| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.16 | On 5/7/2018, Individual #1 was escorted to the bathroom by Individual #2 without staff supervision. Based on the security footage of the hallway and the entrance to the bathroom, Individual #1 and Individual #2 were alone in the bathroom from 9:20:43AM to 9:36:33AM. At 9:36:33AM, Direct Service Worker #1 entered the bathroom. Individual #1 was in a bathroom stall wearing an adult brief with his/her pants down at the ankles. Individual #2 was standing in the corner along the wall a few feet away from the stall. Individual #2 reported being pinched by Individual #1. Direct Service Worker #1 observed blood on Individual #1's hand and clothing and scratches on Individual #2's arm. The emergency Department patient summary completed 5/7/18 indicates that Individual #1 had an obvious bruise from a human bite to the mid upper back, abrasions to the midback just below the bite, abrasion to the midforehead left upper forehead, finger with breaking of the skin and swelling, right fifth digit abrasion to the dorsal aspect, abrasions over the left dorsum hand and right dorsal hand, left knee abrasion. Penis exam reveals an abrasion to the top of the glands with contusion to the bottom of the glands, a small amount of blood in the external urethral meatus. In addition, the summary indicated the injuries to Individual #1 were consistent with an assault. | 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. | Those identified to be neglectful of their job responsibilities have been terminated. An increase in the overall supervision of all individuals occurred while a review of their ISP and supervision care needs was conducted. Meetings for both Individuals have been held to review ISP content and future programming plans. A new process for educating and training staff on supervision and ISP¿s was developed. Program Specialist will review ISP for needed updates/changes and relay this information to SC. Upon approved and/or corrected plan the direct care staff will receive ISP training directly from the Program Specialist. Program Specialist will review all sections of the ISP while direct care staff takes notes in all areas. Direct care staff will sign off that they have been educated and understand the ISP content in its entirety. The ATF Director will review ISP training documentation monthly and submit to training coordinator for filing. The ATF Director will provide the Chief Executive Officer a report quarterly to be reviewed at the quality management meeting. Additional training will be provided by the Prog Spec as needed or with any supervision care need changes. All staff received additional supervision specific training on 6/4/18. This will be provided by the training coordinator for all new hires. [Immediately, the CEO or designated management staff person, shall educate all staff persons that supervision of individuals shall be by staff persons and not by other individuals. Upon completion of aforementioned trainings, the program specialist shall complete onsite observations of program areas at least weekly for 1 month and then continuing at least monthly to ensure the direct service workers are implementing the ISP and supervision needs of individuals as required. Documentation shall be kept. (DPOC by AES,HSLS on 8/29/18)] |
06/25/2018
| Implemented |
| 2380.32(b)(3) | On 5/7/2018, Individual #1 was escorted to bathroom by Individual #2 without supervision from day program staff. While in the bathroom Individual #1 sustained injuries consistent with an assault with concerns for possible sexual assault. The Chief Executive Office #2 and ATF Director #3 were aware that Individual #1 was not to be unsupervised in the bathroom at the facility. | The chief executive officer shall be responsible for the administration and general management of the facility, including the following: Safety and protection of individuals. | Chief Executive Officer has worked with ATF Director and Training Coordinator to increase ISP training at orientation, annual and quarterly mandatory traininsg and through the ongoing process of supervision. The Training Coordinator has increased the training curriculum in her orientation program and annual mandatory training to include the Supervision Needs Guide Sheet to trigger conversation around the supervision needed to support the participants. It goes into detail to explain the supervision terminology. ISP training template has been updated. The ISP training template will be explained during orientation and again at the annual mandatory training. A revised ISP training process has been implemented to document all needed revisions to be communicated at the annual ISP meeting and the use of the ISP training template to train DSP's in any changes to the ISP. Forms have been developed to document the DSP training by the Program Specialist/Supervisor, which will be reviewed monthly by the ATF Director. The Program Specialist/Supervisor is required to observe each program area on a quarterly basis to insure ISP's are being implemented correctly. A form has been developed to document errors and develop a plan to correct errors. The ATF Director will provide a report to the Chief Executive Officer at the quarterly quality Management meeting.