| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On 12/12/23, Direct Service Worker #1 and Direct Service Worker #3 engage in alterations with Individual #1 of abuse to include but not limited to physical abuse and threats in the common area of the home that includes dining room area with a table and chairs and a living room area with couches. There is a doorway in each of these areas between other areas of the home. On 12/12/23 at 1:13 PM, Individual #2 enters the room through the door in the living room area and sits on the couch. Individual #1 immediately exits the room through the same door. Direct Service Worker #3 is sitting at the dining table. Direct Service Worker #1 enters the room through the dining room area door. Individual #1 enters the living room area through the living area door. Individual #1 walks to the other end of the room and reaches with one hand towards Direct Service Worker #3 who is standing near the dining room table. Direct Service Worker #3, using both hands, forcibly grabs Individual #1 by his arms and hands and aggressively shoves Individual #1 against the wall and then on to the floor. Direct Service Worker #1 is standing on the other side of Individual #1 and witnesses the interaction but did not intervene. Individual #1 remains on the floor approximately 30 seconds, until he independently stands up and walks to the living room area away from Direct Service Worker #1 and Direct Service Worker #3. At 1:22PM, Direct Service Worker #3 joined Direct Service Worker #1 in the kitchen. Individual #1 and Individual #2 were unsupervised in the living room area. For approximately two minutes, Individual #1 proceeds to toss a few papers and small toy blocks onto the floor in the living room area. Direct Service Worker #3 and a minute later Direct Service Worker #1 enter through the dining room area door. Individual #1 walks toward the the dining room area while tossing what appears to be articles of clothing. Direct Service Worker #1 aggressively gestures with both arms at Individual #1 to go to living room area. Individual #1 approaches Direct Service Worker #3, who then picks up a dining room chair and raises it to shoulder height and proceeds to forcibly shove the legs of the chair at Individual #1 forcing him backwards. Direct Service Worker #3 continues to stand holding the chair in front of her. Individual #1 approached Direct Service Worker #3 who lunges the chair at Individual #1 causing him to stumble over an end table and couch. Individual #1 approaches Individual #2 on couch and briefly tugs at Individual #2's shirt. Direct Service Worker #1 attempts to grab Individual #1's arm and then proceeds to point at the couch gesturing for Individual #1 to go to the couch. She then proceeded to the dining room area and Individual #1 went toward the couch. For approximately two minutes, Individual #1 stays in the living room area while Direct Service Worker #1 and Direct Service Worker #3 remain in the dining room area. Individual #1 then leaves through the living room area door and then Direct Service Worker #1 and Direct Service Worker #3 enter the hallway area after Individual #1. For approximately one-minute, Direct Service Worker #1 and Direct Service Worker #3 and Individual #1 were out of the room. Individual #1 reenters the living room from the living room doorway. Direct Service Worker #3 reenters the dining room area, stands behind a dining room chair and proceeds to raise her arm and lean on the chairs and walk closer toward Individual #1 while continuing to slide the chair in front of her. All the while she appears to be aggressively yelling at Individual #1. After two minutes Individual #1 picks up the toy blocks from the floor and places them in the small storage container. | 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. | Upon being notified of the additional incident noted in the behavior tracking forms by the state inspector on 1/4/24 that occurred on 12/12/23, Direct Service Worker #3 was removed from the site and placed on immediate suspension, removed from working with individuals on (insert date). Direct service worker #1 had already been terminated from the organization on 12/28/24 as a result of an incident that occurred on 12/14/23 involving individual #1. Trainings had already been established as a result of the incident that occurred on 12/14/23 surrounding the same elements requiring retraining as the incident that occurred on 12/12/23. Those elements include: The behavior specialist was informed of the incident on 1/2/24 and put together a specific training related to behavior crisis intervention for Individual #1. The training was held on 1/4/24 by Triad Behavior Support Services. Additionally, Positive Approaches: An overview training done by The Acentra Health HCQU was held on 1/25/24 for all staff at the site. The behavior support plan and crisis intervention plan are currently being updated by Triad Behavior Support Services to provide staff with more specific de-escalation techniques while Individual #1 is in a behavior. This is meant to include techniques which may involve certain blocking techniques for more aggressive behaviors. Once finalized, all staff that work at the service location will be trained by Triad Behavior