| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Next Step Care video surveillance captured the incident that occurred on July 4th, 2021 at 7:46:34PM. Note this video does not record sound per the Office of Developmental Programs policy. While individual #1 was eating dinner at the kitchen table, staff #13 was on his left side and staff #7 was standing on his right side. Individual #1 began self-injurious behaviors by hitting his head with his fist and he then gripped for staff #13's hand. Staff #7 takes individual #1's phone from him, however individual #1 takes it back quickly. Staff #7 gripped individual #1's right hand and quickly appears to be trying to verbally calm individual #1 down. Individual #1's food plate is then moved forward away from individual #1 at the dining table by staff #7. Individual #1 begins violently, with both his arms, flashing around at both staff #13 and staff #7. As this is happening, individual #1 got up off the kitchen chair and staff #13 and staff #7 are attempting to restrain individual #1 by gripping his arms, shoulders, and neck. Staff #13 and staff #7 escorted individual #1 to the couch. Each staff [staff #13 and staff #7] had one of individual #1's arms while they were escorting him to the couch. Upon arrival to the couch, staff #13 with both arms, pushed individual #1 on to the couch. Individual #1 attempted to get off the couch a few times, but staff #13 pushed individual #1 back down on the couch using both arms while standing in front of individual #1. Staff #7 retrieved staff #13 the blocking pads. Staff #13 continued to stand in front of individual #1 and individual #1 appears to be verbally speaking to him. Staff #13 is still standing in front of individual #1 at a stance, without giving individual #1 his own space. Individual #1 begins to kick at staff #13; staff #13 does not walk away. Staff #13 continues standing in front of individual #1. Individual #1 is still sitting on the couch, he attempts to get up, and staff #13 again, aggressively pushes him back down on the couch again and staff #7 returns to the couch to assist staff #13. Currently, both staff are on top of individual #1; each staff [staff #13 and staff #7] holding a blocking pad. Unable to see individual #1's face watching this video footage; however, both staff #13 and staff #7 have individual #1 restrained holding him down, bound to the couch by his arms, legs, and chest. The blocking pads appear to be on part of individual #1's body also. It is approximately about one minute before both staff #13 and staff #7 release their restraint on individual #1 and slowly move back from individual #1 and stand at a stance once again. Staff #13 and Staff #7 continue to stand in front of individual #1 verbally talking to him. Individual #1 begins kicking staff #13 and staff #7; staff #13 and staff #7 lean forward on top of individual #1; holding individual #1 down by his arms, legs, and body on the couch. This transpires for approximately five seconds until staff #13 and staff #7 release the shackle. They continue to stand at a stance in front of individual #1 speaking to him verbally. Individual #1 gets up off the couch, walks back over to the kitchen table and sits back down at the kitchen table. Staff #13 and staff #7 also walk back to the kitchen table. Staff#13 and staff #7 are at the kitchen table when individual #1 begins to lash out at staff #13 with his left arm trying to hit him. Individual #1 gets up off the kitchen chair, points towards staff #7, staff #7 points back at individual #1, and individual #1 walked down the hallway of the home. Time incident end approximately 7:59:00PM.
Individual #1's current restrictive plan dated 6/28/2021, current individual plan dated 7/1/2021, and current assessment dated 2/20/2021 all do not contain any type of physical restraint component that is approved by a human rights committee; document the use of crisis prevention intervention techniques (CPI); and/or the manual use of blocking pads as a viable option during a crisis intervention for individual #1. Staff #13's witness statement taken on 7/14/2021 gives insight to the overall neglect provider Next Step Care played in the outcome of the events that occurred during the incident of July 4th, 2021 involving individual #1. Staff #13 was very transparent in the interview process. Staff #13 stated, "I was never trained. I was put on the spot to do it; just got thrown into the mix [work at the home because they were short staffed and needed people]". It was all "just see how Individual #1 acts". Staff #13 stated he never read Individual #1's current individual plan. Staff #13 also stated, "I don't think I have ever seen anything [documentation pertaining to individual #1's supports]. I don't think I was ever trained either 50 percent or 100 percent. I was never trained on using blocking pads." | 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. | 1. Based on a Root Cause Analysis completed by the team at NSC, a new policy and procedure for home and individual specific shadowing was initiated. The intent of the policy was to ensure the safety of individuals at Next Step Care through thorough training of staff and to ensure the staff comfort level of providing direct care to the individual. Key contributing factors found in the Root Cause Analysis (attached) were the inappropriate use of blocking pads and the staff not feeling safe in the situation. In addition to the shadowing policy created, the following interventions (2 through 12) were implemented to address all contributing factors.
2. The Behavioral Restrictive Plan for Individual #1 was updated to include approved CPI techniques and was approved by Human Rights Team (HRT) on 7/28/2021.
3. Staff was re-trained on appropriate use of CPI techniques and performed return demonstration to the certified trainer. Training sign-in sheet is documentation of completion.
4. Staff was trained on the new Behavioral Restrictive Plan (BRP) which includes the Crisis Plan. Training sign-in sheet is documentation of completion.
5. Staff will be trained on the appropriate use of blocking pads as a viable option during a crisis intervention for Individual #1.
6. Following staff training and demonstration of proficiency in the safe use of blocking pads, the Behavioral Restrictive Plan will be updated to include blocking pad use and be forwarded to the HRT for approval. Target date 9/29/2021.
