| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | Individual #1 had a behavioral health crisis event on 2/15/24. This event was detailed in EIM #9367437. In response to the incident, all staff were to be retrained in Individual #1's Behavior Support Plan by 2/15/24. This retraining did not occur. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | All staff were retrained in individual #1's Behavior Support Plan by the Behavior Specialist on 7/26/24 (Attachment #7). |
09/30/2024
| Implemented |
| 6400.141(c)(14) | The "medical information pertinent to diagnosis and treatment in case of an emergency" section of Individual #1's 5/20/24 physical states, "does well for fire drills." | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1's physical form was updated on 9/5/24 under "medical information pertinent to diagnosis and treatment in case of an emergency" (Attachment #5). |
09/30/2024
| Implemented |
| 6400.141(c)(15) | The special diet instructions section of Individual #1's 5/20/24 physical is blank. | The physical examination shall include:Special instructions for the individual's diet. | Individual #1's physical form was updated to include special diet instructions on 9/5/24 (Attachment #5). |
09/30/2024
| Implemented |
| 6400.18(a)(4) | A potential physical abuse incident was discovered by Community Services Group on 5/20/24. This incident was not entered into EIM until 6/6/24. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| All staff received additional training completed by the Program Specialist on the IM Bulletin regarding Recognition, Reporting, and Filing incidents in the required timeframe established in the 6400 Regulations on 6/18/24 (Attachment #1). |
09/30/2024
| Implemented |
| 6400.18(b)(1) | On 4/8/24, staff noted in daily logs that Individual #1 was having a behavior and staff had to utilize a "bear hug" to keep Individual #1 from assaulting their roommate and staff. This physical restraint was not reported in the department's incident management system. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
Use of a restraint.
| An incident was entered into EIM on 8/15/24 to look into the 4/8/24 incident and an investigator has been assigned (Attachment #2). Additionally, individual #1's team has been collaborating to address the current challenges and staff received training on appropriate de-escalation techniques to prevent potential crisis situations on 6/18/24 (Attachment #1). |
09/30/2024
| Implemented |
| 6400.18(f) | A potential physical abuse incident was discovered by Community Services Group on 5/20/24.
Individual #1 had bruising of unknown origin on their arm and side. A medical appointment to ensure the health and safety of Individual #1 was not conducted until 6/5/24. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | Staff were trained on daily body charting and CSG's Who to Call for Help by the Program Nurse and Program Specialist on 8/23/2024 (Attachment #4). |
09/30/2024
| Implemented |
| 6400.18(g) | A potential physical abuse incident was discovered by Community Services Group on 5/20/24. A certified investigation was not initiated until 6/6/24. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | All staff received additional training completed by the Program Specialist on the IM Bulletin regarding Recognition, Reporting, and Filing incidents in the required timeframe established in the 6400 Regulations on 6/18/24 (Attachment #1). |
09/30/2024
| Implemented |
| 6400.18(b)(2) | The medication errors described in 6400.167a1 were not reported in the department's incident management system. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | The medication errors described in 6400.167a1 were entered into EIM on 8/15/24 (Attachment #3) by the Program Manager. |
09/30/2024
| Implemented |
| 6400.32(c) | Individual #1 has a bowel protocol in place dated 3/10/2020 which indicates that if Individual #1 does not have a bowel movement within 72 hours, polyethylene glycol is to be administered. If no bowel movement within 24 hours of PRN Poly Glycol administration, Individual #1's PCP is to be contacted. Individual #1 does not currently have Polyethylene Glycol as one of their PRN medications. Sennosides are Individual #1's only PRN related to bowel movements. Additionally, PRN bowel medications are not given consistently. Individual #1 went the following dates without a bowel movement and no PRN medications were administered:
· 3/5/24 8:15am through 3/13/24 at 12pm
· 3/14/24 3:13pm through 3/20 12:53pm
· 3/20/24 12:53pm through 3/26/24 12:50pm
· 3/28/24 6:31pm through 4/1/24 12:33pm
· 4/4/24 5:55pm through 4/9/24 7:44am
· 4/11/24 12:40pm through 4/15/24 12:15pm
· 4/15/24 12:15pm through 4/25/24 6:15pm
· 4/25/24 6:15pm through 5/8/24 7:48am
· 5/9/24 2:04pm through 5/17/24 8:46am
· 5/17/24 8:46am through 5/22/24 8:05am
· 5/29/24 8:10am through 6/11/24
There were 2 occasions where PRN Sennosides were also administered less than 72 hours after a bowel movement:
· 3/22/24 7:54am (a bowel movement was recorded on 3/20/24 at 12:53pm)
· 3/28/24 12:20pm (a bowel movement was recorded on 3/26/24 at 12:50pm)
Failure to have a current bowel movement protocol in place creates conditions conductive to serious harm for Individual #1. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Individual #1's bowel movement protocol was updated by the PCP on 9/5/24 (Attachment #5) and eMAR was updated (Attachment #6). Staff will be trained by the Program Specialist on the update by 9/13/24. |
09/30/2024
| Implemented |
| 6400.166(a)(2) | There was no prescriber name for the following medications on Individual #1's Medication Administration Record: Mucinex Fast Max Cold and Flu, Laxative Sennosides, Vitamin D, Sodium Fluoride, Prenatal vitamin, Pantoprazole, Magnesium Glycate, Loratadine, Lamotrigine, Ear Wax removal drops, Culturelle, and Vitamin B12. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The prescribing physician was added by the Program Supervisor on 8/16/24 to individual #1's Medication Administration Record for the following medications: Mucinex Fast Max Cold and Flu, Laxative Sennosides, Vitamin D, Sodium Fluoride, Prenatal vitamin, Pantoprazole, Magnesium Glycate, Loratadine, Lamotrigine, Ear Wax removal drops, Culturelle, and Vitamin B12 (Attachment #6). |
09/30/2024
| Implemented |
| 6400.166(a)(5) | There was no strength of medication for the following medications on Individual #1's Medication Administration Record: Mucinex, Mirafiber Gummies, Magnesium Glycate. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | The strength of medication was added by the Program Supervisor on 8/16/24 to individual #1's Medication Administration Record for the following medications: Mucinex, Mirafiber Gummies, Magnesium Glycate (Attachment #6). |
09/30/2024
| Implemented |
| 6400.167(a)(1) | Individual #1 did not receive their 8am medications on 4/30/24. Individual #1 did not receive their 9pm dose of Benzotropine on 5/2/24. | Medication errors include the following: Failure to administer a medication. | The medication error individual #1's missed 9pm dose of Benztropine on 5/2/24 was entered into EIM on 8/15/24 by the Program Manager (Attachment #3). |
09/30/2024
| Implemented |
| 6400.182(b) | Individual #1 lived at home with their parents during the COVID-19 pandemic, extending from 2020 through 11/29/23, when Individual #1's transition back to the home resumed. Individual #1 should have been treated as a new admission with an updated Behavior Support Plan completed within 90 days of the individual's return to the home, addressing Individual #1's current behaviors with the transition. The most recent Behavior Support Plan was updated on 11/28/23, prior to Individual #1's return and has not been updated with behaviors that Individual #1 has had since return. | The initial individual plan shall be developed based on the individual assessment within 90 days of the individual's date of admission to the home. | Individual #1's behavior plan was updated by the Behavior Specialist on 7/19/24 (Attachment #8). The Behavior Specialist trained staff in this updated behavior plan on 7/26/24 (Attachment #7). |
09/30/2024
| Implemented |