Support Services on the updated behavior plan. In order to prevent and or avoid future crises the supports coordinator is submitting a referral for DDTT and CTA services for individual #1. To supplement the existing Behavior Support Plan. On 12/20/23 Individual #1 was evaluated by his PCP as a follow up from a prior ER visit. In response to his increased behaviors, the PCP increased his Gabapentin from 100mg 3 times a day to 200 mg 3 times a day and indicated that further increases must be prescribed by the Psychiatrist. The Psychiatrist was on vacation, the earliest available Psych appointment was on 1/18/24 at which time Zoloft 12.5mg was prescribed, and on 1/29/24 it was increased to 25mg once a day. All new staff that begin working at this service location or future service locations occupied by individual #1 shall undergo shadow training with seasoned staff or site management for a minimum of 24 hours before working independently with individual #1. All staff at the site were re-trained on 1/23/24 by The Program Specialist on the agency¿s policy on abuse including identifying, and reporting any reported, suspected, or alleged acts of abuse involving an individual. Additional cameras were installed on 1/24/24 by the Maintenance Technician at the service location to have a more comprehensive view which were previously not within the camera¿s viewpoint. Lastly, a transition meeting was held on 1/25/24 with the individuals plan team to determine a potential fit at a different service location. A new service location has been selected and a tentative move date of 3/7/2024 has been scheduled. |
02/17/2024
| Implemented |
| 6400.16 | On 12/14/23, Direct Service Worker #1 and Direct Service Worker #2 engage in alterations with Individual #1 of abuse to include but not limited to physical abuse and threats in the common area of the home that includes dining room area with a table and chairs and a living room area with couches. There is a doorway in each of these areas between other areas of the home. On 12/14/23, at 4:01PM Individual #1, Individual #2, and Individual #3 were in the common area of the home. Direct Service Worker #1 was sitting on the couch in the living room area. Direct Service Worker #2 while on the telephone, entered the dining room area. Individual #1 walks toward Direct Service Worker #2. Direct Service Worker #2 grabbed right Individual #1's wrist with her left hand and Individual's left chest area and pushed Individual #1 until he fell backwards into a sitting position on the ottoman where Individual #3 had just been sitting. Individual #3 hastily left the room. Individual #1 stood up and Direct Service Worker #2 slid the chair between herself and Individual #1. Individual #1 leaned over the chair to reach a large purse from the dining area table. As Direct Service Worker #1 got up from the couch and walked over toward the altercation. Direct Service Worker #2 forcibly pushes the dining room chair at Individual #1 causing Individual #1 to fall to a sitting position sideways on the chair. As Individual #1 was sitting sideways on the chair, Direct Service Worker #1 was in front of the chair and Direct Service Worker #2 was behind the chair. Direct Service Worker #2 forcibly pulls at the bag from the back while Direct Service Worker #1 forcibly pulls Individual #1 the opposite direction. During altercation of Individual #1, Direct Service Worker #1 kneels across Individual #1's lap for 30 seconds and then pulls Individual #1 out of the chair by his right hand. As Individual #1 is reaching across the table with his left hand, he falls across the table and the chair which tips over on to the floor. The physical altercation continues with Individual #1 on the floor, two chairs knocked over near him, Individual #1's leg being lifted off the floor by Direct Service worker #1 who along with Direct Service Worker #2 is standing over Individual #1. The altercation goes on for over a minute until Direct Service Worker #1 and Direct Service Worker #2 step back while moving the dining room chairs away from Individual #1. As Individual #1 gets up from the floor, Direct Service Worker #2 lifts a chair over her head pointing the legs of the chair in a threatening manner at Individual #1. Direct Service Worker #1 gets in front of Individual #1 and physically redirects Individual #1 towards the living room. Individual #1 reaches for a plastic water bottle on the living room area coffee table which is grabbed away from him by Direct Service Worker #1. Individual #1 then turns back toward the dining room area. Direct Service Worker #2 then picks up another plastic water bottle and gestures as if she is going to throw it at Individual #1 who turns away from the threat. Individual #1 and Direct Service Worker #1 then walk toward the couch where Individual #2 is sitting. Individual #1 starts to move quicker toward the couch and Direct Service Worker #1 speeds up and pushes Individual #1 on to the couch. The physical altercation continues the couch between Direct Service Worker #1 and Individual #1. It appears Direct Service Worker #1 is attempting to hold Individual #1 onto the couch. During the interaction, Individual #1 gets a finger from his right hand in the front of Direct Service Worker #1's