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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.52(c)(6) | All staff were to be retrained in Dr. Cherpes Health Alert by 7/1/22. Staff person #14 did not complete this training until 7/19/22. Staff person #10 did not complete this training until 7/13/22. Staff person #20 was on FMLA until 7/7/22, and they did not receive training until 7/11/22.
All staff were to watch "I Go Home" and have training on regulation 6400.32d by 7/1/22. Staff person #10 did not complete this training until 7/13/22. Staff person #20 was on FMLA until 7/7/22, and they did not receive training until 7/13/22.
All staff were to receive retraining in prohibited restraints and a nursing department training on how behavioral and physical changes can be medical concerns by 7/1/22. Staff persons #1, #5, #6, #9, #10, #13, #14, #16, and #18 have not completed these trainings. | 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 identified as being out of compliance with the previous plan of correction, associated with mechanical restrains, has been retrained in this regulation. Signature sheets have been emailed to confirm the completion of this training. |
11/01/2022
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual #1's daily logs for 3/13/22, 3/14/22, and 3/15/22 indicate that each evening, Individual #1 "chose to not get off the toilet" for extended periods of time. On 3/13/22, the refusal lasted approximately 2 hours and 15 minutes. On 3/14/22, the refusal lasted approximately 6 hours. On 3/15/22, the refusal lasted approximately 5 hours. At 10:19pm on 3/15/22, staff person #1 called staff person #2 to get advice on how to proceed. Staff person #2 attempted to talk Individual #1 into getting off the toilet at that time, which was unsuccessful. At approximately 10:51pm, after 3 hours of Individual #1 sitting on the toilet, staff person #1 sent a text message to staff person #3 requesting advice. At 11:54pm, staff person #3 called staff person #1. At this time, staff person #3 directed staff person #1 to find a robe belt or something that could be used to help Individual #1 off the toilet. Staff person #1 made a "makeshift gait belt" utilizing a pair of legging style pajama pants to assist Individual #1 off the toilet and into bed. At approximately 5:30am, staff person #1 noticed that Individual #1 was awake and laying on their stomach but could not roll over in bed. Individual #1 was also "saturated from head to toe" in urine. Staff person #1 waited until staff person #2 arrived at 6:30am to attempt to roll individual #1 over, which is when both staff noticed a quarter dollar sized bruise on Individual #1's upper right thigh. Staff person #1 contacted staff person #5 at 6:30am, and staff person #5 indicated that 911 should be called. Neither staff person contacted 911 immediately, and individual #1 did not receive EMS care until 9:20am. When individual #1 arrived at the emergency room, it was discovered that they had a broken femur which required surgery. | 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.
| AN EIM (8994741) was entered and an investigation occurred. The incident was confirmed as an unexplained injury. All staff working in this program were retrained on the Health Alert issued by Dr. Cherpes on 1/4/2015, regarding calling 911 in a medical emergency. |
07/01/2022
| Implemented |
| 6400.32(c) | The delay of care described in 6400.144 violates Individual #1's right to be free from mistreatment. Individual #1 began refusing to get off the toilet for long periods of time starting on 3/13/22. On 3/15/22, staff person #1 created a makeshift gait belt to move Individual #1 off the toilet and to their bed. At 5:30am on 3/16/22, staff person #1 noticed that Individual #1 was awake, laying on their stomach, and could not roll over. Individual #1 was also saturated in urine from head to toe. Staff person #1 did not attempt to help individual #1 until staff person #2 arrived at 6:30am. A quarter dollar sized bruise was noted on Individual #1's right femur at this time. Medical attention was not sought until 6:30am when the agency nurse advised staff person #1 and #2 to contact 911. 911 was not contacted right away, and Individual #1 did not receive EMS attention until 9:20am. Individual #1 was admitted to the hospital and diagnosed with a femur fracture which required surgery. As of the 4/20/22 inspection, Individual #1 remains hospitalized. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | AN EIM (9013307) was entered and an investigation occurred. The incident was confirmed as neglect, for failure to provide needed care. The two target staff responsible for the delay in care, terminated their employment with Shadowfax prior to receiving corrective action/education. Individual #1's SEEN plan was updated to reflect current behaviors and communication skills and all staff working with Individual #1 have been trained on the updated plan. Individual #1 returned to a residential group home, on 5/16/22, that does not have stairs and is more accessible. Individual #1's supervision levels were reassessed and Individual #1 now has line of sight supervision during awake hours in the program. |
07/01/2022
| Implemented |
| 6400.32(d) | On the night of 3/15/22, staff person #1 noted in daily logs that Individual #1 "chose not to get off the toilet" for approximately 5 hours. At 11:54pm, staff person #1 spoke to management, staff person #3, who advised staff person #1 to find a robe belt or something similar to use as a "gait belt" (an assistive device secured around the waist to allow a caregiver to grasp the belt and assist with moving a person) to assist Individual #1 off the toilet and to their bed. Staff person #1 made a makeshift gait belt out of a pair of legging style pajama pants, lifted Individual #1 off the toilet, and walked them to their bed. Allowing an individual to sit on the toilet for 5 hours and utilizing clothing to mimic a medical device that is not prescribed for individual #1 not only presents a health and safety risk but constitutes undignified treatment.
At 5:30am on 3/16/22, staff person #1 entered Individual #1's room and discovered that Individual #1 was lying on their stomach, saturated in urine from head to toe. Individual #1 was unable to roll over on their own, and staff person #1 waited until 6:30am, when staff person #2 arrived at the home, to roll Individual #1 over and assist Individual #1 in cleaning up and changing to dry briefs and clothes. Allowing an individual to remain saturated head to toe in urine is not respectful treatment of an individual. | An individual shall be treated with dignity and respect. | Multiple EIMs (8994741, 9013307, and 9013252) were entered and investigations occurred. All three EIMs were confirmed and all staff directly involved were voluntarily or involuntarily terminated. |
07/01/2022
| Implemented |
| 6400.52(c)(6) | At the time of the 4/19/22 inspection, Staff person #4 was not trained in Individual #1's Fall Prevention Plan. Staff person #4 has worked with Individual #1 since the 10/19/21 fall plan was implemented. | 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. | On 4/19/22 Staff person #4 was trained on Individual #1's Fall Prevention Plan. All homes will be reviewed to insure that any direct support professional working in a residential program is up to date on all applicable trainings related to plans and specific needs of an individual in the residence by 5/1/22 |
06/01/2022
| Implemented |
| 6400.207(5)(I) | On the night of 3/15/22, staff person #1 noted in daily logs that Individual #1 "chose not to get off the toilet" for approximately 5 hours. At 11:54pm, staff person #1 spoke to management, staff person #3, who advised staff person #1 to find a robe belt or something similar to use as a "gait belt" to assist Individual #1 off the toilet and to their bed. Staff person #1 made a makeshift gait belt out of a pair of legging style pajama pants, lifted Individual #1 off the toilet, and walked them to their bed. Individual #1's PCP has never advised or prescribed the use of a gait belt. This makeshift device was not approved for Individual #1's care. | 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: Post-surgical or wound care. | An EIM (9013252) was entered and an investigation occurred. The incident was confirmed and the management responsible was terminated, the staff that performed the restraint terminated their employment. All staff working in this home will be re-trained in this regulation by the Associate Director before 6/1/22. Documentation of this training will be kept. |
07/01/2022
| Implemented |
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