7. The Assessment for Individual #1 was updated to include approved CPI techniques and forwarded the Assessment or the BRP.
8. The Behavioral Specialist will train the staff on the ISP after updates are made.
9. Assessment was sent to Individual #1¿s parents and the SC on 9/2/2021 for their review. The current Assessment remains in progress pending parent review and agreement. Target date 10/1/202 |
10/01/2021
| Implemented |
| 6400.21(a) | No criminal history record check was provided for staff #15 when requested during the investigatory process. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| 1. Criminal History was found to be ran on 8/11/20.
2. The License Compliance Manager/Regional Manager will be trained by the CEO and VP on requirements for employee records. |
09/30/2021
| Implemented |
| 6400.22(d)(1) | Individual #1 did not have a personal property record that included his personal possessions. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | 1. Individual #1 personal property record will be completed by 9/1/21 and will be updated as needed when items are received and will be reviewed annually.
2. All staff will be trained on this regulation 6400.22 (d)(1) by the License Compliance Manager/Regional Manager to ensure all locations remain in compliance with this regulation.
3. All staff will sign off on a signature page by 9/30/21. |
09/30/2021
| Implemented |
| 6400.32 | As it relates to violations 16, 18f, 32t, 188c, and 208d. | An individual may not be deprived of rights.
| 1. All individuals and/or parent/guardians are informed of the individual¿s Rights under PA Code Chapter 6400.32 upon admission which is signed by either the Individual or parent/guardian.
2. All homes are provided with a copy of the Individual Rights which is readily accessible to all staff.
3. Staff will be trained on PA Code 6400.32 Individual Rights by the Regional Manager/License Compliance Manager. Target Date 9/30/2021. |
09/30/2021
| Implemented |
| 6400.43(b)(1) | As it pertains to violations 18a, 18c, 18g, 32f, 52c5, and 186. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | 1. The CEO participates in the development and provides final approval of all policies and procedures at Next Step Care, Inc.
2. The CEO reviews policies as needed and when any changes or updates are made, at a minimum annually.
3. Staff will be re-trained on NSC Policies and Procedures by the CEO. Target Date 9/30/2021. |
09/30/2021
| Implemented |
| 6400.43(b)(3) | Staff #5 is the CEO and program specialist. As it pertains to violations 16,18f, and 208d. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | 1. The CEO analyzes monthly data including goals, outcomes, incident reports, behavioral data, sleep patterns, medical incidents and appointments in collaboration with the behavioral specialist, medical coordinator, regional manager, Vice President, license compliance manager, and staff.
2. The CEO addresses any negative trends in the above data with the involved persons.
3. The CEO directs any training that is required based on trends.
4. The CEO reports incidents as required including notifications as indicated (ie. SC, parent/guardian, APS, law enforcement) within the specified time frame.
5. The CEO has the authority to immediately remove any staff that is known or suspected to pose a threat to the safety of an individual. |
09/30/2021
| Implemented |
| 6400.46(j) | Staff #7 completed 6100/6400 regulation training on 5/3/2021 for training duration of 4 hours. The trainer is documented as Staff #7 [himself]. A certificate of completion was also awarded on 5/3/2021 for this training to Staff #7, by Staff #7 [himself]. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | 1. Staff #7 was re-trained on 8/26/2021 by Regional Manager.
2. Training policy was amended to include, Any staff that is a trainer in any subject matter may not train themselves on the material and will be trained by a member of management or other designated trainer.
3. LCM/Regional Manager will train the trainers on the amended policy. All trainers will sign off on the amended policy by 9/30/2021. |
09/30/2021
| Implemented |
| 6400.62(a) | There was a Febreze Air aerosol can on the basement bathroom window sill which is an unlocked poison. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 1. The Febreze Air can was removed and placed in the locked cupboard.
2. All staff will be trained on regulation 6400.62 (a) by the Regional Manager/License Compliance Manger to ensure all staff remain in compliance with this regulation. All staff will sign off on a signature page by 9/30/21. |
09/30/2021
| Implemented |
| 6400.64(a) | The room which is padded had dirty windows and dead bugs in the window sill. | Clean and sanitary conditions shall be maintained in the home. | 1. Staff were addressed regarding the situation from the Regional Field Manager and the windows and seals were cleaned properly.
2. All staff will be trained on this regulation 6400.64(a) by the Regional Manager/License Compliance Manager to ensure that all homes remain in compliance with this regulation. All staff will sign off on a signature page by 9/30/21. |
09/30/2021
| Implemented |
| 6400.67(a) | The top of the door jamb above Individual # 1's bathroom is missing molding.
There is a 3 inch by 3 inch hole in the drywall separating the toilet from the bathtub.
There is a 5 inch by 4 inch triangular shaped section of tile missing in the bath tub.
The cleaning supply closet door has a 5 inch crack on the exterior of the door.
The Refrigerator door handle is broken.
The Oven door handle is broken.
There is a missing cabinet door in the upper cabinet next to individual #1's pantry.
The top pantry door to Individual # 1's pantry is loose and not well secured.
There is a 5 inch hole in the basement wall to the right of the television.
There is a 3 foot by 3 foot unpainted drywall patch on the basement wall across from the basement stairs.
There is a 6 foot crack in the ceiling area by the dining room table. | Floors, walls, ceilings and other surfaces shall be in good repair. | 1. The repairs were made to the molding and the hole in the drywall were completed within 36 hours from first inspection.
