| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's Certificate of Compliance expiration date was 8/19/2022. The agency completed the self-assessment of the home on 11/28/2022. | 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.
| Self-assessments were completed, however not within a timely manner. CEO and Program Specialist will complete future self-assessments within the required timeframe of 3 to 6 months prior to expiration date of the certificate of compliance. CEO and Program Specialist will complete all self-assessments by 5/19/23 and will begin self-assessments no later than 3/1/23 to measure compliance with applicable regulations and correct any identified deficiencies. Violations will be identified, and written summaries of corrective actions taken will be documented. |
03/01/2023
| Implemented |
| 6400.15(c) | Violations were identified by marking the "V" on the self-assessment; however, the agency did not identify the violations and complete a written summary of corrections made. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Self-assessments were completed, however not within a timely manner. CEO and Program Specialist will complete future self-assessments within the required timeframe of 3 to 6 months prior to expiration date of the certificate of compliance. CEO and Program Specialist will complete all self-assessments by 5/19/23 and will begin self-assessments no later than 3/1/23 to measure compliance with applicable regulations and correct any identified deficiencies. Violations will be identified, and written summaries of corrective actions taken will be documented. |
03/01/2023
| Implemented |
| 6400.16 | Individual #1's Individual plan, last updated 11/29/22, in the Know and Do section reads "All of [Individual #1]'s food has to be pureed and thicket has to be added to all liquids so that they are nectar consistency. [Individual #1] takes 2-3 bites and takes a drink when he eats" ···In the General Health and Safety Risk section reads "[Individual #1] is at risk for choking and aspiration···In the Meals/Eating section reads [Individual #1] has a potential for choking and aspiration. Meals need to be pureed and liquids must be at nectar consistency. [Individual #1] must take 2-3 bites and then take a drink. [Individual #1] needs to sit up for 30 minutes after each meal or snack. [Individual #1] is at risk for aspiration if he lies down after eating···[Individual #1] is generally independent with eating once the meals/snacks are prepared but may need verbal prompts from staff to take a drink and/or slow down"···In the Supervision needs section "Home supervision is 24/7 with 1:1 staff required for safety of himself, others, and his welfare in general." On 11/19/22, in the morning, Individual #1 reportedly, was lethargic, and sluggish and was unsteady on his feet and slept most of the morning and throughout the day. At approximately 5:00PM, Direct Service Worker #2 attempted to wake Individual #1 and then proceeded to have Direct Service Worker #1 assist in waking Individual #1. Individual #1 was offered and declined dinner three times prior to agreeing to eat in a reclining chair in the living room of the home. Direct Service Worker #1 prepared baked chicken nuggets and French fries and served to Individual #1 without pureeing. Direct Service Worker #1 then went to the kitchen leaving Individual #1 unattended. Individual #1 was found unresponsive, emergency services were contact and transported Individual #1 to the hospital. Individual #1 died at 4:50PM on 11/20/2022 due to choking on Food Bolus. | 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. | Report submitted into HCSIS for serious injury, death and neglect that were investigated by department certified investigator. All staff to be retrained on all aspects of Neglect and Abuse and reporting of these incidents and including the importance of following an individuals ISPs and specific dietary restrictions and/or meal preparations/requirements. |
03/01/2023
| Implemented |
| 6400.43(b)(3) | Individual #1's food must be pureed. Individual #1 is at risk for chocking and needs verbal prompts to take a drink and/or slow down when eating. On 11/19/2022, Individual #1 reportedly was lethargic, sluggish, and slept throughout the day. In addition, Individual #1 declined dinner several time prior to agreeing to eat in a reclining chair in the living room of the home. Direct Services Workers providing support to Individual #1 failed to correctly prepare Individual #1's food and supervise Individual #1 as needed for verbal prompting. Individual #1 was served baked chicken nuggets and French fries. On 11/20/22, Individual #1 died due to choking on Food Bolus. The Chief Executive Office #1 failed to manage the home to ensure the health and safety and protection of Individual #1. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | Reports submitted into HCSIS and investigated by department approved/trained certified investigator. CEO in contact with HCQU to ensure dysphagia and fatal five trainings are completed by all staff in addition to ensuring that all staff retrain on ISPs and specifically any and all dietary restriction/requirements. |
03/01/2023
