| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | (Repeat from inspection dated 1/11/21) No self-assessment was completed for this home. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| This occurred due to Self-Assessments not being collected and reviewed for completion. Staff will be trained on how to complete the Self-Assessment form thoroughly. Quality department will monitor for completion. Staff will be trained on how to complete the Self-Assessment form thoroughly by 2/22/22 |
02/22/2022
| Implemented |
| 6400.144 | (Repeat from inspections dated 1/11/21, 4/26/21 and 10/12/21)-Individual #1's Restrictive Procedure Plan (RPP) states that after instances of headbanging, staff must ensure that the individual has returned to baseline mental status. If the individual has not, if they experience seizure activity, or if there is a visible wound to their head that would require treatment, 911 is to be called. To determine if the individual has returned to baseline mental status, staff will ask the individual to state their full name.
· Staff documented on 3/22/21 that after intense headbanging and 7-minute physical restraint used, two staff witnessed the individual's mouth to be bleeding, a mark on the individual's forehead, staff "monitored for concussion," and informed the next staff on shift of the incident and instructed them to continue to monitor for signs of concussion. There were no records maintained that the individual's bleeding mouth was examined by a medical professional or that the individual's physician was notified. There are no records that staff attempted to determine if the individual returned to baseline via the instructions outlined in their RPP.
· There are no records maintained that staff determined if Individual #1 returned to baseline via the instruction outlined in their RPP, after every headbanging incident.
Individual #1's RPP lists many items that staff need to implement for RPP success. Those items being: visual schedule used daily outlining events, schedules, and daily living skills, daily sleep schedule, two scheduled phone conversations with their mother daily, tracking episodes of self-injury, physical aggression, property destruction, and functional communication responses, tracking of restraints, documentation if they broke their personal phone, and if the individual's mother was contacted in attempts to gain a new phone, and tracking/monitoring of the plan by the home's management staff. The agency was asked to provide documentation that all aspects of the plan are being implemented and nothing was provided. | 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.
| This occurred due to staff not being trained on medical appointments, required documentation, retraining/ educating individuals when refusing and documenting, nor were medical appointments, forms or orders being monitored following appointments. Staff will be retrained on medical appointments and requirements including printing medical appointment form prior to appointment, taking the form along, ensuring the form is completed and signed my licensed medical professional (not CRNP or nurse). This will be completed by 2/16/22.
QD is currently going through records to determine dates of all individual's annual physicals and will contact appropriate management to schedule the appointment (PS, PM). This will be completed by 2/16/22. Physicals will be scheduled in advance to ensure completion. |
02/28/2022
| Not Implemented |
| 6400.193(b)(1) | Individual #1's RPP states that instances of Individual #1 headbanging should first be verbally redirected by support staff. If the individual continues to engage in the behavior, staff should attempt to block the headbanging. If the individual continues to engage in the behavior, Emergency Safety Physical Intervention (ESPI) should be utilized.
· According to a 6/11/21 physical restraint incident reported by the agency, Individual #1 was witnessed to engage in headbanging behaviors and the individual's RPP and less restrictive measures were not utilized prior to the physical restraint. Agency reported Individual #1 started to bang their head on the office bathroom wall, staff gave several verbal prompts to "stop or staff would need to put {the individual} in an ESPI", then staff used a ESPI cradle assist for 5 minutes. | For each incident requiring restrictive procedures: Every attempt shall be made to anticipate and de-escalate the behavior using methods of intervention less intrusive than restrictive procedures. | All BSPs have been reviewed and are in the process of being updated by the Director of Behavioral Services. Staff have been trained on the BSP/ RPP as of 02/09/2022 and Director of Behavioral Services has been in the house completing observations to ensure the plan is being followed appropriately. TLC created Human Rights Team and held to review and approve the RPP. |
02/09/2022
| Implemented |
| 6400.195(a) | Individual #1's restrictive procedure plan (RPP) states that it was implemented on 3/1/21. The plan was not approved by a human rights team until 9/3/21. The agency reported through the Enterprise Incident Management system, Individual #1 has had 7 physical restraints applied to them from 3/1/21 to 9/3/21. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | All BSPs have been reviewed and are in the process of being updated by the Director of Behavioral Services. Staff have been trained on the BSP/ RPP as of 02/09/2022 and Director of Behavioral Services has been in the house completing observations to ensure the plan is being followed appropriately. TLC created Human Rights Team and held to review and approve the RPP. |
02/09/2022
| Implemented |
| 6400.195(b) | The human rights team met on 9/3/21 to review Individual #1's RPP. The team recommended that more specific goals be added. There are no records maintained that any changes were made to Individual #1's 3/1/21 RPP or that more specific goals were added after the team's recommendation. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | All BSPs have been reviewed and are in the process of being updated by the Director of Behavioral Services. Staff have been trained on the BSP/ RPP as of 02/09/2022 and Director of Behavioral Services has been in the house completing observations to ensure the plan is being followed appropriately. TLC created Human Rights Team and held to review and approve the RPP. |
02/09/2022
| Implemented |
| 6400.195(c)(1) | Individual #1's RPP does not include all behaviors to be addressed, for which a restraint has been used. Individual #1 makes statements that they are going to kill themselves and has bitten staff and themselves. These behaviors are not included in the RPP. | The behavior support component of the individual plan shall include: The specific behavior to be addressed. | All BSPs have been reviewed and are in the process of being updated by the Director of Behavioral Services. Staff have been trained on the BSP/ RPP as of 02/09/2022 and Director of Behavioral Services has been in the house completing observations to ensure the plan is being followed appropriately. TLC created Human Rights Team and held to review and approve the RPP. |
