| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 was sexually abused by Staff #1. In a phone interview conducted 12/30/20, Staff #1 admitted to this Licensing Representative that she had a sexual relationship with Individual #1 sometime between Halloween and Thanksgiving. Staff #1 also admitted to letting Individual #1 drink "a couple glasses of wine" during a Thanksgiving celebration on 11/26/21 at the residence of Staff #1. Individual #1 is prescribed several medications where it is recommended not to consume alcohol. These medications include Lexapro, Latuda, and Depakote. Staff #1 also reported that she drank "a couple of glasses of wine" during this celebration while she was supposed to be providing 1:1 supervision to Individual #1. According to Individual #1's Individual Support Plan, Individual #1 requires 1:1 supervision. Staff #1, after drinking "a couple of glasses" of wine, drove Individual #1 home to his hotel room a trip that takes approximately 20 minutes. Staff #1 neglected the care of Individual #1 by consuming alcohol while she was assigned to provide 1:1 supervision to Individual #1, giving alcohol to Individual #1 who is prescribed several medications where it is recommended alcohol not be consumed, and driving Individual #1 to his hotel room after Staff #1 consumed alcoholic beverages. | 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. | Staff #1 was terminated since December 7th, 2020. The abuse allegations inclusive of all the details were reported to the Bethlehem Police department and the adult protective services. CRHS will ensure and commit to maintaining a workplace free of substance and alcohol abuse. CRHS has updated the employee handbook which includes the revision of Sexual harassments and Substance Abuse. All the employees have been provided the most recently updated handbook. CRHS staff have also been trained on Sexual Health, Personal Relationship , and Substance Abuse which also includes but not limited to prohibiting staff taking individuals to their personal homes or personal community engagement during work hours without prior consent from their supervisors or any part of the management team. |
03/03/2021
| Implemented |
| 6400.144 | Individual #1 is prescribed Lexapro, Latuda, Depakote. It is recommended that alcohol not be consumed while taking this prescribed medications. Staff #1 reported during a telephone interview with this Licensing Representative that on 11/26/20, Staff #1 gave Individual #1 "a couple glasses" of wine. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| - Individual's #1 primary doctor approved for the consumption of 1-2 maximum of alcoholic beverages on
special occasions.
- CRHS team will not encourage alcohol consumption at any given time unless Individual #1 insists. |
12/07/2020
| Implemented |
| 6400.18(a)(4) | Abuse is an incident required to be reported in the Enterprise Incident Management (EIM) system within 24 hours. Individual #1 called Staff #2, who is a Program Coordinator, on 12/26/2020 and reported having sex with Staff #1. This incident wasn't entered into EIM until 12/30/2020. Repeat Violation: 11/12/2020 | 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.
| Staff #2 acknowledged that she read Adult Protective Services PowerPoint presentation from ODP and trained on "Understanding Incident Management Training" on 2/28/21. CRHS staff were all trained on Incident Management by Advocacy alliance on 12/1/2020. CRHS will ensure that this is continuous by committing to train all staff upon hire on Incident Management during orientation and prior to them working alone on shift. Incident management policy executes the importance of reporting incident in a timely manner. CRHS will also add more point persons to ensure that all incidents are reported and in a timely manner. |
02/28/2021
| Not Implemented |
| 6400.186 | Individual #1 requires 1:1 supervision both at home and in the community due to a history of property destruction, aggression, inappropriate sexual behavior and stealing. During a telephone interview conducted 12/30/20, Staff #1 reported to this Licensing Representative that Staff #1 drank a "couple glasses" of wine while assigned to provide 1:1 supervision to Individual #1 on 11/26/2020. Individual #1 was not provided the proper level supervision he requires as per his Individual Support Plan. | The home shall implement the individual plan, including revisions. | - Individual #1 ISP was revised to staffing ratio 1:1 both at home and in the community from 9.00 am to 11.00 pm and 1:2 staffing ratio from 11.00 pm to 9.00 am.
- CRHS involved Behavioral Support Team and staff were trained about individual #1 Behavioral support plan. |
01/13/2021
| Implemented |