2. All staff will be trained on this regulation 6400.67(a) by the License Compliance Manager to ensure that all homes remain in compliance with this regulation. All staff will sign off on a signature page by 9/30/21. |
09/30/2021
| Implemented |
| 6400.67(b) | The left switch on the double light switch for the upper level hallway was cracked and broken. The light was not working during the physical site walk through.
The left switch on the double light switch in the basement bathroom was cracked and the light was flickering when the switch was used during the walk through.
The dryer lint trap had a golf ball sized amount of lint. | Floors, walls, ceilings and other surfaces shall be free of hazards. | 1. The light switch was inspected for damage and the cracked cover was replaced. The light fixture was repaired within 36 hours of first inspection and confirmed to be functioning properly after repair.
2. All staff will be trained on this regulation by the License Compliance Manager to ensure that all homes remain in compliance with this regulation. All staff will sign off on a signature page by 9/30/21. |
09/30/2021
| Implemented |
| 6400.80(a) | There is a 4 inch gap in a concrete step in the front walk way which runs the length of the step. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | 1. The 4 inch gap was repaired on within 36 hours of first inspection.
2. All staff will be trained on this regulation by the License Compliance Manager to ensure that all homes remain in compliance with this regulation. All staff will sign off on a signature page by 9/30/21. |
09/30/2021
| Implemented |
| 6400.80(b) | The rear basement window well had a dead animal and leaves within the window well.
The area between the drive way and front entry walk way had weeds and overgrowth.
The metal eve flashing on the left side of the home facing the home was falling off of the eve and the flashing was hitting the office window during the inspection.
The outdoor windows were covered in dirt and cobwebs.
An unattached electrical outlet was left on the ground by the outside Air Conditioner compressor.
The light above the front entryway was covered in bugs and cobwebs. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | 1. The window well was cleaned and the area between the driveway and the front entry walkway were trimmed and weeded on 7/16/21.
2. All staff will be trained on this regulation by the License Compliance Manager to ensure that all homes remain in compliance with this regulation. All staff will sign off on a signature page by 9/30/21. |
09/30/2021
| Implemented |
| 6400.103 | Nest Step Care Inc. Emergency Evacuation Plan states it was issued on "5/3/30". The document pertains to fire evacuation procedures for individual #1's home. It also states that in an emergency staff and individuals shall be transported to the Holiday Inn Express in Harrisburg, PA, it does not give an address of which Holiday Inn hotel. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| 1. The Emergency Evacuation Plan has been updated to include an address where staff and individuals shall be transported.
2. All plans have been proofread and typos have been corrected.
3. All staff will be trained on the Emergency Evacuation Plans by the Regional Manager/License Compliance Manager to ensure that all procedures remain in compliance with this regulation.
4. All staff will sign off on a signature page by 9/30/21. |
09/30/2021
| Implemented |
| 6400.142(f) | Individual #1's current individual plan dated 7/1/2021 includes a dental plan from 2018. That plan is irrelevant and requires to be updated. The 2018 dental plan states, "attempt to have individual #1 floss at least once per day. Staff will utilize verbal prompts and modeling of flossing to help individual #1 with this new task." Individual #1 no longer uses floss; an electric water pic has been introduced as part of his current dental hygiene plan. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | 1. As the dental exam record was completed by the dentist on 7/29/2021 and he was aware of the use of the electric water pic, the dentist amended the dental exam record to include the use of the water pic.
2. The ISP will be coordinated with the SC to include the updated dental plan
3. The Medical Coordinator will train the staff on the revised ISP Dental Plan and staff will complete a sign-off sheet by 9/30/21. |
09/30/2021
| Implemented |
| 6400.145(3) | Next Step Care Inc. written emergency medical plan effective date 5/30/2020 does not include an emergency staffing plan. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | 1. The emergency medical plan was amended to include the emergency staffing plan.
2. The Individuals ISP will be updated to include the emergency staffing plan.
3. The Regional Manager/License compliance manager will train all staff on the Emergency Medical Plan including the emergency staffing plan and staff will complete a sign off by 9/30/21. |
09/30/2021
| Implemented |
| 6400.151(c)(2) | Staff #14 had the tuberculin skin testing completed 9/25/2020 and 9/28/2020. The test was completed, and test results determined, by a certified medical assistant. | 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. | 1. Staff #14 had a repeat TB skin test on 9/3/2021 to be read on 9/5/2021 by a person certified and credentialed to read TB tests.
2. The completed test documentation was placed in the employee file.
2. The Medical Coordinator will review all current staff physicals and ensure they are complete and that they were signed by a credentialed provider. If a physical is found to be not in compliance, the Medical Coordinator will take appropriate action to ensure completion/compliance. |
09/30/2021
| Implemented |
| 6400.190(c) | Documentation of individual #1's community participation outcome, too include the documentation of the recreational and social activities individual #1 participates in, are not kept in the individual's record at the home. Licensing staff had to ask staff #2 for a copy of said documented activities from March 2021 through August 2021. Licensing staff was not provided a copy of May 2021. Staff #17 and staff #18, individual #1's legal guardians, also stressed in an email on 3/25/2021 to staff #3 the importance of maintaining a routine for individual #1 and offering a wider variety of activities in the community. Also, individual #1's current individual plan 7/1/2021 does not reflect current recreational and social activities and experiences with the support of Next Step Care. | Documentation of recreational and social activities shall be kept in the individual¿s record.
| 1. Individual #1 community participation outcomes were documented, however they were not available in the individual record at the home due to them being at the office at that time in use by the behavioral specialist.
