Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.22(d)(1) | At the time of the 4/15/24 inspection, there was not a current and up-to-date financial record at the home. In April 2024, there were two math errors that were never reconciled. The cash balance was documented as $3.52. The actual cash balance at the time of inspection was $2.61. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | April 2024 financial record was completed by the Program Supervisor and mathematical errors found were corrected on 4/16/24. Funds were audited by the Program Supervisor and Program Manager on 5/6/24 (attachment #1). Staff were trained by the Program Supervisor in keeping an up to date financial and property record for individuals, including personal possessions and funds received by or deposited with the home on 5/16/24 (attachment #2). |
06/20/2024
| Implemented |
6400.43(b)(1) | At the time of the 04/15/24 physical site inspection, two plastic water bottles full of discarded cigarettes and an accumulation of ash were found on the front porch. Staff at the home stated that there is to be no smoking on provider properties. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Plastic water bottles containing discarded cigarettes and ash were disposed of on 4/15/24 (attachment #4). All staff were retrained on CSGs Tobacco Free Workplace policy on 5/16/24 (attachment #2). |
06/20/2024
| Implemented |
6400.80(a) | At the time of the 04/15/24 physical site inspection, the front concrete porch had a deep crack and was detached from the first stair, creating tripping hazards. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The front concrete porch was repaired on 5/8/24 (attachment #6). |
06/20/2024
| Implemented |
6400.80(b) | At the time of the 04/15/24 physical site inspection, both rear window wells were rusted through and the siding on the rear of the home was covered in a dark substance. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The rear window wells were replaced and the home was pressure washed on 5/8/24 (attachment #7). |
06/20/2024
| Implemented |
6400.144 | Individual #1 is prescribed 600mg of Ibuprofen as needed. At the time of the 4/15/24 inspection, only 200mg of Ibuprofen was available for Individual #1. | 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.
| Individual #1s PCP was contacted by the program supervisor on 5/2/24 due to the need for ibuprofen 600mg. It was discussed with the PCP office that since individual #1 has not had a need for ibuprofen, the PCP discontinued this medication on 5/2/24 (attachment #8). |
06/20/2024
| Implemented |
6400.32(c) | Individual #1's PCP indicated that the individual should be eating no more than 3000 calories per day until 2/27/24, when this recommendation changed to no more than 2400 calories per day due to the increase in Individual #1's weight. Additionally, Individual #1 is to be exercising at least 30 minutes per day and taking at least 10,000 daily steps. Individual #1 frequently refuses to exercise and take their daily recommended steps. They also frequently exceed their daily calories. Individual #1 was 382.4 pounds on 1/1/24, and, by 4/1/24, their weight had increased to 396 pounds.
Community Services Group was to implement a plan of correction by 12/18/23 that included a desensitization plan to address Individual #1's frequent refusals of daily exercise and steps. Additionally, Individual #1 has exceeded their daily caloric intake goals on 55 days from 1/1/24 through 4/8/24, with daily calories reaching 6412 calories. As of the 4/4/24 inspection, Individual #1 is still not being educated on the importance of exercise, daily steps, and staying below daily caloric recommendations from the PCP. Individual #1 has gained nearly 14 pounds in the last 3 months.
Failure to implement plans to address refusals and ensure that Individual #1 is adhering to diet recommendations puts Individual #1's health at serious risk. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | The Behavior Specialist completed training with all staff on 5/9/24, providing education on documentation requirements (attachment #3). This includes where and how to document refusals to complete daily recommended steps and staying below daily caloric recommendations from the PCP, and the education to be provided as a result of the refusals. During this 5/9/24 training, the Behavior Specialist elicited input from the team regarding effective approaches with individual #1. Individual #1's team does not believe that a desensitization plan will be the best approach due to their diagnosis of oppositional defiant disorder. The Behavioral Specialist has completed a restrictive token DRA plan to assist in encouraging individual #1 to follow diet and exercise recommendations, which was submitted and approved by HRT (Attachment #13). Staff will be trained on the plan on 5/30/24 and the plan will be implemented on that date (Attachment #14). The Program Director provided training to the Program Specialist on CSGs Policy and Procedure for Health Services for Individuals in Intellectual and Developmental Disability Services C.7.e-IDD (Attachment #17) on 5/29/2024 (Attachment #15) to promote person-centered physical healthcare practices that aim to proactively address health issues and reduce the risk of harm to individuals. These practices include supporting and educating individuals on their physical health conditions and following medical recommendations. The Program Specialist trained all staff, Program manager and supervisor on this policy 5/30/24 (Attachment #16). |
06/20/2024
| Implemented |
6400.50(a) | Staff persons #1, #3, #4, #5, #6, #8, and #9 have all received medication administration training via routes other than oral, however, the training records kept do not have all the required information. The information required by the medication administration training course includes: staff person name, initial qualification date, most recent annual practicum date, names of non-oral meds staff person received training on and date for each, staff person signature and date, and training provider name, signature and date. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Staff were trained by the Program Nurse on 5/16/24 in routes other than oral and training records will contain the required information (attachment #2). It was communicated to CSG Medication Trainers 5/7/24 that training records need to contain this information moving forward (attachment #5). |
06/20/2024
| Implemented |
6400.52(c)(6) | Individual #1 has an Individual Support Plan (ISP) and Behavior Support Plan (BSP) that staff are to be trained on before working with the individual. Staff persons #7 and #9 have not received training on Individual #1's ISP. None of the 9 staff persons who have worked with Individual #1 since 1/1/24 have been trained on Individual #1's BSP. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | All staff will be trained on individual #1s ISP and behavior support plan by 5/30/24 (Attachment #14; Attachment #16). |
06/20/2024
| Implemented |
6400.163(h) | At the time of the 4/15/24 inspection, the following expired medications were in the home: Fiber, Loratadine, and Promethazine. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Expired medications were disposed of on 5/2/24 (attachment #9). Individual #1s PCP was contacted by the program supervisor on 5/2/24 due to the need for Promethazine and Fiber. It was discussed with the PCP office that since individual #1 has not had a need for Promethazine, the PCP discontinued this medication on 5/2/24 (attachment #8). The Fiber was refilled and obtained on 5/2/24 (attachment #10). |
06/20/2024
| Implemented |
6400.167(a)(4) | There have been many occasions where Individual #1's medications have been administered more than an hour before or an hour after the prescribed administration time.