02/09/2022
| Implemented |
| 6400.195(c)(3) | The outcomes desired is not clearly identified within Individual #1's 3/1/21 RPP. Their plan states 2 outcomes: 1) they will have 0 instances of behaviors targeted for reduction (physical aggression, self-injurious behavior, and property destruction) for 30 consecutive days, and 2) they will independently engage in the functional communication response (FCR, "I changed my mind") on 15 occasions over a 30-day period. However, the plan also includes criteria for success with the outcomes being, "{the individual} will have 0 behaviors targeted for reduction for 30 consecutive days and 10 unprompted FCRs within the same 30 days." | The behavior support component of the individual plan shall include: The outcome desired. | All BSPs have been reviewed and are in the process of being updated by the Director of Behavioral Services. Staff have been trained on the BSP/ RPP as of 02/09/2022 and Director of Behavioral Services has been in the house completing observations to ensure the plan is being followed appropriately. TLC created Human Rights Team and held to review and approve the RPP. |
02/09/2022
| Implemented |
| 6400.195(c)(4) | At the time of the 1/3/2022 inspection, the only RPP provided for Individual #1 states the target date to complete the behavior outcomes identified within the plan, was to be met by 8/23/21. The individual did not have a RPP that included a current outcome(s) to obtain. | The behavior support component of the individual plan shall include: A target date to achieve the outcome. | All BSPs have been reviewed and are in the process of being updated by the Director of Behavioral Services. Staff have been trained on the BSP/ RPP as of 02/09/2022 and Director of Behavioral Services has been in the house completing observations to ensure the plan is being followed appropriately. TLC created Human Rights Team and held to review and approve the RPP. |
02/09/2022
| Implemented |
| 6400.195(c)(6) | Individual #1's RPP does not include the specific physical restraints that are approved to be used and the circumstances under which they may be used. | The behavior support component of the individual plan shall include: Types of restrictive procedures that may be used and the circumstances under which the procedures may be used. | All BSPs have been reviewed and are in the process of being updated by the Director of Behavioral Services. Staff have been trained on the BSP/ RPP as of 02/09/2022 and Director of Behavioral Services has been in the house completing observations to ensure the plan is being followed appropriately. TLC created Human Rights Team and held to review and approve the RPP. |
02/09/2022
| Implemented |
| 6400.195(c)(8) | Individual #1's 3/1/21 RPP does not include the name or job title of the staff responsible for monitoring and documenting the individual's functional communication responses (FCRs), that is criteria for success and part of the behavioral outcome, outlined in the RPP. The 3/1/21 plan states that staff will use the behavior tracking system to track episodes of self-injury, physical aggression, or property destruction. | The behavior support component of the individual plan shall include: The name of the staff person responsible for monitoring and documenting progress with the behavior support component of the individual plan. | All BSPs have been reviewed and are in the process of being updated by the Director of Behavioral Services. Staff have been trained on the BSP/ RPP as of 02/09/2022 and Director of Behavioral Services has been in the house completing observations to ensure the plan is being followed appropriately. TLC created Human Rights Team and held to review and approve the RPP. |
02/09/2022
| Implemented |
| 6400.196(a) | Individual #1 received 1 staff to 1 individual staffing ratio. During the 1/3/2022 onsite inspection, the agency did not provide documentation that any staff working with Individual #1 were trained in the use of the specific techniques or procedures outlined in Individual #1's RPP. | A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used. | All BSPs have been reviewed and are in the process of being updated by the Director of Behavioral Services. Staff have been trained on the BSP/ RPP as of 02/09/2022 and Director of Behavioral Services has been in the house completing observations to ensure the plan is being followed appropriately. TLC created Human Rights Team and held to review and approve the RPP. |
02/09/2022
| Implemented |
| 6400.196(b) | Individual #1 received 1 staff to 1 individual staffing ratio. During the 1/3/2022 onsite inspection, the agency did not provide documentation that any staff working with Individual #1 have experienced the use of the physical restraints, discussed in Individual #1's RPP, directly on the staff person. | If a physical restraint will be used, the staff person who implements or manages the behavior support component of the individual plan shall have experienced the use of the physical restraint directly on the staff person. | All BSPs have been reviewed and are in the process of being updated by the Director of Behavioral Services. Staff have been trained on the BSP/ RPP as of 02/09/2022 and Director of Behavioral Services has been in the house completing observations to ensure the plan is being followed appropriately. TLC created Human Rights Team and held to review and approve the RPP. |
02/09/2022
| Implemented |
| 6400.209 | According to agency reporting in the Enterprise Incident Management system, Individual #1 had a physical restraint used on them 7 times in the 6-month period from April to October 2020 and 6 times from December 2020 to February 2021. Individual #1 did not have a restrictive procedure implemented until 3/1/21. But as referenced in 6400.195(a) of this report, there are no records maintained that the individual's RPP was reviewed and approved by a human rights committee prior to implementation on 3/1/21. | If a physical restraint is used on an unanticipated, emergency basis, §§ 6400.194 and 6400.195 (relating to human rights team; and behavior support component of the individual plan) do not apply until after the restraint is used for the same individual twice in a 6-month period. | All BSPs have been reviewed and are in the process of being updated by the Director of Behavioral Services. Staff have been trained on the BSP/ RPP as of 02/09/2022 and Director of Behavioral Services has been in the house completing observations to ensure the plan is being followed appropriately. TLC created Human Rights Team and held to review and approve the RPP. |
02/09/2022
| Implemented |