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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.32(c) | (Repeated Violation -- 12/17/24) Individual #2's Individual Support Plan (ISP) states that this individual requires line of sight supervision while in the community due to traffic awareness, limited stranger awareness, and personal safety concerns. There are also concerns for the safety of those in the community. Individual #2 began working at Pizza Hut in June 2025. Individual #2's daily logs note at least 16 times, with timespans of up to 7 hours, when Individual #2 was at work in the community with no staff or job coach present.
The failure to provide required supervision created conditions conducive to serious harm for Individual #2. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | On 9/22/25, Individual #2 and their team met to discuss Individual #2's alone time in the home and community. The team reviewed all data starting on 6/1/25 through to 9/22/25 and there were no incidents documented that would preclude Individual #2 from being safe in the community or home for up to 8 hours, with staff available should the individual need them. It was decided by the team that individual #2 has shown that they can safely use up to 8 hours of alone time in the home and community with access to staff, should they need it, using their cell phone. It was determined that 8 hours could be utilized at home and, in the community, by their choice. They agreed to ensure the individual has a working cell phone when utilizing their time in the community as well as regular check-ins with staff if needed. The individual understands they cannot use their alone time outside of the home if they do not have a working cell phone. If after 3 months, there are no incidents, more alone time will be discussed. It should be noted that Individual #2 has successfully and safely used up to 8 hours without staff supervision, starting in June of 2025 through to September 2025, while working at Pizza Hut. Line of sight supervision has been discontinued and has been updated to; Staff will be available by telephone or hearing distance should Individual #2 need them. VCS will explore, with Individual #2, the use of integrated technology to promote independence. VCS will discuss with Individual #2 the use of Amazon Alexa as a means of communication in the event they are not able to access their cell phone.
Extensive review of the current ISP has been completed by the Program Specialist and Behavior Specialist to ensure information is accurate and to refine the wording to ensure clarification. The corrections are attached for review. A meeting was held on September 22, 2025, with Individual #2, their SC, OD, PS, PM and BS. Individual #2 has been approved for 8 hours of alone time. This will be used at home and in community. Attachment #1, Attachment #2 and Attachment #3 were sent for review.
Individual #2 did work with CRB until OVR-funded supported employment services were concluded on April 30, 2021, and the case was closed. Individual #2 found their current job on their own. The employer and the individual do not feel that any supervision from the home is necessary, as there is always a "lead" at work and the individual shows understanding that any issues they may have can be addressed and resolved by the management on shift. VCS Supported Employment is being offered for their support should they need it. |
10/03/2025
| Implemented |
| 6400.195(c)(2) | Individual #1's Behavior Support Plan dated 12/18/24 and Individual #2's Behavior Support Plan dated 3/9/25 do not include a suspected reason for the behaviors. | The behavior support component of the individual plan shall include: An assessment of the behavior, including the suspected reason for the behavior. | Individual #1's Behavior Support Plan dated 12/18/24 and Individual #2's Behavior Support Plan dated 3/9/25 have been reviewed by the Behavior Team. Individual's #1 plan dated 12/18/24 has been discontinued as of 09/09/2025.
Individual #2's plan was amended as of 09/09/2025. The False Accusations plan was removed. The Suicidal Ideation was also removed. Data collection is attached. (Attachment A). The HRC concern for locking up sharps was also removed, as this was in place to ensure their safety while the Suicidal Ideation plan was active. During the time Suicidal Ideation plan was active, Individual #2's time permitted in the home alone was suspended. Individual #2's alone time in the home was added per their request. Individual #2 was stressed with the need to accompany their housemate to appointments due to staffing. When the Suicidal Ideation plan was in place, the HRC required that the 1-hour alone time in the home was not safe and would need to be removed until such time that Individual #2 reached their target goal.
Submission by the Behavior Specialist to the Human Rights Committee (HRC) was completed on September 9, 2025. Approved and discontinued plans are submitted for review. Training on 195c2 with the Behavior Support staff was conducted on September 9, 2025, prior to the HRC meeting. Suspected reasons must be addressed in each plan. If missing, plans must be updated, submitted, and approved by the Licensed Psychologist prior to September 23, 2025, at which time restrictive behavior plans will be reviewed by the HRC.
Extensive review of the current ISP has been completed by the Program Specialist and Behavior Specialist to ensure information is accurate and to refine the wording to ensure clarification. The corrections are attached for review. A meeting was held on September 22, 2025, with Individual #2, their SC, OD, PS, PM and BS. Individual #2 has been approved for 8 hours of alone time. This will be used at home and in community. Attachment was sent for review.
Recommendations by ARC or any managerial staff must be discussed with the Licensed Psychologist for approval, including those that that are not restrictive. All current False Accusation plans will be pulled and must be updated, submitted, and approved by the Licensed Psychologist prior to September 23, 2025, at which time restrictive behavior plans will be reviewed by the HRC. Functional Behavioral Assessments will continue to be utilized to determine root causes, including, but not limited to, false accusations.
