Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00242480 Renewal 04/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.207(5)(III)On 04/03/24 at 11:43 AM, Individual 1's bed contained full bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for the bed rails on 01/09/20. The most current assessment, dated 04/14/23, does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #1's individual plan does not include periodic relief of the device to allow freedom of movement.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.Individual #1 had bedrails on her bed at the time of licensing. All staff in the home were trained on the regulation 6400.207(5)(III) by Program Specialist on April 16-17, 2024. A copy of the verification of training form 930 is included in a separate email. Individual #1¿s primary care physician wrote a prescription for ongoing use of bedrails on individual #1¿s bed on April 10, 2024. A copy of the prescription is attached in a separate email. Program Specialist updated the assessment (April 10, 2024) and requested an update of the ISP from the Supports Coordinator to reflect the use of bedrails. The ISP was updated on April 12, 2024, to reflect the use of bedrails. Copies of both documents included. Provider sent a copy of the prescription and an updated ISP to the Human Rights Committee with PCDS for development of a Restrictive Procedure Plan. The plan was reviewed and approved by the Human Rights Committee on April 18, 2024, with effective date of April 20, 2024. 04/18/2024 Implemented
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