| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual # 1's ISP last updated 02/27/23 reads "Individual # 1 RECEIVES 2:1 STAFFING FROM 7AM TO 11PM AND 1:1 STAFFING 11PM TO 7 AM SEVEN DAYS PER WEEK. DURING AWAKE HOURS TWO STAFF WILL BE WORKING AND DURING SLEEPING HOURS ONE STAFF. SHE CAN BE ALONE IN HER BEDROOM. Individual # 1 CAN HAVE PERSONAL TIME IN HER ROOM DURING WAKE HOURS WITH 30 MINUTE CHECKS UNLESS SHE IS IN A BEHAVIOR THEN IT IS 15 MINUTE CHECKS UNTIL ONE HOUR OF ABSOLUTE CALM HAS BEEN NOTED THEN SHE GOES BACK TO THE 30 MINUTE CHECKS. DURING SLEEPING HOURS Individual # 1 HAS ONE HOUR CHECKS" .
Staff # 14 (CEO) reported that the agency changed the level of supervision for Individual # 1 to 1:1 support on 01/15/23 and that the service coordinator did not update the ISP. The Service Coordinator reported that the ISP team met on 01/10/23, discussion occurred surrounding Res Hab services and the Program Specialist then requested from the SC via email that the following changes be included in the ISP:
"Staffing Ratio-Home: REMOVE: Individual # 1RECEIVES 2:1 STAFFING FROM 7AM AND 1:1 STAFFING 11PM TO 7AM···" This Should State She Has 2:1 Staffing At All Times"
2:1 staff was identified in the ISP and the agency only provided 1:1 staffing from 01/10/23 through the dec 2023.
Additionally, as cited in violation 193(b), the agency did not ensure nor document that less restrictive techniques were used prior to the 9 restraints which occurred in October 2023. | 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. | The CEO of the company along with the program specialists have reviewed all current ISPs for all individuals that we serve. This included, but was not limited to, the level of supervision that is outlined in each of their plans. The CEO has ensured that all levels of supervision in the homes are currently correct. Any information that was not correct or needed to be updated was submitted to each individual¿s Support Coordinator. (Attachment #1) |
02/09/2024
| Implemented |
| 6400.64(a) | A package of frozen ground meat was found in the freezer without a date to determine expiration. | Clean and sanitary conditions shall be maintained in the home. | LCSS field manager's have inspected each of our homes including all food within the home to ensure all products are properly dated and not expired. |
02/05/2024
| Implemented |
| 6400.66 | The light above the exterior walkway did not work during the physical site walk through. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The light has been fixed (Picture #1). |
02/05/2024
| Implemented |
| 6400.67(a) | The floorboard radiator in the kitchen was missing an end cap. | Floors, walls, ceilings and other surfaces shall be in good repair. | The end cap has been fixed. (Picture #2) |
02/05/2024
| Implemented |
| 6400.77(b) | There were no tweezers in the First Aid Kit during the physical site walk through. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | First aid kit was updated with all required items. (Picture #3) |
02/05/2024
| Implemented |
| 6400.80(b) | The exterior sidewalk leading down to the home from the road is cracked and not level. Individual # 1 has challenges with her gait. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | LCSS maintenance has fixed the cracks in the sidewalk Picture #4 |
02/05/2024
| Not Implemented |
| 6400.82(e) | A non slip mat was not in the bath during the physical site walk through. | Bathtubs and showers shall have a nonslip surface or mat. | The bathmat has been placed in the tub. |
02/05/2024
| Implemented |
| 6400.82(f) | Individual clean paper towels nor bath towels were in the bathroom at the time of the physical site walk through. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Paper towels was replenished in the bathroom. Each bathroom has a paper towel dispenser and paper towels are readily available at the office. |
02/05/2024
| Implemented |
| 6400.101 | The egress from the staff office was unable to be opened due to carpet scraping the bottom of the door. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The area of carpeting that was stopping the door was replaced and linoleum has been put down. The door is able to be opened without and issues. (Picture #5) |
02/05/2024
| Implemented |
| 6400.143(a) | Individual # 1 is recommended to have her weight checked every Monday. Individual # 1 refused to have her weight measured on October 02, 09, 23 and 30 of 2023. There is no evidence of staff providing training or a desensitization plan for Individual # 1's refusals of weight checks. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | A new form has been created and implemented for refusals of any type, which includes the documentation of education given to the individuals. |
02/05/2024
| Implemented |
| 6400.45(d) | Individual # 1's ISP last updated 02/27/23 reads "Individual # 1 RECEIVES 2:1 STAFFING FROM 7AM TO 11PM AND 1:1 STAFFING 11PM TO 7 AM SEVEN DAYS PER WEEK. DURING AWAKE HOURS TWO STAFF WILL BE WORKING AND DURING SLEEPING HOURS ONE STAFF. SHE CAN BE ALONE IN HER BEDROOM. Individual # 1 CAN HAVE PERSONAL TIME IN HER ROOM DURING WAKE HOURS WITH 30 MINUTE CHECKS UNLESS SHE IS IN A BEHAVIOR THEN IT IS 15 MINUTE CHECKS UNTIL ONE HOUR OF ABSOLUTE CALM HAS BEEN NOTED THEN SHE GOES BACK TO THE 30 MINUTE CHECKS. DURING SLEEPING HOURS Individual # 1 HAS ONE HOUR CHECKS"
The agency CEO reported, via email, that Individual # 1's supervision level was changed to 1:1 staffing on 01/15/23, however the CEO does not have documentation that the ISP team agreed to change the level of supervision from 2:1 to 1:1. The 02/27/23 ISP required 2:1 supervision from 7am-11pm and the agency only provided 1:1 staffing from 01/15/23 -- 12/23. | The staff qualifications and staff ratio as specified in the individual plan shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c ). | The CEO of the company along with the program specialists have reviewed all current ISPs for all individuals that we serve. This included, but was not limited to, the level of supervision that is outlined in each of their plans. The CEO has ensured that all levels of supervision in the homes are currently correct. Any information that was not correct or needed to be updated was submitted to each individual¿s Support Coordinator. (Attachment #1) |
02/09/2024
| Implemented |