Training with the Behavioral Support department by the licensed Psychologist will be completed prior to October 3, 2025, in regard to supervision as non-restrictive. Discussion on requesting input at any Team or House meeting where supervision is on the agenda will be requested at the next scheduled Program Specialist/Operations Director quarterly meeting. This will be conducted by the Quality Assurance Director of Psychological Services.
Individual #1's plan was determined to be inaccurate and unnecessary, and the plan was discontinued. Individual #2's trauma was determent to be the reason for the false accusations, which in turn was moved into the verbal aggression and the plan was updated accordingly. Both have been submitted for review. |
10/03/2025
| Implemented |
| 6400.195(c)(4) | (Repeated Violation -- 12/17/24) Individual #1's Behavior Support Plan dated 12/18/24 and Individual #2's Behavior Support plan dated 3/9/25 do not include a target date to achieve the outcome. | The behavior support component of the individual plan shall include: A target date to achieve the outcome. | All Behavior Support plans include an objective page where target dates are listed. They are advanced when the objective is met. Objectives may be extended if the target is not reached by the proposed date. Individual #1 and Individual #2 both had target dates to achieve the outcome. These are attached for review. |
09/09/2025
| Implemented |
| 6400.195(c)(5) | Individual #1's Behavior Support Plan dated 12/18/24 and Individual #2's Behavior Support Plan dated 3/9/25 do not include methods for facilitating positive behaviors. While there are methods described for interventions, this only addresses the immediate behavior, and not how to teach or facilitate positive behaviors. | The behavior support component of the individual plan shall include: Methods for facilitating positive behaviors such as changes in the individual's physical and social environment, changes in the individual's routine, improving communications, recognizing and treating physical and behavior health conditions, voluntary physical exercise, redirection, praise, modeling, conflict resolution, de-escalation and teaching skills. | Individual #1's Behavior Support plan dated 12/18/24 and Individual #2 Behavior Support Plan dated 3/9/205, have been reviewed. Individual #1's plan dated 12/18/24 has been discontinued as of 09/09/2025. Individual #2's plans were amended to address the methods for facilitating positive behaviors.
Training on 195c4 with the Behavior Support staff was conducted on September 9, 2025, prior to the HRC meeting. Positive Approaches listed are trained by the Behavior Support Specialist with the staff . Positive Approaches are utilized on a daily basis as methods to facilitate positive behaviors. Positive interventions will be person-centered and adjusted as needed. When interventions are necessary, the list of positive approaches may be used for redirection. Teaching adaptive behaviors is in all behavior plans. This will be facilitated by adding systematic attention to teaching adaptive behaviors. This procedure includes DRO/DRA methods of positive reinforcement to teach appropriate behaviors. Individual #2 utilizes coping skills and time alone to listen to music and to relax in the garage. Individual #2 is to receive a punching bag that will be set up in the home's completed basement. They will have access to this area as they choose. This area will be specifically designed for their use only, to alleviate the stress that causes verbal aggression.
Staff training will be completed once the room is set up. Staff will be expected to follow Individual #2's rights to: refuse to participate in activities and services and the right to control their own schedule and activities, per 6400.32e and 6400.32f. |
09/23/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(f) | The fire extinguishers in the home were inspected on 7/8/22 and not again until 7/14/23, outside of the annual timeframe. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Program Managers have been retrained on 6400.112(c), 112(d), and 112(h) by the quality assurance director. As drills are completed, program managers are required to scan and submit the form to compliance@valleyc.org. The Quality Assurance Director or designee will review and move the form into the SharePoint. The file will be accessible to Program Managers, Program Specialists, and Operation Directors. An example of a completed Fire Drill is now placed in the binder for reference. |
01/31/2024
| Implemented |
| 6400.112(c) | The fire drill record for the 11/7/23 fire drill did not include the time it took to evacuate the home. Additionally, it is unclear what time the drill was held because the "time" line says 1:10 and 10 and the AM is circled. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Program Managers will be retrained on 6400.112(c), 112(d), and 112(h) by the quality assurance director by 1.31.2024. As drills are completed, program managers are required to scan and submit the form to compliance@valleyc.org. The Quality Assurance Director or designee will review and move the form into SharePoint. The file will be accessible to Program Managers, Program Specialists, and Operation Directors. An example of a completed Fire Drill is now placed in the binder for reference. |
01/31/2024
| Implemented |
| 6400.112(d) | The fire drill conducted on 5/6/23 took 2 minutes and 40 seconds. This home does not have an extended evacuation time, nor was a repeat drill conducted within the month of May 2023. | 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. | Program Managers will be retrained on 6400.112(c), 112(d), and 112(h) by the quality assurance director by 1.31.2024. As drills are completed, program managers are required to scan and submit the form to compliance@valleyc.org. The Quality Assurance Director or designee will review and move the form into SharePoint. The file will be accessible to Program Managers, Program Specialists, and Operation Directors. An example of a completed Fire Drill is now placed in the binder for reference. |
01/31/2024
| Implemented |
| 6400.112(h) | The fire drill record for the 6/14/23 fire drill did not indicate if all individuals made it to the designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Program Managers will be retrained on 6400.112(c), 112(d), and 112(h) by the quality assurance director by 1.31.2024. As drills are completed, program managers are required to scan and submit the form to compliance@valleyc.org. The Quality Assurance Director or designee will review and move the form into SharePoint. The file will be accessible to Program Managers, Program Specialists, and Operation Directors. An example of a completed Fire Drill is now placed in the binder for reference. |
01/31/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(e) | The trash can, over 18 inches high, containing Individual #2's used, recycling cans was in the garage of the home, not equipped with a lid. The trash can not equipped with a lid was sitting next to a large, industrial, 64-gallon trash can. The trash can without a lid was more than half the height of the industrial trash can. | Trash receptacles over 18 inches high shall have lids. | The trash can utilized by the person served in the home as a receptacle for recyclable cans has been removed and replaced with one with a lid. Photograph has been submitted for review. (#23) Program Managers were trained on 6400.64(e) by the Director of Quality Assurance & Training on 03/09/21. The outline and attendance record are submitted for review. Program Managers will ensure all trash cans over 18 have lids. The Program Specialist and Operations Directors will continue to complete walkthroughs of the homes periodically to ensure lids on all trash cans. Monitoring will also be completed by the Quality Assurance & Training Associate during biannual inspections. |
03/09/2021
| Implemented |
| 6400.80(a) | The front, cement walkway leading to the home was cracked in one location, across the entire width of the walkway, approximately 2 and ½ feet long. The crack caused one side of the cement walkway to raise higher than the other section of walkway, creating a tripping hazard.
