identify any gaps in the completion of tasks and prompts and address the issues in a timely manner. |
01/29/2026
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Clean and sanitary conditions are not maintained in the heating vent in the kitchen area of the home. The heating vent in the ceiling of the kitchen had a layer of dust. | Clean and sanitary conditions shall be maintained in the home. | The kitchen vent was cleaned within 48 hours of the licensing date. |
10/26/2023
| Implemented |
| 6400.104 | Notification to the fire department is not kept current. The most recent fire department notification dated 6/23/23 indicated that there are 5 individuals residing in the home. Currently, four individuals reside in the home. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| A letter (notification) will be sent to the Fire Company no later than 10/27/2023. |
10/26/2023
| Implemented |
| 6400.112(b) | Fire drills held on 6/16/23, 5/25/23, 4/18/23 12/22/22, and 9/28/22 were not held during normal staffing conditions. Normal staffing condition are a 2:4 ratio. There were three staff in the home assisting with fire drills on the listed dates. | Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. | A successful fire drill was conducted on 10/3/2023 in which the staffing ratio was maintained. |
10/26/2023
| Implemented |
| 6400.112(d) | Individuals were not able to evacuate the home within the extended evacuation time of 3 minutes 15 seconds on 4/14/23. The evacuation took 3 minutes and 45 seconds. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Our current fire drill log is being updated to include a statement about the amount of time permitted at each program of 2 1/2 min. or approved extended evacuation time. This will serve as a reminder of the regulated time upon completion of the form, and immediate action which may need to be taken. |
10/26/2023
| Implemented |
| 6400.112(f) | Fire drills are not held during sleeping hours at least every 6 months. There was a sleep fire frill conducted on 4/14/23 that was an unsuccessful drill and a successful sleep drill conducted on 4/30/23. There was not a sleep drill conducted prior to 4/14/23. | Alternate exit routes shall be used during fire drills. | A successful sleep drill was conducted on 10/3/2023. The staffing ratio was met (2:4). A sleep drill will be conducted in April 2024 as identified on the Fire Drill Log & Systems Check form. |
10/26/2023
| Implemented |
| 6400.142(f) | Individual #1 does not have a dental hygiene plan | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Individual #1 will have a follow-up appointment scheduled immediately. Prospectus Berco's Dental form will be utilized and completed in its entirety to include the hygiene plan. |
10/26/2023
| Implemented |
| 6400.181(a) | Individual #1's annual assessment was completed late. Individual #1's annual assessment was completed 2/9/22 and not again until 6/8/23. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The supervisor/associate director will ensure that the next assessment is completed no later than 6/7/2024. Checklists and oversight will be utilized to ensure timely completion. |
10/26/2023
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment does not include Recommendations for specific areas of training, programming and services. Individual #1's assessment included an area for recommendations; however the area indicated the individual's current level and progress, not recommendations. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | An updated assessment will be completed by the program supervisor/Associate Director no later than 10/27/2023 which will include the training, programming, and services information required by regulation. |
10/26/2023
| Implemented |
| 6400.165(a) | Prescription medications are not prescribed in writing by an authorized prescriber. There were 5 packets or aspirin, 5 packets of non-aspirin and 3 packets of antacid located in the first aid kit that were not prescribed to any individual in the home. | A prescription medication shall be prescribed in writing by an authorized prescriber. | The non-aspirin and antacid packets were removed from the first aid kit and disposed of by end of licensing review. |
10/26/2023
| Implemented |
|
|