2. Behavioral Specialist will be re-trained by the CEO that community participation outcomes are not to be removed from the individuals record in the home and copies are to be made for office use.
3. All staff will be trained on this regulation by the CEO to ensure records remain in compliance. Staff will sign off on a signature form by 9/30/21. |
09/30/2021
| Implemented |
| 6400.18(a)(4) | Next Step Care video surveillance captured the incident that occurred on July 4th, 2021 at 7:46:34PM. Per Individual #1's current behavioral support plan dated 6/28/2021 and Individual #1's current individual plan dated 7/1/2021, access to both live and recorded feed is available to the CEO, program specialists, behavior specialist, and other staff as designated by the director of residential services (i.e., house supervisors, staff trainers). individuals with access can view the live and recorded feed remotely, up to 45-60 days from the recording date, both live and recorded video feed will be monitored intermittently for supervision purposes, treatment integrity of programming, virtual support and coaching provided to staff, and review of incidents for reporting and corrective action purposes. A Next Step Care internal incident report was completed by staff #7 on 7/4/2021 also notifying the Next Step Care behavioral specialist [staff 1#] at 8PM, via phone call. According to the witness statement of staff #1 taken on 7/16/2021, she received a phone call from staff #7 at approximately 10PM on the evening of July 4th, 2021. Staff #7 explained to staff #1 that, "Individual #1 was highly agitated prior to having a snack and staff #13 and staff #7 attempted to run the plan. Staff #7 also stated staff #13 was not running the plan correctly".
Staff #1 stated she requested a copy of the video of this incident "a couple days after" and she also worked on site at individual #1's home as a resident support worker on July 5th, 2021 and still did not yet review this video incident. Staff #1 worked with staff #2 on July 5th, 2021. Staff #2, [per the witness statement taken on July 13th, 2021] reported the incident to staff #1 and the need to view the video footage. Staff #1 did not ask for a copy of the video footage from staff #2 while at individual #1's home July 5th, 2021. Staff #1 did not see the video footage of this incident "until days later".
On July 13th, 2021 at the onset of the Office of Developmental Programs (ODP) internal investigation, staff #17 had already contacted staff #3 via email 7/11/2021 requesting an urgent meeting to review the video footage of this incident that happened July 4, 2021. Licensing staff arrived at Individual #1's home 9am on July 13, 2021 and called staff #3 in the morning hours to discuss the initiation of this investigation. When asked if staff #3 was aware of the incident that occurred on July 4th, 2021 he said, "yes, however, something was wrong with that video footage and could not watch it in its entirety." Licensing instructed staff #3 to begin the investigatory process for abuse. Staff #2 sent the entire video footage of that incident to staff #3. Staff #3 and staff #5 called licensing back at individual #1's home after watching the video of the incident on July 4, 2021 involving individual #1 and agreed an investigation must begin. This incident was eight days late from being entered into the incident management system. Next Step Care failed in meeting the timeliness of this regulation and it's intent to support individual #1's health and safety and dignity. There was clearly no lack of urgency for Next Step Care to view this incident. | 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.
| 1. Staff are trained on reporting requirements, types of incidents, reporting time frames, how to report and chain of command for reporting upon new hire orientation and annually.
2. Staff are trained on 6400 Regulations upon new hire orientation and annually.
3. Staff will be re-trained on Incidents and Reporting and 6400 Regulations by the CEO and complete a sign-off by 9/30/2021.
4. The CEO reports incidents as required including notifications as indicated (ie. SC, parent/guardian, APS, law enforcement) within the specified time frame
Additionally, POC for PA Code 6400.16 applies to comprehensively address this correction.
1. Based on a Root Cause Analysis completed by the team at NSC, a new policy and procedure for home and individual specific shadowing was initiated. The intent of the policy was to ensure the safety of individuals at Next Step Care through thorough training of staff and to ensure the staff comfort level of providing direct care to the individual. Key contributing factors found in the Root Cause Analysis (attached) were the inappropriate use of blocking pads and the staff not feeling safe in the situation. In addition to the shadowing policy created, the following interventions (2 through 12) were implemented to address all contributing factors.
2. The Behavioral Restrictive Plan for Individual #1 was updated to include approved CPI techniques and was approved by Human Rights Team (HRT) on 7/28/2021.
3. Staff was re-trained on appropriate use of CPI techniques and performed return demonstration to the certified trainer. Training sign-in sheet is documentation of completion.
4. Staff was trained on the new Behavioral Restrictive Plan (BRP) which includes the Crisis Plan. Training sign-in sheet is documentation of completion.
5. Staff will be trained on the appropriate use of blocking pads as a viable option during a crisis intervention for Individual #1.
6. Following staff training and demonstration of proficiency in the safe use of blocking pads, the Behavioral Restrictive Plan will be updated to include blocking pad use and be forwarded to the HRT for approval. Target date 9/29/2021.
7. The Assessment for Individual #1 was updated to include approved CPI techniques and forwarded the Assessment or the BRP.
8. The Behavioral Specialist will train the staff on the ISP after updates are made.
9. Assessment was sent to Individual #1s parents and the SC on 9/2/2021 for their review. The current Assessment remains in progress pending parent review and agreement. Target date 10/1/202 |
10/01/2021
| Implemented |
| 6400.18(c) | Staff #17 and Staff #18 were never notified of the July 4th 2021 incident involving individual #1. Staff #17 and staff #18 are individual #1's legal guardians. On 7/11/2020 Staff #17 emailed staff #3 with grave concerns regarding not being notified of incidents involving individual #1.
