| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | (Repeated Violation -- 12/12/25) Individual #1 is diagnosed with schizophrenia, bipolar disorder, impulse control disorder, and moderate ID. The individual is independent with personal hygiene, ambulation, and most activities of daily living. Individual #1 has a history of unexplained injuries, and a twice daily body check has been in place since at least 6/3/25 to ensure Individual #1's health and safety.
Individual #1's date of admission to Valley Community Services is 04/29/14, with a move to the current home on 11/12/25. Between 12/11/25 and 2/19/26, at least 13 falls, a mixture of witnessed and unwitnessed, were noted in daily logs. Staff believed the falls were behavioral, and it wasn't until January 2026 that it was suggested to make sure there was not a medical reason for the falls. A PCP appointment was not held for this reason until 02/24/26, when the physician prescribed ASAP lab work to be completed to determine next steps. As of 03/10/26, there is no documentation verifying this lab work was completed or that further medical care has been sought for Individual #1's increase in falls.
As part of Individual #1's Behavior Support Plan, twice daily body checks are to be completed to ensure Individual #1's health and safety. After a 12/22/25 injury of unknown origin, it was discovered that these checks are not being completed consistently. All staff were retrained on 01/14/26. Between 01/14/26 and 03/10/26, there were 17 days when there weren't two daily checks completed.
When there is a new injury, a GER is to be completed, and On-Call notified. On 8 occasions between 01/14/26 and 03/10/26, there were new injuries of an unknown origin discovered and noted, but a GER was not completed, and medical follow-up was not conducted. These occasions were described in 6400.144.
On 12/02/25, Individual #1's restrictive component of their behavior support plan was updated to note that staff now believed that some of Individual #1's many unreported injuries are due to Individual #1 engaging in private Non-Suicidal Self-Injurious Behavior. While this statement was added to the restrictive component, there were no other adjustments made to the behavior support plan to address this behavior.
Failure to seek timely medical attention, especially the recommended bloodwork, failure to ensure consistent health and safety checks are completed, failure to have a fall risk assessment completed, failure to develop a fall protocol, and failure to ensure plans are updated appropriately created conditions conducive to serious harm for Individual #1. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Lab work for individual was completed on 2/27/26, Program Manager will contact physician for copy of results.
Individual #1 updated behavior plan on 12/02/25, NSSIB was not properly added as baseline data. The staff's belief needs data to ensure the NSSIB is accurate. The Behavior Support Specialist gathered the information for three months. Upon review, there was data that supported the NSSIB for the falls only. The behavior plan will continue to include NSSIB for falls, along with the strategies to use to reduce and eliminate NSSIB. Data will be collected monthly and adjustments to the strategies will be made as needed. The behavior plan for NSSIB will be completed by the behavioral support specialist, approved by the Human Rights Team prior to 04/14/2026, and trained to all staff on 04/17/2026.
The staff working with Individual #1 will be retrained by the behavioral support specialist on the documentation required with the two required body checks, along with the responsibility of the Program Manager and designees to ensure daily that the checks are being completed on 04/17/2026.
GERs will be logged into the system for the 8 occasions there were new injuries of unknown origin but a GER was not completed at the time.
Staff will be retrained on calling on-call to report any injuries and completing GERs in a timely manner.
A fall protocol will be created for the individual and staff will be trained on it. |
04/20/2026
| Accepted |
| 6400.80(a) | At the time of the 03/04/26 inspection, the was a 2" plus gap between the concrete slabs in front of the main entrance. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Repair has been scheduled, weather permitting. Concrete slab will be removed, cleaned up, and new concrete slab set and poured to eliminate 2 inch gap. |
04/20/2026
| Accepted |
| 6400.110(b) | At the time of the 03/04/26 inspection, there was not a smoke detector within 15 feet of all the bedrooms. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | Smoke detector was replaced in the hallway within 15 feet of all bedrooms |
03/25/2026
| Accepted |
| 6400.114(b) | At the time of the 03/04/26 inspection, there were cigarette butts scattered on the lawn near a metal bucket at the street. | Written smoking safety procedures shall be followed. | Program Managers will be retrained on VCS Smoking Policy |
03/26/2026
| Accepted |
| 6400.144 | (Repeated Violation -- 10/20/25, 12/12/25) As part of Individual #1's Behavior Support Plan, twice daily body checks are to be completed to ensure Individual #1's health and safety. After a 12/22/25 injury of unknown origin, it was discovered that these checks are not being completed consistently. All staff were retrained on 01/14/26. Between 01/14/26 and 03/10/26, there were 3 days when no checks were documented and 14 days when only one check was documented. There were 15 body checks that Individual #1 refused, and there was no education provided to the Individual about the importance of these checks.
When a new injury is discovered, a GER is to be completed in the provider agency's computer system. On the following occasions, there were injuries of unknown origin that were not reported in a GER, and follow up medical care was not sought.
· 02/06/26 8:30am -- New mark under belly left side nickel sized
· 02/22/26 10:45am -- 3 small deep scabbed scratches left side lower back
· 02/26/26 AM -- scratch under right breast, scratch on left side abdomen
· 03/01/26 12:25pm -- left shoulder back purple bruise
· 03/03/26 8am -- right lower side midsize purple bruise
· 03/04/26 8am -- right lower back bruise, light/dark purple, hand sized; right forearm nickel size light/dark purple bruise
· 03/05/26 9:30am -- right upper arm bruise; light purple, quarter sized; left upper arm bruise, light purple, dot sized
· 03/06/26 7:45pm -- left upper back quarter size dark purple bruise | 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 staff working with Individual #1 will be retrained by the behavioral support specialist on the documentation required with the two required body checks, along with the responsibility of the Program Manager and designees to ensure daily that the checks are being completed on 04/17/2026. |
04/17/2026
| Accepted |
| 6400.171 | At the time of the 03/04/26 inspection, there was a container of "liquid egg substitute" in the basement refrigerator that expired 02/02/26. Corrected on site. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Staff will be retrained on weekly food checks to ensure no expired food items are in refrigerators or pantries |
04/13/2026
| Accepted |
| 6400.181(e)(1) | In the functional strengths section of Individual #1's 05/21/25 assessment, it states that the individual has a 1000ml per day fluid restriction. This is inaccurate. Individual #1's fluid restriction is 1500-2000ml per day. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Program Specialist will complete an addendum to the assessment for the individual to reflect the correct fluid restriction throughout the report. |
04/20/2026
| Accepted |
| 6400.214(b) | At the time of the 03/04/26 inspection, Individual #1's current Annual Assessment was not available at the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Program Specialist completed Individual #1's Assessment and will be retrained on timely deadlines for reports. |
03/27/2026
| Accepted |
| 6400.182(c) | On 12/02/25, Individual #1's restrictive component of their behavior support plan was updated to note that staff now believed that some of Individual #1's many unreported injuries are due to Individual #1 engaging in private Non-Suicidal Self-Injurious Behavior. While this statement was added to the restrictive component, there were no other adjustments made to the behavior support plan to address this behavior. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Individual #1 updated behavior plan on 12/02/25, NSSIB was not properly added as baseline data. The staff's belief needs data to ensure the NSSIB is accurate. The Behavior Support Specialist gathered the information for three months. Upon review, there was data that supported the NSSIB for the falls only. The behavior plan will continue to include NSSIB for falls, along with the strategies to use to reduce and eliminate NSSIB. |
04/17/2026
| Accepted |