| 6400.182(a) | The agency CEO reported that supervision was changed to 1:1 staffing on 01/15/23, however the CEO does not have documentation that the ISP team agreed to change the level of supervision from 2:1 to 1:1. The 02/27/23 ISP required 2:1 supervision from 7am-11pm and the agency only provided 1:1 staffing from 01/15/23 -- 12/23. There is no documentation that the Program Specialist requested revisions to the 02/27/23 ISP to reflect the agency was providing 1:1 supervision. | The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team. | The CEO of the company along with the program specialists have reviewed all current ISPs for all individuals that we serve. This included, but was not limited to, the level of supervision that is outlined in each of their plans. The CEO has ensured that all levels of supervision in the homes are currently correct. Any information that was not correct or needed to be updated was submitted to each individual¿s Support Coordinator. (Attachment #1) |
02/09/2024
| Implemented |
| 6400.186 | Individual # 1's Behavioral Plan/Restrictive Plan last reviewed on 09/28/23 includes strategies to be utilized by staff in the event of the target behaviors of verbal aggression, physical aggression, refusals, property destruction and Self-Injurious behaviors. Staff # 14 reported via email that of the 9 physical restraint incidents which occurred in October 2023, there is no documentary evidence of staff utilizing the preventative strategies as written in the BSP/RP aside from "verbal redirection" prior to restraint. Examples of strategies to be utilized are:
1. Non-Selective attention/Planned Ignoring.
2. Refrain from emotional Response.
3. Asking Individual to Notify once she has calmed.
4. Offer Choice of Activity
5. Social Stories
6. Ensure Safety through relocation
7. Avoid Over Prompting
8. Acknowledge Trigger and Validate Feelings
9. Offer Preferred Activities
10. Refrain from Making Demands
11. Appropriate Responses during escalation
12. Carry-On- Move to next activity when refusals occur
13. Offer Praise for Completed Tasks
14. Ask Rather than Tell.
15. Address Trigger and Validate Feelings
16. Offer Sensory Items
Preventative and Alternative Strategies for specific target behaviors are found on pages 6-15 of the 09/28/23 Restrictive Procedure/Behavioral Plan. | The home shall implement the individual plan, including revisions. | New documentation for incident reporting has been created to include what staff utilized prior to hands on per each persons behavior support plan. |
02/05/2024
| Implemented |
| 6400.193(b)(1) | Individual # 1 had 9 restraints in October 2023. The restraints occurred on 10/03, 06, 07, 15, 17, 20, 21, 26 & 30. The agency CEO reported via phone call on 12/20/23 that there is no documentation that less restrictive techniques were utilized prior to restraints. | 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. | LCSS has held trainings for all staff and management on utilizing least restrictive techniques to most restrictive. All staff participated in this training. Staff was also trained on proper documentation in reporting the strategies that they utilized to help our individuals when they are having a difficult time.
The training outline consisted of the following: (this documentation has been given to home so that it can be resourced as needed)
At times, everyone can have moments of anger and frustration. This does not mean that we will end up in physical aggression. Some of what we do can make these moments easier for the individual as well as for us the support staff.
Suggestions:
Teaching and Replacement Strategies
Selective non-attention
¿ Staff will withdraw attention from an individual's negative behavioral displays. It is important to note that you are ignoring the behavior and not the individual. If at any time, the individual needs genuine support, staff are expected to provide it but if the behavior is not dangerous and destruction and can be ¿ignored¿ staff should be empowered to remove attention.
Modeling
¿ Staff will demonstrate and display appropriate and desired behaviors in front of the individual so that he/she can observe and learn through the demonstration. Staff should be doing the modeling intervention with coping skills and communication exchanges so that individuals understand more appropriate ways to interact and react when he is presented with a frustrating or non-preferred situation.
Proximity Control
¿ This intervention entails using a physical presence to provide support and redirect behavior to something safer and more functional. For example, staff will provide proximity control to certain areas of the home that individuals are not permitted to be in when he is not safe such as the staff room door. They will provide proximity control by standing in front of the door to offer the stimulus prompt that Individual¿s is not permitted to enter. If at any point Individual¿s becomes physically aggressive, staff are to remove themselves from Individuals¿ direct person and follow crisis policy which may include but is not limited to CPI restraints, only to be conducted by those authorized to do so and after all other least restrictive attempts have been made.
Prompting
¿ In simplest terms, this is a cue. This can be verbal, indirect, gestural, or physical. Verbal prompt would include telling individuals to do something. An indirect prompt would be presented as more of a question, ¿What are you supposed to be doing?¿ A gestural prompt would be pointing to a task or area that individuals were to be engaged in. While a physical prompt may look like handing individuals a task to complete. We do this when we want to encourage cooperation and display of a target behavior or facilitate a given response.
Teaching Alternative Behaviors
¿ This includes teaching individuals how to communicate and cope with frustrations in lieu of target behaviors. For example, if the behavior is punching a wall to relieve frustration, alternative behavior may be engaging with punching a pillow. Communication exchanges in lieu of attempting to gain access to items in an unsafe way online.
Behavior Momentum
¿ Providing 3 or more requests or demands placed on Individuals that he has a high probability of completing prior to presenting Individual¿s with a non-preferred task or directive that there is a low probability of completing. The momentum of completing the 3 preferred tasks will encourage completion of the non-preferred task. |
02/09/2024
| Implemented |