Individuals designated by the individual must be notified of significant events to have a great quality of life. Next Step Care failed to support individual #1.
As pertains to violations 16, 18a, and 18f. | The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual. | 1. Staff are trained on reporting requirements, types of incidents, reporting time frames, how to report and chain of command for reporting upon new hire orientation and annually.
2. Staff are trained on 6400 Regulations upon new hire orientation and annually.
3. Staff will be re-trained on Incidents and Reporting and 6400 Regulations by the CEO and complete a sign-off by 9/30/2021.
4. The CEO reports incidents as required including notifications as indicated (ie. SC, parent/guardian, APS, law enforcement) within the specified time frame
Additionally, POC for PA Code 6400.16 applies to comprehensively address this correction.
1. Based on a Root Cause Analysis completed by the team at NSC, a new policy and procedure for home and individual specific shadowing was initiated. The intent of the policy was to ensure the safety of individuals at Next Step Care through thorough training of staff and to ensure the staff comfort level of providing direct care to the individual. Key contributing factors found in the Root Cause Analysis (attached) were the inappropriate use of blocking pads and the staff not feeling safe in the situation. In addition to the shadowing policy created, the following interventions (2 through 12) were implemented to address all contributing factors.
2. The Behavioral Restrictive Plan for Individual #1 was updated to include approved CPI techniques and was approved by Human Rights Team (HRT) on 7/28/2021.
3. Staff was re-trained on appropriate use of CPI techniques and performed return demonstration to the certified trainer. Training sign-in sheet is documentation of completion.
4. Staff was trained on the new Behavioral Restrictive Plan (BRP) which includes the Crisis Plan. Training sign-in sheet is documentation of completion.
5. Staff will be trained on the appropriate use of blocking pads as a viable option during a crisis intervention for Individual #1.
6. Following staff training and demonstration of proficiency in the safe use of blocking pads, the Behavioral Restrictive Plan will be updated to include blocking pad use and be forwarded to the HRT for approval. Target date 9/29/2021.
7. The Assessment for Individual #1 was updated to include approved CPI techniques and forwarded the Assessment or the BRP.
8. The Behavioral Specialist will train the staff on the ISP after updates are made.
9. Assessment was sent to Individual #1s parents and the SC on 9/2/2021 for their review. The current Assessment remains in progress pending parent review and agreement. Target date 10/1/202 |
10/01/2021
| Implemented |
| 6400.18(f) | As it pertains to violations 16 and 18a. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | 1. Upon discovery of the incident of 7/4/2021, staff involved were immediately suspended pending investigation.
2. Adult Protective Services was notified 7/13/2021.
3. CEO immediately filed the report in HCSIS 7/13/2021.
4. CEO collaborated with SC, parents, and team to set up and hold weekly meetings regarding the current status of Individual #1 and allow for any concerns to be voiced. The first meeting was held 7/15/2021.
5. Re-training was done on reporting requirements and incident reports for all staff. All staff will sign off by 9/30/2021. |
09/30/2021
| Implemented |
| 6400.32(t) | Per individual #1's current individual plan dated 7/1/2021, food can be a trigger for Individual #1's aggressive behaviors toward staff and self-injurious behaviors. Individual #1 has a history of gorging any food item, including raw meat and history of dumping food in the trash. It is a safety measure to lock food downstairs and keep the only needed menu items (1-2 day supply of food upstairs in the kitchen/freezer) available to Individual #1 upstairs in the refrigerator/freezer. Individual #1 has sufficient amount of healthy snacks that are available to his disposal. During the investigatory process and walk-through of the home 7/13/2021, there were only fresh apples in individual #1's upstairs refrigerator. In the upstairs freezer there was only a container of leftover food and a bottled water. Individual #1's kitchen "snack pantry" it had various different types of candy, cereals, and minimal "healthy" snacks available. Staff #2 stated, "if individual #1 is hungry, he will just ask staff for it and we will get it for him". Staff #2 also informed licensing during the investigatory process that individual #1 does not even like apples. | An individual has the right to access food at any time. | 1. As documented in the Behavioral Restrictive Plan, the individual will have access to food at any time.
2. Program specialist and Team Lead will collaborate to determine a list of Individual #1¿s food preferences and ensure that Individual #1 has access to foods he prefers. Team Lead and Behavioral Specialist will work with Individual #1 to ensure preferred foods contain healthy choices.
3. A menu will be planned and posted in the home as per regulation based on Individual #1 preferences and ensuring a balanced diet.
4. The refrigerator, freezer, and cupboards will be stocked with enough food to provide choices for the individual, but will follow BRP due to Individual #1¿s behaviors relating to food as outlined in the BRP.
5. Staff will be trained on the BRP and complete a sign-off by 10/1/2021 |
10/01/2021
| Implemented |
| 6400.44(b)(2) | Staff #5 is the CEO and program specialist. Pertaining to violation 186. | The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter. | 1. The Program Specialist will provide the individual¿s assessment to the team members including parents of Individual #1 30 days prior to scheduled ISP meeting.