shirt. Direct Service Worker #1 backs away punching three to five times with both hands at Individual #1's right hand, then she holds Individual #1's right hand with her left hand and punches with her right hand an additional two to three times at Individual #1's right hand. Direct Service Worker #2 joins the altercation and appears to join Direct Service Worker #1 in holding Individual #1 on the couch for another minute. Individual #2 gets up from the couch and stands just outside the doorway continuing to observe the interactions. Direct Service Worker #2 then backs away from the altercation and moves a smaller black stackable chair in front of herself. Direct Service Worker #1 backs away from Individual #1, at the same time, as Direct Service Worker #2 raises the chair over her shoulder in a threating manner facing towards Individual #1. Direct Service Worker #1 and Direct Service Worker #2 continue to stand in front of Individual #1 as he remains on the couch for at least several more minutes. On 12/25/2023, Individual #1's Mother reported to the Direct Service Worker #1 that Individual #1's finger appeared to be swollen. On 12/27/2023, Individual #1 was seen in the Med Express Urgent Care for "Right hand pinky finger with pain swelling and redness." Individual #1 was diagnosed with a "displaced fracture in the middle phalanx of right, little finger, initial encounter for closed fracture." Individual #1 was treated with a splint and prescribed Ibuprofen for pain. Instructions included "follow-up with an Orthopedic Specialist within 1 week." | 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. | Upon being notified of the additional incident noted in the behavior tracking forms by the state inspector on 1/4/24 that occurred on 12/12/23, Direct Service Worker #3 was removed from the site and placed on immediate suspension, removed from working with individuals on (insert date). Direct service worker #1 had already been terminated from the organization on 12/28/24 as a result of an incident that occurred on 12/14/23 involving individual #1. Trainings had already been established as a result of the incident that occurred on 12/14/23 surrounding the same elements requiring retraining as the incident that occurred on 12/12/23. Those elements include: The behavior specialist was informed of the incident on 1/2/24 and put together a specific training related to behavior crisis intervention for Individual #1. The training was held on 1/4/24 by Triad Behavior Support Services. Additionally, Positive Approaches: An overview training done by The Acentra Health HCQU was held on 1/25/24 for all staff at the site. The behavior support plan and crisis intervention plan are currently being updated by Triad Behavior Support Services to provide staff with more specific de-escalation techniques while Individual #1 is in a behavior. This is meant to include techniques which may involve certain blocking techniques for more aggressive behaviors. Once finalized, all staff that work at the service location will be trained by Triad Behavior Support Services on the updated behavior plan. In order to prevent and or avoid future crises the supports coordinator is submitting a referral for DDTT and CTA services for individual #1. To supplement the existing Behavior Support Plan. On 12/20/23 Individual #1 was evaluated by a PCP as a follow up from a prior ER visit. In response to his increased behaviors, the PCP increased Gabapentin from 100mg 3 times a day to 200 mg 3 times a day and indicated that further increases must be prescribed by the Psychiatrist. The Psychiatrist was on vacation, the earliest available Psych appointment was on 1/18/24 at which time Zoloft 12.5mg was prescribed, and on 1/29/24 it was increased to 25mg once a day. All new staff that begin working at this service location or future service locations occupied by individual #1 shall undergo shadow training with seasoned staff or site management for a minimum of 24 hours before working independently with individual #1. All staff at the site were re-trained on 1/23/24 by The Program Specialist on the agencies policy on abuse including identifying, and reporting any reported, suspected, or alleged acts of abuse involving an individual. Additional cameras were installed on 1/24/24 by the Maintenance Technician at the service location to have a more comprehensive view which were previously not within the cameras viewpoint. Lastly, a transition meeting was held on 1/25/24 with the individuals plan team to determine a potential fit at a different service location. A new service location has been selected and a tentative move date of 3/7/2024 has been scheduled. |
01/25/2024
| Implemented |
| 6400.214(b) | On 1/4/24, Individual #1's current assessment and physical examination were not kept in the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| A review of the most recent assessment and individual physical at the corporate office for Individual #1 was done by the COO on 1/5/24. A copy of the assessment and Individual Physical for Individual #1 was placed in the records at individual #1 home on 1/5/24 by the Program Specialist |
01/05/2024
| Implemented |
