| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | The 09/21/16 daily log for Individual #1 indicates that he/she was a little upset about having to go up to # 310 so late. She did her laundry .¿ Interviews with staff #1, (part time direct care), Staff #2 (Assistant Program Manager), staff #3 (Assistant Program Manger) and staff #4 (Associate Director) confirm that individuals were not given the opportunity to participate in program planning or the scheduling of visitations. | 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. | Individual #1 and the Director of residential discussed her rights and that she can deny visits to other homes and that she has the right and opportunity to be a part of her program planning and visits. The Shadowfax residential department has stopped having individuals visit other homes as of the date of 11-16-16 when MH-IDD informed us this could not be done. All Management & schedulers were notified on 11/16/2016 that they will not combine any programs for the convenience of staffing and there will be no exception. All targets of the investigation that are still employed were given performance feedback and it was discussed that this is not an option in the future. Residential has instituted sign on bonuses to hire more staff, have offered bonus/incentive pay to fill shifts, have worked with temp agencies to get additional staff, have downsized by 2 homes, and have worked with other departments to have additional staff available to work in residential. Recruiting efforts were also increased to hire additional staff. A new position of ¿On-Call Associate Director¿ was established, effective 11/22/2016. This AD will be responsible for all scheduling and to supervise the scheduling department to ensure that individuals are not visiting other homes and to ensure adequate staffing per home. The Quality Assurance coordinator had a discussion with MH/IDD supervisor and asked that at any time the SC¿s are aware of something that is happening in our programs, we would like to be notified. Moving forward, Shadowfax will not have homes visit other homes. If individuals wish to visit friends in another home, a written consent will be obtained and kept on file to show their desire to do so. |
11/16/2016
| Implemented |
| 6400.33(d) | Individual #2 was interviewed on 12/15/16. They reported that other people would visit her home. He/she would visit on Saturday and Sunday. They reported that staff would make that decision to have visitors and he/she was not included in the decision process. | An individual has the right to participate in program planning that affects the individual. | The Shadowfax residential department has stopped having individuals visit other homes as of the date of 11-16-16 when MH-IDD informed us this could not be done. Residential has instituted sign on bonuses to hire more staff, have offered bonus pay to fill shifts, have worked with a temp agency to get additional staff, have downsized by 2 homes, and have worked with other departments to have additional staff available to work in residential. Recruiting efforts were also increased to attract and hire additional staff.
Shadowfax will not have homes visit other homes. If individuals wish to visit friends in another home, a written consent will be obtained and kept on file to show their desire to do so. Individuals will be given the right to participate in the program planning that affects them. Individual # 2 will be included in all decision making that involves her and staffing needs will be adjusted accordingly to her decisions. |
11/16/2016
| Implemented |
| 6400.188(a) | Individual #2 was interviewed on 12/15/16. He/she reported that she was unable to work on any of her goals while visiting program #310. | The residential home shall provide services including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment. | Shadowfax has stopped having individuals visit other homes as of 11-16-16 so this will no longer be an issue. Residential Management will ensure that individual # 2 works on any goals and tasks she desires when she desires to do so. Recruitment efforts were increased to attract more staff so individual # 2 will not visit other homes. If she chooses to visit other homes, a consent will be obtained and kept on file. |
11/16/2016
| Implemented |