2. A target date of 1 week prior to the meeting will be requested for any concerns/requested changes to the assessment.
3. The updated assessment will be incorporated into the ISP in collaboration with the SC.
4. A copy of the individuals assessment and ISP will be readily available in the home and accessible to all staff working in the home.
5. All staff will be trained on the individual¿s assessment and ISP by the program specialist and will complete a sign off on a signature sheet. |
10/01/2021
| Implemented |
| 6400.45(d) | As it relates to violation 186 and staff ratio. | 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 ). | 1. The program specialist will ensure that the staffing ratio is followed as indicated in the assessment and restrictive plan 2:1 staffing 24/7 and an additional staff in the community as needed.
3. The ISP will be coordinated with the ISP to ensure that staffing ratios are in included in the plan.
4. The Emergency Staffing Plan will be utilized when necessary to ensure adequate staffing is available at all times.
5. All staff will be trained on the Emergency Staffing Plan, the Assessment, and the BRP as they relate to staffing ratios. Target date 9/30/2021 |
09/30/2021
| Implemented |
| 6400.52(c)(5) | During the investigatory process, staff #1 and staff #5 did not provided any current, up-to-date completed training hours that reflected appropriate, accurate materials that are needed to support individual #1. Staff #1 has a requirement to provided behavioral supports at individual #1's home with staff that support him. [Training provided in accordance with 6400.52(b)(5)-(6) must be person-specific and based on the most current assessment and Individual Plan and should include knowledgeable about the needs of the person and practices necessary to assure the person's health, safety and welfare including the person's mode of communication; what is important to the person including preferred activities, foods, and relationships, safe eating/feeding procedures, respiratory maintenance and treatments, positioning and transferring procedures, skin integrity protocols, individual-specific emergency procedures, the safe and appropriate use of trauma-informed behavior supports, and an understanding of age-related factors such as interests, preferred activities, and stamina, as specified in the Individual Plan.] | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | 1. The Behavioral Restrictive Plan for Individual #1 was updated to include approved CPI techniques and was approved by Human Rights Team (HRT) on 7/28/2021.
2. Staff was re-trained on appropriate use of CPI techniques and performed return demonstration to the certified trainer. Training sign-in sheet is documentation of completion.
3. Staff was trained on the new Behavioral Restrictive Plan (BRP) which includes the Crisis Plan. Training sign-in sheet is documentation of completion.
4. Staff will be trained on the appropriate use of blocking pads as a viable option during a crisis intervention for Individual #1.
5. Following staff training and demonstration of proficiency in the safe use of blocking pads, the Behavioral Restrictive Plan will be updated to include blocking pad use and be forwarded to the HRT for approval. Target date 9/29/2021.
6. The Assessment for Individual #1 was updated to include approved CPI techniques and forwarded the Assessment or the BRP.
7. The Behavioral Specialist will train the staff on the ISP after updates are made.
8. Incidents where CPI techniques and/or blocking pads are used will be reported as required in HCSIS and each incident will be reviewed and a debriefing will occur with the Behavioral Specialist and the involved staff which may include use of video surveillance as needed. The Behavioral Specialist will review the Next Step Care Inc. Incident Report and will forward results to the CEO, VP, and License Compliance Manager for tracking and trending.
9. Any negative trends noted will initiate additional training based on staff needs.
10. to Individual #1¿s parents and the SC on 9/2/2021 for their review. The current Assessment remains in progress pending parent review and agreement. Target date 10/1/2021. |
10/01/2021
| Implemented |
| 6400.166(a)(11) | Individual #1's medication Meletonin 10mg tablet take (1) tablet by mouth at bedtime and the medication Klonopin 2mg take at 8am, 2pm, and 8pm do not state the diagnosis or purpose for the medication on the July 2021 Medication Administration Record (MAR). | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | 3. The pharmacy service was contacted and entered the diagnoses on the Klonopin 2mg and the Melatonin 10mg.
3.All staff will be trained on this regulation by Medical Administrator to ensure all homes remain in compliance with this regulation. All staff will be trained by 9/30/21. |
09/30/2021
| Implemented |
| 6400.181(f) | Staff #16 reports she has not received a current copy of individual #1's assessment. Next Step Care did not provide the evidence that a current copy of the assessment was provided per regulation(s). | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | 1. The Program Specialist will provide the individuals assessment to the team members including parents of Individual #1 30 days prior to scheduled ISP meeting.
2. A target date of 1 week prior to the meeting will be requested for any concerns/requested changes to the assessment.
3. A copy of the individuals assessment will be readily available in the home and accessible to all staff working in the home.
4. All staff will be trained on the individuals assessment by the program specialist and will complete a sign off on a signature sheet by 10/1/2021 |
10/01/2021
| Implemented |
| 6400.183(a)(3) | Individual #1 DOA to Next Step Care services was May 3rd, 2020. According to witness statements taken during the investigation process, Team Lead [Staff #2] at Individual #1's home stated he personally never participated in the development of individual #1's individual plan under Next Step Care. Staff #2 also stated he does not know of any direct staff persons who work with individual #1 that ever was given the opportunity to participate in an individual plan meeting to support individual #1. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons. | 1. The CEO/Behavior Specialist will ensure that the Team Lead as well as any interested staff will receive notification of the date of the individuals interdisciplinary assessment and be given the opportunity to participate.
2. The Program Specialist will provide the individuals assessment to the team members including parents of Individual #1 30 days prior to scheduled ISP meeting.
