| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The upstairs second bedroom bathroom had a clogged toilet, and the inside of the toilet bowl was stained brown. | Clean and sanitary conditions shall be maintained in the home. | The residential site was cleaned and disinfected in all areas. The upstairs bathroom was unclogged by the maintenance department . CRHS will ensure that the residential site will be cleaned and disinfected on an everyday basis in all areas regardless of the area being utilized or not. |
10/22/2020
| Implemented |
| 6400.64(e) | The kitchen garbage can is approximately 2 ½ to 3 feet high and did not have a lid on it. | Trash receptacles over 18 inches high shall have lids. | The kitchen garbage can was replaced immediately. CRHS will ensure that moving forward that all the garbage cans will have a lid on them if they are at least 18 inches high. |
10/22/2020
| Implemented |
| 6400.67(a) | In the upstairs second bedroom, the left closet right accordion door was off the track. The blinds on the middle bay window in the kitchen had a broken slat at the bottom. The upstairs second bedroom walls had multiple spots of varying size brown substance that was splattered across it. | Floors, walls, ceilings and other surfaces shall be in good repair. | The upstairs second bedroom closet was fixed and put back on track. The blinds in the kitchen windows were replaced with brand new ones. The second bedroom wall was wiped cleaned. CRHS is to ensure that the residential site is clean at all times in all areas regardless of it being utilized or not. The staff have been made aware that maintenance needs are to be reported immediately to the management team which includes any damage around the home however big or small. |
11/12/2020
| Implemented |
| 6400.67(b) | In the upstairs second bedroom, on the wall located under the window next to the bed the outlet was missing an outlet cover. The exposed outlet creates a safety hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The outlet cover in the wall was replaced. CRHS is to ensure that safety is a priority in all the residential sites. Moving forward staff are to report anything that might appear as safety issue so that it will be attended to immediately. |
11/12/2020
| Implemented |
| 6400.18(a)(4) | Abuse is to be reported within 24 hours through the department's Enterprise Incident Management (EIM) system. On 10/20/2020, during interviews it was brought up that in September 2020, as the exact date is unknown, an alleged incident of psychological abuse occurred. Staff in the home were allegedly having a verbal altercation and waiving a knife around while Individual #1 and another individual from another home were at the site visiting. The incident was reported to management in September but was not entered into EIM or reported on a Department issued form until 10/31/2020. | 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.
| The incident entered was reported to Administration on 10/31/20 by the county. The management team met and discussed that moving forward anything that is reported by any individual or staff that might appear to be psychological as big or small, will be entered into EIM so that it can be investigated. The accused staff are also to be removed immediately pending investigation. On 12/1/2020, the management team and staff were trained on Incident Management by the Advocacy Alliance. |
12/01/2020
| Implemented |
| 6400.18(a)(5) | Individual #1 requires 2:1 supervision with line of sight supervision with no alone time while in the home. House Supervisor, Staff #6, has witnessed Individual #1 being upstairs, and 2 unknown staff being downstairs, leaving her unsupervised. According to Individual #1's 7/1/2020-6/30/2021 ISP "Individual #1 has used many kitchen items to harm herself and cannot be left alone or out of staff's sight for any periods of time. Individual #1 also has a history of saying she is going to go into one room but will sneak off to another room or go outside or use a common household item to harm herself. Staff must not believe that Individual #1 is safe in any room by herself (Know and Do)." Her ISP states "staff cannot be on different floors as Individual #1, and Staff must always be able to see Individual #1. This is due to Individual #1's persistent self-injurious behaviors. Individual #1 is unpredictable, and her mood can change from one minute to the next (General Health and Safety Risks). These incidents of neglect of supervision were not reported in the Enterprise Incident Management system. | 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:
Neglect.
| All staff were re-trained on the ISP while emphasizing on the supervision levels. The supervisor was also re-trained on her job duties such as reporting to her immediate supervisor in regards to incidents that need to be entered in the EIM. The incidents were reported immediately the administration were made aware on 10/17/20. CRHS will continue to inform and coach staff on the importance of recognizing and reporting incidents. CRHS administrative team and staff were trained on incident management on 12/1/20 by the advocacy alliance. |
12/01/2020
| Implemented |
| 6400.32(c) | Individual #1's safety needs were neglected at this residence. Staff report Individual #1 started receiving 2:1 staffing 24 hours/day on 10/14/2020. Prior to 10/14/2020, she received 2:1 staffing 16 hours/day (8am-12am). According to Individual #1's 7/1/2020-6/30/2021 ISP, she requires 2:1 supervision with line of sight supervision with no alone time while in the home. Individual #1 has used many kitchen items to harm herself and cannot be left alone or out of staff's sight for any periods of time. Individual #1 also has a history of saying she is going to go into one room but will sneak off to another room or go outside or use a common household item to harm herself. Staff must not believe that Individual #1 is safe in any room by herself (Know and Do)." Her ISP states "staff cannot be on different floors as individual #1, and Staff must always be able to see Individual #1. This is due to individual #1's persistent self-injurious behaviors. Individual #1 is unpredictable, and her mood can change from one minute to the next (General Health and Safety Risks). Both staff were to have line-of-sight supervision except for when Individual #1 was in the bathroom. During interviews, several staff reported that, at times, 1 staff would be with individual #1 while the other staff would be elsewhere in the house. Staff #10 is the Program Specialist and stated she instructed staff that both did not have to be physically present with Individual #1 at all times. Individual #1 was neglected as her supervision needs were not being met according to her Individual Support Plan. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Staff were trained on the Individual #1 ISP on 10/22/20 . During the ISP training, the importance of individual supervision levels was discussed and clarified especially since the ISP was not consistent. Staff provided the supervision levels as directed on the ISP until team meeting was held to discuss other options. On 10/27/20, Individual #1 team inclusive of SCO started the discussion of the supervision levels to be revised. The team continuously met until supervision levels were finally revised as everyone agreed. The staff were made aware of the changes and it was also reflected on the RPP. |
11/06/2020
| Implemented |
| 6400.50(a) | Staff #6 was hired on 9/20/2020. There is no orientation record for her. | 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. | All the staff are to complete an orientation prior to working with the individuals alone. CRHS is to ensure that at least 24hr shadowing is completed as part of the orientation.