The exterior, cement walkway leading to the exterior cement landing pad off of the porch, was not level and created numerous tripping hazards. The cement walkway was comprised of individual cement sections that had risen and fallen from the level ground, creating areas where corners of cement were protruding in the air and sticking down in the ground.
The exterior, cement walkway dropped off from the exterior cement landing pad, approximately 3 inches in one location. There weren't any visual cues to notify someone of the uneven surface or that it dropped down a few inches. The individuals use this egress route to evacuate the home during fire drills and night and in day light. This uneven surface created a tripping hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The Facilities Director, Operations Director, and Director of Quality Assurance & Training are scheduled to survey the homes cement walkway once weather permits. Upon review, the Facilities Director will obtain bids from local concrete finishers. Estimates will be submitted, and an appropriate resolution will be obtained. The drop off area from the cement landing pad has been painted to highlight the drop until the construction is completed. Photograph is submitted for review The Operations Director will train the Program Manager and staff at the Valley Road CLA on the following: Staff will ensure entering and exiting the home during fire drills is safe until the issues are resolved. The person pulling the alarm will immediately station themselves at egress and staff will also follow to ensure the persons we serves safety.
The Director of Quality Assurance & Training will submit updates to the lead surveyor until the walkway issues are resolved. |
05/01/2021
| Implemented |
| 6400.145(3) | The home's written emergency medical plan did not include the emergency staffing plan in place in the event of a medical emergency. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | Program Managers were trained on regulation 6400.145(3) by the Director of Quality Assurance and Training on March 9, 2012. The outline and attendance record are submitted for review (#3). The emergency medical plan was placed in pdf format to ensure no information is inadvertently omitted. The form and Individuals #1 & 2 forms have been submitted for review. Program Managers were instructed to review each person we serves emergency medical plan to ensure accuracy. All updated forms are to be sent to the Quality Assurance department by 03/11/21. To ensure no further infractions occur, the Program Specialist will review each plan for assigned persons. An email will be sent to the Operations Director by 03/12/21 with completion of the task. Monitoring of the document will be completed by the Quality Assurance & Training Associate during biannual inspections |
03/11/2021
| Implemented |
| 6400.32(s) | During the 1/27/21 remote inspection of the home, Individuals #1 and #2 reported that they do not have a key to the door of their home and weren't offered a key. Both individuals reported to the Department and staff present during the inspection, that they would like to have a key to their home so they can enter, exit and lock and unlock the door to their home. | An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. | Program Managers, Program Specialists, and Operations Directors were trained on regulation 6400.32(s) by the Director of Quality Assurance & Training on 03/09/21. Outline and attendance record have been submitted for review.(#14) A Key Request form and a Key Agreement form, used with mandatory Teams meetings, have been created. Both forms have been submitted for review. Individual #1 and #2 have signed the Key Request form and it is submitted for review, also. The Program Managers are required to utilize the Key Request form for all individuals assigned who request for a key by March 15, 2021 and submit copy to the Program Specialist. The form will be kept in the individuals permanent chart. The Program Specialists are required to utilize the Key Agreement form with attached team meeting minutes for all other individuals within the agency. Team meetings will be schedule and/or completed by 03/31/2021. Program Specialists will submit the meeting schedule to the Operations Director once completed. The Operations Director will participate in team meetings to: 1) ensure all alternative key options are discussed, 2) the individual is part of the meeting unless they indicate otherwise, 3) the team is in agreement. All Key Agreement Team Meetings forms will be submitted to the Quality Assurance & Training department to ensure all individuals needs have been addressed. The Key Agreement Team Meeting form will be kept in the individuals permanent chart. To ensure no further infractions occur, the Quality Assurance & Training Associate will review forms during their biannual inspections. |
03/31/2021
| Implemented |
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