3. A target date of 1 week prior to the meeting will be requested for any concerns/requested changes to the assessment.
4. All staff will be trained on the individuals assessment by the program specialist and will complete a sign off on a signature sheet by 10/1/2021 |
10/01/2021
| Implemented |
| 6400.186 | Individual #1's date of admission to Next Step Care is documented as May 3rd, 2020. Per the Home and Community Services Information System (HCSIS), Individual #1's individual plan has been updated 12 times since May 4th, 2020. During the investigation process, it was discovered by licensing the grave amount of irrelevant and/or false information or pertinent information regarding individual #1 that needed to be revised in Individual's current individual plan dated 7/1/2021.
This plan states individual #1 does not have a mental health diagnosis.
A neurological plan/check was discussed with staff #20 which staff use to assess damage if individual #1 bangs his head. Individual #1 has a history of displaying extreme negative behaviors when staffing is not consistent, he is not properly preparing for staffing changes, when staff is not sufficiently trained in his plans and protocols and when a staff member who is a good fit for individual #1's program leaves any of these can lead to increases in sibs, aggression and/or property destruction. Therefore, careful attention must be paid to each of these factors. -- During the investigation process staff #2, Team Lead, stated, "this section of the individual plan is outdated. An "After Crisis Observation" document was introduced by staff #20. Staff who work with individual #1 should be trained on the after-crisis document now."
Individual #1 mostly 2:1 support 24 hours a day 7 days a week but there are occasions when he may need 3:1 support in certain community locations. When Individual #1 is in the bathroom or has requested alone time in his bedroom, staff will provide auditory supervision and complete visual checks every 30 minutes. During the investigatory process, both staff #1 and staff #2 stated this statement is incorrect. Currently, Individual #1 receives 2:1 supports 24/7 line of sight supervision. Other needed supervision needs are not clear currently.
Individual #1 has difficulty attending medical appointments. There is a specific appointment protocol in place in order to help prepare Individual #1 for appointments. During the investigatory process, both staff #1 and staff #2 stated there is no active protocol in place.
Individual #1 should have 2:1 support in the following locations: drive-thrus, parks and other known locations, as determined by his team. Individual #1 should have 3:1 support in the following locations due to potential safety concerns: paying for items, etc., novel locations, sit-down restaurants, grocery stores, and doctor/dentist appointments. During the investigatory process, both staff #1 and staff #2 stated this information is incorrect.
Food can be a trigger for Individual #1's aggressive behaviors toward staff and self-injurious behaviors. Individual #1 has a history of gorging any food item, including raw meat and history of dumping food in the trash. It is a safety measure to lock food downstairs and keep the only needed menu items (1-2 day supply of food upstairs in the kitchen/freezer) available to Individual #1 upstairs in the refrigerator/freezer. Individual #1 has sufficient amount of healthy snacks that are available to his disposal. During the investigatory process 7/13/2021 there were only fresh apples in individual #1's upstairs refrigerator. In the upstairs freezer there was only a container of leftover food and a bottled water.
Using individual #1's iPad or iPod: individual #1 typically listens to music, plays YouTube videos or plays games. Time limits have been established so that individual #1 does not spend hours at a time on electronic devices. During the investigatory process, it was discussed how this is a violation of individual #1's rights. There is no current restrictive plan in place for the iPad.
Important to individual: having a scheduled routine that reflects what is going on throughout the entire day. Allow additional time for Individual #1 to process written or verbal communication especially if it is information that he may not be happy to hear. Staff's schedule needs to be consistent as possible for Individual #1 to lessen his anxiety. During the investigatory process it was discovered that Individual #1 does not have scheduled days or a routine. Individual #1's sleep pattern is erratic, and it is monitored by staff #20. There is no structure to priorities in individual #1's daily life.
Individual #1's sleep continues to be disturbed and does not sleep throughout the night on a regular basis. Staff #20 prescribed light therapy each morning starting in 2017-2018. This was continued for approximately 1 year. Individual #1 became resistant to it and vaso discontinued use. Individual #1's parents feel that it should be reintroduced. During the investigatory process it was discovered that the light therapy was not yet introduced per Individual #1's parents [staff #17 and staff #18] request.
Per doctor's orders: staff will encourage healthy eating and portion control and limit calories from added sugar. offer alternatives when snacks are requested, especially if it is second serving of snack. Individual #1 is unable to make appropriate food selection for himself. Individual #1 does not need to be given every food he requests. Offer alternatives to chips, snacks. Limit snacks to 2 portions a day. During the investigatory process and record review, Individual #1 does not have any snack limitations.
Revised dental plan 7/8/18: Individual #1 will brush his teeth twice a day with an electric toothbrush. Staff will put toothpaste on his toothbrush and place in his bathroom or hand to him. Individual #1 may require verbal prompts to initiate brushing and verbal prompts for thoroughness. Staff will attempt to have will floss at least once per day. Staff will utilize verbal prompts and modeling of flossing to help will with this new task. During the investigatory process and record review, Individual #1 no longer uses floss. This dental plan is out-of-date; a dental plan must be update annually.
Individual #1 requires 3:1 staffing to novel community locations, but familiar locations are being faded to 2:1. This needs to be reevaluated with next step care once transition occurs. Individual #1 needs support going to and from the van to any location. Two staff who have been trained for community trips are needed to escort Individual #1 out of and into the van while a third staff member pays the bill, etc. Individual #1 has a van protocol, which is located on file at the home. During the investigatory process and record review it was conformed individual #1 does not have a current "van protocol". Also, it is unclear what the definition is of "novel community locations". Next Step Care does not provide individual #1 with 3:1 staff ratio at any time to support individual #1.