((Staff #6 no longer works for the agency -CH 12/15/20)) |
10/24/2020
| Implemented |
| 6400.51(b)(1) | Person-centered practices, community integration and supporting individuals to maintain & develop relationships were not included in the orientations for Staff #3, Staff #4, Staff #5, Staff #7, Staff #8 and Staff #9. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | CRHS will ensure that staff moving forward will be orientated following the new updated documentation as a guide that is equipped with all requirements from DHS as per the 6100/6400 Regulations. All new employees will complete 24hr shadowing as part of the orientation prior to working alone with the individual. |
11/17/2020
| Implemented |
| 6400.51(b)(3) | Staff #3, Staff #4, Staff #5, Staff #7, Staff #8 and Staff #9 were not trained on all of the rights of an individual as per this Chapter. | The orientation must encompass the following areas: Individual rights. | The individual rights documentation previously provided by the agency was updated and given to staff to read and review. CRHS will ensure that all staff prior to working with individuals alone will read and review the individuals Rights and choice during orientation. Individual Rights and Choices training will also be part of the annual training requirement. |
12/07/2020
| Implemented |
| 6400.51(b)(5) | Staff #8 was hired on 7/6/2020. All training documentation sent to licensing is for another home operated by this agency. Staff #8 was not trained on job-related knowledge and skills relating to Individual #1. | The orientation must encompass the following areas: Job-related knowledge and skills. | Staff #8 completed orientation in another residential site prior to working with Individual #1 on. CRHS will ensure that staff moving forward will be orientated following the new updated documentation as a guide that is equipped with all requirements from DHS as per the 6100/6400 Regulations. All new employees will complete 24hr shadowing as part of the orientation prior to working alone with the individual.
((Staff #8 has been trained on the needs of Individual #1 -CH 12/15/20)) |
12/07/2020
| Implemented |
| 6400.52(c)(3) | Staff #1 and Staff #2 were not trained in all individual rights as per this Chapter. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff #1 completed training on Individual Rights through ODP on 3/31/2020 and Staff #2 completed CDS Individual Rights online training on 7/1/2020 . The individual rights documentation previously provided by the agency was updated and given to staff for review. CRHS will ensure that all staff prior to working with individuals alone will read and review the individuals Rights and choice during orientation. |
12/07/2020
| Implemented |
| 6400.52(c)(5) | Staff #1, Staff #2, Staff #3, Staff #4, Staff #5, Staff #6, Staff #7, Staff #8, Staff #9, and Staff #10 were not trained on the Behavior Support Plan developed created on 9/22/2020 or 10/14/2020. | 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. | A BSP training was developed and sent to the CRHS Team on 10/14/20. The team reached out to the BSP team and discussed the delay of sending the completed Behavior Supported Plan. CRHS will ensure that the contracted Behavioral Specialist team will provide any BSP's or any updates regarding any individual as soon as possible. A training was scheduled on 10/30/20 and staff were trained by the designated Behavioral Specialist. |
10/30/2020
| Implemented |
| 6400.186 | The agency failed to implement Individual #1's Individual Support Plan (ISP). According to Individual #1's 7/1/2020-6/30/2021 ISP, Individual #1 requires 2:1 supervision with line of sight supervision with no alone time while in the home. "Individual #1 has used many kitchen items to harm herself and cannot be left alone or out of staff's sight for any periods of time. Individual #1 also has a history of saying she is going to go into one room but will sneak off to another room or go outside or use a common household item to harm herself. Staff must not believe that Individual #1 is safe in any room by herself (Know and Do)." The ISP states "staff cannot be on different floors as Individual #1, and Staff must always be able to see Individual #1. This is due to Individual #1's persistent self-injurious behaviors. Individual #1 is unpredictable, and her mood can change from one minute to the next (General Health and Safety Risks). The House Supervisor, Staff #6, reports that she has made pop unannounced visits to the home and the staff on shift are not provided 2:1 staffing. Individual #1 was upstairs, and the 2 staff were downstairs which did not follow the supervision plan in the ISP. | The home shall implement the individual plan, including revisions. | Staff were trained on the Individual #1 ISP on 10/22/20 . During the ISP training, the importance of individual supervision levels was discussed and clarified especially since the ISP was not consistent. CRHS also reached out the SCO to discuss the supervision levels to get clarity. The team agreed for supervision levels on the ISP to be revised so it can give clarity to the staff, supervisors and management for easier implementation. CRHS will ensure that after a team meeting, the program specialist will continuously follow up with the SCO to confirm the changes and any update required on the ISP. |
10/27/2020
| Implemented |