[Immediately, the CEO or designated management staff person, shall educate all staff persons that supervision of individuals shall be by staff persons and not by other individuals. Upon completion of aforementioned trainings, the program specialist shall complete onsite observations of program areas at least weekly for 1 month and then continuing at least monthly to ensure the direct service workers are implementing the ISP and supervision needs of individuals as required. Documentation shall be kept. (DPOC by AES,HSLS on 8/29/18)] |
06/25/2018
| Implemented |
| 2380.33(b)(7) | Individual #2's ISP updated 2/12/18 in the supervision care need section indicates Individual #2 ''requires no less than line of sight while in the day program setting.'' Individual #2 ''is able to use the restroom independently; however; staff monitor his length of time out of the room and provide check-ins if need be." | The program specialist shall be responsible for the following: Reporting content discrepancy to the SC or plan lead, as applicable, and plan team members. | Individual #2 began utilizing the single person restroom with staff supervising from outside of the restroom. The new practice was reviewed with Individual #2. An Interdisciplinary Team Meeting for individual #2 was held on 5/26/18 to update/change or clarify any discrepancies in the ISP Supervision Care Needs sections and other sections related to health and safety. Direct care staff was trained on changes to ISP. Individual #2 will use single bathrooms when available or if only a mutli-person bathroom is available or is chosen by individual #2 it may be used provided no other individual is present in the bathroom. Staff was trained on updates/new protocol/supervision needs. Program Specialists will adhere to the revised ISP training process. This process addresses both in reporting content discrepancies, updates/changes to SC and how to effectively train the direct care staff. ISP Training Process for ATF Direct Care Staff ¿ copy of process e-mailed[Immediately, the CEO or designated management staff person, shall educate all staff persons that supervision of individuals shall be by staff persons and not by other individuals. Upon completion of aforementioned trainings, the program specialist shall complete onsite observations of program areas at least weekly for 1 month and then continuing at least monthly to ensure the direct service workers are implementing the ISP and supervision needs of individuals as required. Documentation shall be kept. (DPOC by AES,HSLS on 8/29/18)] |
06/25/2018
| Implemented |
| 2380.34 | On 5/7/2018 at approximately 9:20AM, Direct Service Worker #4 allowed Individual #1 to be escorted to the bathroom by Individual #2 without staff supervision. Individual #1's ISP, updated 4/16/18 in the supervision care need section reads "[Individual #1] is supervised at all times while at the day program.'' Individual #2's ISP updated 2/12/18 in the supervision care need section reads "[Individual #2] requires no less than line of sight while in the day program setting.'' | A direct service worker shall be responsible for the daily care, training and supervision of individuals. | Direct care staff will be provided training on each individuals ISP to which they are assigned. This training will be provided by the Program Specialist following the annual ISP meeting and approval of the plan by the AE. Program Specialist will re-train direct care staff should any changes/updates in the supervision care needs section occur. Staff assigned as regular staff to each program area will be provided this training before working with any new program participant. ISP training sheet has been updated and will be filled out by each staff during the training. Staff will also sign off that the ISP has been reviewed and understood in its entirety. Training specific to the varying degrees of supervision will also be provided to all incoming and current staff. Current staff received the supervision training on 6/4/18.[Immediately, the CEO or designated management staff person, shall educate all staff persons that supervision of individuals shall be by staff persons and not by other individuals. Upon completion of aforementioned trainings, the program specialist shall complete onsite observations of program areas at least weekly for 1 month and then continuing at least monthly to ensure the direct service workers are implementing the ISP and supervision needs of individuals as required. Documentation shall be kept. (DPOC by AES,HSLS on 8/29/18)] |
06/25/2018
| Implemented |