For times when individual #1 is in the bathroom or has requested alone time in his bedroom, staff will provide auditory supervision and completed visual checks every 15 minutes. During the investigatory process it was confirmed this statement is false by staff #1 and staff #2.
Task analyses: can be used to create written task cards and activity schedules. Individual #1 often reacts negatively to verbal prompting. Task analyses can be used for skill acquisition training and to prompt him through steps in a task/activity without the need for verbal prompts. Utilize his strengths of being able to learn new tasks quickly, follow written directions in the absence of severe behaviors, and demonstrate an excellent work ethic, follow these guidelines: -create a task-analysis card. write the goal on top & detail each step needed to complete the task. During the investigatory process, task-analysis cards could not be located at Individual #1's home. Through witness interviews, staff who work with Individual #1 did not know what a task-analyses is. | The home shall implement the individual plan, including revisions. | 1. The Program Specialist will provide the individuals assessment to the team members including parents of Individual #1 30 days prior to scheduled ISP meeting.
2. A target date of 1 week prior to the meeting will be requested for any concerns/requested changes to the assessment.
3. The updated assessment will be incorporated into the ISP in collaboration with the SC.
4. A copy of the individuals assessment will be readily available in the home and accessible to all staff working in the home. |
10/01/2021
| Implemented |
| 6400.188(a) | As it relates to violation 186. | The home shall provide services, including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment. | 1. The Program Specialist will provide the individuals assessment to the team members including parents of Individual #1 30 days prior to scheduled ISP meeting.
2. A target date of 1 week prior to the meeting will be requested for any concerns/requested changes to the assessment.
3. The updated assessment will be incorporated into the ISP in collaboration with the SC.
4. A copy of the individuals assessment will be readily available in the home and accessible to all staff working in the home. |
10/01/2021
| Implemented |
| 6400.188(c) | As it relates to violation 186. | The home shall provide services to the individual as specified in the individual plan. | 1. The Program Specialist will provide the individuals assessment to the team members including parents of Individual #1 30 days prior to scheduled ISP meeting.
2. A target date of 1 week prior to the meeting will be requested for any concerns/requested changes to the assessment.
3. The updated assessment will be incorporated into the ISP in collaboration with the SC.
4. A copy of the individuals assessment and ISP will be readily available in the home and accessible to all staff working in the home.
5. All staff will be trained on the individuals assessment and ISP by the program specialist and will complete a sign off on a signature sheet by 10/1/2021 |
10/01/2021
| Implemented |
| 6400.195(d) | Staff #1 did not provide documentation that the behavioral specialists is meet the following
standards:
1.Complete training in conducting and using a Functional Behavioral Assessment.
2.Complete training in positive behavioral support. | If a physical restraint will be used or if a restrictive procedure will be used to modify an individual's rights in § 6400.185(6) (relating to content of the individual plan) the behavior support component of the individual plan shall be developed by a professional who has a recognized degree, certification or license relating to behavioral support. | 1. The behavioral specialist holds a professional degree relating to behavioral support ¿ Bachelor of the Arts ¿ Behavioral Health. This documentation was placed in the employees file.
2. The behavioral specialist is responsible for developing Individual #1¿s BRP.
3. All Behavioral Restrictive Plans must be approved by the Human Rights Team. |
09/30/2021
| Implemented |
| 6400.208(d) | As it pertains to violation 16. | A physical restraint that inhibits digestion or respiration, inflicts pain, causes embarrassment or humiliation, causes hyperextension of joints, applies pressure on the chest or joints or allows for a free fall to the floor is prohibited. | 1. Based on a Root Cause Analysis completed by the team at NSC, a new policy and procedure for home and individual specific shadowing was initiated. The intent of the policy was to ensure the safety of individuals at Next Step Care through thorough training of staff and to ensure the staff comfort level of providing direct care to the individual. Key contributing factors found in the Root Cause Analysis (attached) were the inappropriate use of blocking pads and the staff not feeling safe in the situation. In addition to the shadowing policy created, the following interventions (2 through 12) were implemented to address all contributing factors.
2. The Behavioral Restrictive Plan for Individual #1 was updated to include approved CPI techniques and was approved by Human Rights Team (HRT) on 7/28/2021.
3. Staff was re-trained on appropriate use of CPI techniques and performed return demonstration to the certified trainer. Training sign-in sheet is documentation of completion.
4. Staff was trained on the new Behavioral Restrictive Plan (BRP) which includes the Crisis Plan. Training sign-in sheet is documentation of completion.
5. Staff will be trained on the appropriate use of blocking pads as a viable option during a crisis intervention for Individual #1.
6. Following staff training and demonstration of proficiency in the safe use of blocking pads, the Behavioral Restrictive Plan will be updated to include blocking pad use and be forwarded to the HRT for approval. Target date 9/29/2021.
7. The Assessment for Individual #1 was updated to include approved CPI techniques and forwarded the Assessment or the BRP.
8. The Behavioral Specialist will train the staff on the ISP after updates are made.
9. Assessment was sent to Individual #1¿s parents and the SC on 9/2/2021 for their review. The current Assessment remains in progress pending parent review and agreement. Target date 10/1/2021 |
10/01/2021
| Implemented |