· 1/1/24 -- 6am medications administered at 8:01am
· 1/2/24 -- 6am medications administered at 7:12am
· 1/3/24 -- 6am medications administered at 7:47am; 6pm medications administered at 7:12pm
· 1/4/24 -- 6am medications administered at 7:44am
· 1/12/24 -- 6am medications administered at 7:34am; 6pm medications administered at 7:10pm
· 1/13/24 -- 6am medications administered at 9:39am; 8am medications administered at 9:26am
· 1/14/24 -- 6am medications administered at 7:48am
· 1/15/24 -- 6am medications administered at 8:34am
· 1/16/24 -- 6am medications administered at 7:36am
· 1/17/24 -- 6am medications administered at 7:06am; 6pm medications administered at 7:10pm
· 1/18/24 -- 6am medications administered at 8:36am
· 1/22/24 -- 6pm medications administered on 1/23/24 at 5:18pm
· 1/26/24 -- 6am medications administered at 7:09am
· 1/27/24 -- 6am medications administered at 8:05am
· 1/28/24 -- 6am medications administered at 7:36am
· 1/29/24 -- 6am medications administered at 7:31am
· 1/30/24 -- 6am medications administered at 9:21am; 8am medications administered at 9:19am
· 1/31/24 -- 6am medications administered at 8:42am
· 2/1/24 -- 6am medications administered at 7:28am
· 2/9/24 -- 6am medications administered at 7:23am
· 2/10/24 -- 6am medications administered at 7:53am; 6pm medications administered at 7:06pm
· 2/11/24 -- 6am medications administered at 7:44am; 6pm medications administered at 7:27pm
· 2/13/24 -- 6am medications administered at 7:48am; 6pm medications administered at 7:11pm
· 2/14/24 -- 6am medications administered at 7:41am; 6pm medications administered at 7:06pm
· 2/15/24 -- 6am medications administered at 7:20am
· 2/23/24 -- 6pm medications administered at 7:27pm
· 2/24/24 -- 6am medications administered at 7:55am; 6pm medications administered at 7:02pm
· 2/25/24 -- 6am medications administered at 7:53am; 6pm medications administered at 7:10pm
· 2/26/24 -- 6am medications administered at 8:20am; 6pm medications administered at 7:19pm
· 2/27/24 -- 6am medications administered at 7:06am; 6pm medications administered at 7:19pm
· 2/28/24 -- 6am medications administered at 7:15am
· 2/29/24 -- 6am medications administered at 7:49am
· 3/9/24 -- 6am medications administered at 7:24am
· 3/10/24 -- 6am medications administered at 8:05am
· 3/11/24 -- 6am medications administered at 7:14am
· 3/12/24 -- 6am medications administered at 7:22am
· 3/13/24 -- 6am medications administered at 8:28am
· 3/14/24 -- 6am medications administered at 7:24am
· 3/17/24 -- 6pm medications administered at 7:01pm
· 3/20/24 -- 6pm medications administered at 7:22pm
· 3/22/24 -- 6am medications administered at 7:11am
· 3/23/24 -- 6am medications administered at 8:19am; 6pm medications administered at 7:19pm
· 3/24/24 -- 6am medications administered at 7:49am
· 3/25/24 -- 6am medications administered at 7:24am; 6pm medications administered at 7:23pm
· 3/26/24 -- 6am medications administered at 8:00am; 6pm medications administered at 7:03pm
· 3/27/24 -- 6am medications administered at 7:41am
· 3/28/24 -- 6am medications administered at 7:20am | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | All staff were trained by the Program Nurse on 5/16/24 regarding administering medications and signing off on the MAR in the timeframe that is allowed under the Medication Administration Guidelines (attachment #12). |
06/20/2024
| Implemented |
6400.167(c) | The medication errors described in 6400.167a4 were not reported in the department's incident management system. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | Medications errors were entered into the EIM system by the Program Manager on 5/9/24 (attachment #11). |
06/20/2024
| Implemented |
6400.186 | Individual #1 has a behavior support plan dated 7/24/23 to address the following behaviors: stealing, physical aggression, property destruction, intentional voiding, verbal aggression, verbal/physical threats, food seeking, self-injurious behavior, refusal, passive aggressive behavior, inappropriate sexual behavior, boundary challenges, false allegations, suspected non-compliance with shower, decreased energy, decreased interest in pleasurable activities, increased use of self-stimulation/psychomotor agitation, sleep disturbance, and weight/appetite change. With every behavior, staff are to document the type of behavior, redirection methods, and Individual #1's response. There were 32 times between 1/1/24 and 4/8/24 that behaviors were noted, but there was no further information recorded. It is not known if staff implemented Individual #1's behavior support plan, which methods of redirection were used, and what Individual #1's response was to this redirection. | The home shall implement the individual plan, including revisions. | The Behavior Specialist completed training with all staff on 5/9/24, providing education on documentation requirements per individual #1s behavior support plan (attachment #3). |
06/20/2024
| Implemented |