| 6400.18(a)(4) | On 1/4/24 at approximately 10:30 AM Individual #1's behavior tracking forms indicated that on 12/12/2023 Individual #1 and staff "got tangled up and staff and him went down landed on the floor. other staff intervened and tried to get him to release the staff's shirt, wouldn't got up and was taken back down by both staff, was restrained and was released". This incident was witnessed by Direct Service Worker #1 and Direct Service Worker #3 and documented in house notes, but no incident was submitted until after the incident was identified during investigation that occurred on 1/4/24. There were incidents of suspected abuse, neglect and unauthorized use of restraints that were witnessed by Direct Service Worker #1 and Direct Service Worker #2 on 12/14/23 that were not reported until 12/27/23. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| Upon being notified of the additional incident noted in the behavior tracking forms by the state inspector on 1/4/24 the agency reviewed its current policies on incident management and reporting incidents. The CEO initiated the agencies formal SOP process to update the policy on Incident management and finalized the revisions on 1/18/24 to include additional elements in the reporting process of all incidents, adding procedures to follow within 24 hours of incidents requiring investigation including mandatory documentation review, more detailed and specific reporting of information, and additional detail during nights and weekends. Training on these updated procedures was done for all staff at this service location on 1/23/24 by the Program Specialist. |
01/23/2024
| Implemented |
| 6400.166(a)(13) | Chlorhexidine, DOK soft gel, Levetiracetam, and Risperidone prescribed to Individual #1 were initialed with "MR" as administered on 1/3/2024 at 8:00PM. Individual #1's January Medication Administration Record did not include a corresponding name for the initials. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Upon being informed of the medication record violation by the state inspector on 1/4/24, the agency followed its medication error protocol for the staff involved which was already scheduled due to a different error which occurred on 12/24/23 as the result of a medication error. The staff was informed they had not signed the back of the medication record by the Program Site Manager on 1/4/24. The staff underwent a medication observation on 1/6/24 by the Program Site Manager. The staff also underwent medication administration retraining on 1/9/24 done by the Staff Development Coordinator who is a Certified Medication Trainer. |
01/24/2024
| Implemented |
| 6400.167(a)(1) | Methylphenidate and Clonazepam prescribed to Individual #1 was initialed as administered on 12/24/23 at 6:00PM by Direct Service Worker #1. These medications remained in the medication pouches and were not administered. | Medication errors include the following: Failure to administer a medication. | As a note, in the violation description it was noted that ¿Direct Service Worker #1¿ initialed as administered on 12/24/23. It was a different direct support professional that initialed for administering this medication to individual #1 on 12/24/23.
Upon discovery of the medication error on 12/26/23 the program coordinator notified the staff of the error on 12/26/23and initiated the agencies medication error protocol. The staff underwent a medication observation on 1/6/24 by the Program Site Manager. The staff also underwent medication administration retraining on 1/9/24 by the Staff Development Coordinator who is a Certified Medication Trainer. |
01/24/2024
| Implemented |
| 6400.208(a) | On 12/14/2023, between 4:02PM and 4:05PM, Direct Service Worker #1 and Direct Service Worker #2 engaged in a physical altercation with Individual #1. During the altercation, Direct Service Worker #1 and Direct Service Worker #2 used unauthorized physical restraints of Individual #1. The restraints included kneeling across Individual #1's lap, blocking Individual #1 with a chair, and holding Individual #1 on the couch. | A physical restraint, defined as a manual method that restricts, immobilizes or reduces an individual's ability to move the individual's arms, legs, head or other body parts freely, may only be used in the case of an emergency to prevent an individual from immediate physical harm to the individual or others. | Upon discovery of the incident occurring on 12/14/23, Direct service worker #1 and Direct service worker #2 were removed from the site and placed on immediate suspension, removed from working with individuals on 12/27/23. Upon review and due to the seriousness of the violation, both Direct service worker #1 and Direct service worker #2 were terminated from the agency on 12/28/23. All staff working at the DSP at this site were retrained by Triad Behavior Support Services on Individual #1 behavioral support plan as well as the appropriate use of a physical restraint and what is permitted vs. prohibited on 1/4/24. The behavior specialist is continuing to work on additions to individual #1 crisis intervention plan to provide staff with more specific de-escalation techniques for when individual #1 enters a crisis. Once completed, all staff will be further trained on additional techniques as outlined by the behavior specialist for individual #1. |
01/25/2024
| Implemented |