| 6400.144 | On June 6, 2025, Individual #1 underwent an upper gastrointestinal endoscopy. The exam results indicated no abnormalities in the esophagus and no significant lesions in the stomach. Four biopsies were taken from the upper third of the esophagus and the gastroesophageal junction. The report recommended that if the biopsies were normal, the observed choking might be behavioral, suggesting the use of chopped food and dividing the meals into smaller portions. On June 18, 2025, the biopsy results were communicated to Hope Enterprises Inc., indicating that the throat biopsies did not show eosinophilic esophagitis and that there were no concerning features apart from mild reflux esophagitis. It was advised to continue with acid-blocking medication for this condition. Since the biopsy findings were normal, the earlier recommendation on June 6 regarding the choking incidents being behavioral, along with the suggestions for meal adjustments, such as chopped foods and dividing meals into small portions should have been incorporated and implemented in Individual #1's eating protocol.
On October 16, 2025, Individual #1 had their annual physical exam. Under the behavioral recommendations, it states that they are recommended to sit upright in the chair for meals, using a slow rate, taking small bites and sips, alternate bites of food, with sips of liquid at all meals, modify tougher or drier foods that feel difficult to swallow by taking smaller bites adding moisture and considering finely chopped or ground meats/fruit/vegetables, and consider avoiding tougher meats, raw vegetables and raw fruits. These full mealtime suggestions were not incorporated or added to Individual #1's eating protocol. | 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 #1 has been discharged from services as of August 16, 2026.
The Program Case Administrators (PCAs) will review records of individuals currently receiving residential services to identify healthcare recommendations related to dietary needs that may affect an individual's current ADLs or daily support. Any identified mealtime recommendations not reflected in the individual's current eating protocol will be revised and updated accordingly.
Quality Management will review and revise the present process for health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual and shall be arranged for or provided.
Quality Management or designee will educate the Programs Case Administrators (PCAs), Support and Services Managers (SSMs), Home Coordinators (HCs), and Direct Support Professionals (DSPs) on the revisions to the process and responsible staff for each step which will include how to communicate the new or revised recommendations, how to update and revise the ADL protocols as recommended by medical professionals, implement health services that are planned and prescribed for the individual, and monitor the implementation. |
10/30/2026
| Implemented |