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #1's most recent tuberculin screening was completed on 10/21/20. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | CEO and program specialist will conduct immediate audit of all employee files and then at least monthly audit of all employee files to ensure compliance with applicable regulations. Any concerns or areas of non-compliance will be addressed immediately. All staff physical examinations and TB screenings will be monitored monthly. As a staff member is coming due for any required documentation, CEO and program specialist will alert appropriate employee and ensure compliance is maintained. |
03/01/2023
| Implemented |
| 6400.214(b) | Individual #1's most recent physical examination and dental examination are not being kept in the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| All necessary and required documentation is at each house currently. Program specialist has placed all necessary documents at the houses and included a checklist of required paperwork that is to be kept at the house in order for staff and house managers to utilize when monitoring for compliance. |
03/01/2023
| Implemented |
| 6400.165(g) | Individual #1's psychiatric medication review completed on 6/15/2022 did no include the reason for Diazepam and Scopolamine being prescribed. The review completed on 8/17/2022 did not include the reason or need to continue for all medications prescribed. Individual #1 completed psychiatric medication reviews through telehealth in October 2021, January 2022, and April 2022, however the agency did not obtain any medical records from the healthcare provider for these appointments. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | CEO and program specialist to conduct immediate review of all individual files for completeness of documentation and compliance of applicable regulations. In the future and on a monthly basis, CEO and program specialist will conduct monthly review of each individual file for compliance of applicable regulations. Any issues or concerns identified during the review will be addressed immediately. |
03/01/2023
| Implemented |
| 6400.166(b) | Thick-It powder to use as a food or beverage thickener prescribed to Individual #1 was not initialed as administered on 11/19/2022. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | All staff to be retrained on medication administration requirements by provider medication administration trainer. Kepro has been scheduled on 1/13/23 to begin training for all staff on dysphasia and then fatal five trainings to start. All staff at all houses will receive these initial trainings among other required annual trainings. HCQU training for Dysphagia completed on 01/17/2023. Fatal five training to be completed 2/17/23. Trainings for Fatal Five will be conducted at all houses by HCQU among others as scheduled. |
03/01/2023
| Implemented |
| 6400.188(c) | Individual #1's Individual plan, last updated 11/29/22, in the Know and Do section reads "All of [Individual #1]'s food has to be pureed and thicket has to be added to all liquids so that they are nectar consistency. [Individual #1] takes 2-3 bites and takes a drink when he eats" ···In the General Health and Safety Risk section reads "[Individual #1] is at risk for choking and aspiration···In the Meals/Eating section reads [Individual #1] has a potential for choking and aspiration. Meals need to be pureed and liquids must be at nectar consistency. [Individual #1] must take 2-3 bites and then take a drink. [Individual #1] needs to sit up for 30 minutes after each meal or snack. [Individual #1] is at risk for aspiration if he lies down after eating···[Individual #1] is generally independent with eating once the meals/snacks are prepared but may need verbal prompts from staff to take a drink and/or slow down"···In the Supervision needs section "Home supervision is 24/7 with 1:1 staff required for safety of himself, others, and his welfare in general." On 11/19/22, in the morning, Individual #1 reportedly, was lethargic, and sluggish and was unsteady on his feet and slept most of the morning and throughout the day. At approximately 5:00PM, Direct Service Worker #2 attempted to wake Individual #1 and then proceeded to have Direct Service Worker #1 assist in waking Individual #1. Individual #1 was offered and declined dinner three times prior to agreeing to eat in a reclining chair in the living room of the home. Direct Service Worker #1 prepared baked chicken nuggets and French fries and served to Individual #1 without pureeing. Direct Service Worker #1 then went to the kitchen leaving Individual #1 unattended. Individual #1 was found unresponsive, emergency services were contact and transported Individual #1 to the hospital. Individual #1 died at 4:50PM on 11/20/2022 due to choking on Food Bolus. | The home shall provide services to the individual as specified in the individual plan. | All staff trained on ISP for individual being served. All staff will be required to retrain on each ISP for any individual they provide direct service to and will be required to review ISP on an at least monthly basis. House managers will keep a sign off sheet in the house for monthly ISP reviews. CEO and program specialist are responsible for conduct checks at each house at least monthly to ensure compliance and that ISP are reviewed. |
03/01/2023
| Implemented |