Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00224624 Unannounced Monitoring 05/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The window in the second-floor bathroom on the right side of the hallway was painted shut and could not be opened. Additionally, there was no mechanical ventilation in the room.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The window in the second floor bathroom was fixed by the Property Manager so that it can open and close. 05/26/2023 Implemented
6400.67(a)Pipes, faucet and knobs in the shower of the second-floor bathroom on right side of the hallway were not properly secured. When attempting to turn on water the pipes, faucet and knobs would move within the wall and visibly in and out of the surface of the shower.Floors, walls, ceilings and other surfaces shall be in good repair. The faucet, knobs, and pipes were secured in the second floor bathroom by our Property Manager. 05/26/2023 Implemented
6400.67(b)The surface of the handrail to the first landing of the basement steps appeared to be a rough one inch by three-inch rectangular piece of wood. The surface was roughly cut on the ends leaving splinters on the surface. The sides and top of the wood were not sanded leaving many small pieces of the wood capable of splintering and causing injury. At time of inspection Licensing Representative attempted to use the handrail and was poked with one of the splintering pieces of wood. In the second-floor bathroom on right side of the hallway the handheld shower head bracket was broken and the piece missing, causing the showerhead to not sit securely in the bracket creating the potential for it to fall onto an individual as are they are showering. Floors, walls, ceilings and other surfaces shall be free of hazards.A new handrail for the basement steps were installed and the surface of the new handrail is free of any hazards. The showerhead bracket on the second-floor was fixed so that the showerhead is secure and free from hazards. 05/26/2023 Implemented
6400.166(a)(4)At time of inspection the May 2023 Medication Administration Record (MAR) included an entry for GNP Antacid. The antacid available for use for Individual #4 was a bottle of Mintox Maximum Strength Susp which does not match the label of "Mintox Maximum Strength Susp" with a generic name on the label or the generic identifier on the label "Mag Hydrox/aluminum hyd/sim." Dosage instructions for both medications were the same. The name on the Mar was incorrect. (REPEAT VIOLATION 4/23)A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.The MAR was fixed so that the name of the medication on the label matches the name of the medication on the MAR. 06/09/2023 Implemented
SIN-00222343 Unannounced Monitoring 04/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(e)At the time of inspection there was two garbage cans in the kitchen. One was a large garbage can that was comparable to an outdoor garbage can with a lid secured to the top. There was a second garbage can to the right of the back door which was a kitchen size garbage receptable. This garbage did not not have a lid and it was 18 inches or higher.Trash receptacles over 18 inches high shall have lids. New garbage and recycling containers with lids were purchased to replace the ones without the lids. The ones without the lids were disposed of by the Program Supervisor. 04/17/2023 Implemented
6400.144Individual #1 is prescribed mupirocin 2% ointment to be used twice a day as needed for infection. At the time of the inspection this ointment was not available in the home. The home did not provide prescribed pharmaceutical services as prescribed.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. The prescribed ointment was returned to the home by individual #1's mother, who had it at her house since individual #1 stayed there for a home visit recently and she forgot to return the ointment with the other prescribed medications. 04/17/2023 Implemented
SIN-00217608 Unannounced Monitoring 01/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The laminate flooring in Individual #3's bedroom at the food of their bed had a hole that was approximately 1 foot long and 4 inches wide with pieces of the flooring sticking up and presenting a hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.The laminate flooring was repaired in Individual # 3's bedroom at the foot of their bed by the property manager on 1/13/2023. 01/13/2023 Implemented
SIN-00214654 Unannounced Monitoring 10/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions are not being maintained in the home. There was grease spattered over the ceiling in the kitchen. The ceiling fan in Individual #2's bedroom was covered in a significant amount of dust. There were several piles of debris located on the floor of the attic that appear to have been swept into piles but were not disposed of. (Repeat Violations 6/7/22 and 9/16/22)Clean and sanitary conditions shall be maintained in the home. The grease on the ceiling in the kitchen and the ceiling fan in Individual # 2's bedroom was cleaned by the direct support professionals working at the home. The debris in the attic was also cleaned. The Program Supervisor also assisted. 11/16/2022 Implemented
6400.163(h)Individual #1 is prescribed SSD 1% ointment, apply small amount topically to burn on forehead twice a day as needed. This medication expired on 10/4/2022 and was still in the home.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The Program Supervisor ordered the medication that was expired after she was notified that it was expired on 10/28/22. The expired medication was disposed of. The prescribed SSD 1% ointment is now available in the home for Individual #1. 10/28/2022 Implemented
6400.166(a)(11)Individual #1 is prescribed Levothyroxine sodium 112 take 2 tablets by mouth daily. The medication record did not include the diagnosis or purpose for the medication, including pro re nata.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.After discovery that the Levothyroxine sodium was missing a diagnosis, the Program Supervisor wrote in the diagnosis for the Levothyroxine sodium on the medication record on 10/28/22. 10/28/2022 Implemented
6400.166(c)Individual #1 is prescribed Levothyroxine sodium 112, give 2 tablets by mouth daily, Lamotrigine 25mg tablet, give 1 tablet by mouth twice daily; Levetiracetam 1,000mg, give 2 tablets by mouth twice daily; Famotidine 20mg tablet, give 1 tablet by moth twice daily; Lamotrigine 200mg tablet, give 1 tablet by mouth twice daily; Metformin HCL 500mg tablet, give 1 tablet by mouth twice daily; Propranolol ER 120mg capsule, give 1 capsule by mouth twice daily; Clobazam 20mg tablet, give 1 tablet by mouth twice daily; and Olanzapine ODT 15mg tablet, give 2 tablets at bedtime. All of the morning medications which are administered at 10AM were documented as sleeping on 10/9 and 10/11/22 and all of the evening or bedtime medications which are administered at 7PM were documented as sleeping on 10/25/22. Staff indicated that they Individual #1 is a very heavy sleeper and difficult to wake and will often not wake to take medications resulting in medication refusals.If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.The MARs were corrected to reflect the refusals on 10/9/22, 10/11/22, and 10/25/22. The Program Supervisor contacted Individual # 1's prescribing doctor to retrieve a refusal for his medications in case he refuses in the future. 11/17/2022 Implemented
SIN-00211532 Unannounced Monitoring 09/16/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The basement of the home had an overwhelming amount of spiderwebs and cobwebs. These webs covered all parts of the ceiling in every room in the basement. As the Licensing Representative did the walk through they were constantly walking through spiderwebs from room to room. (REPEAT VIOLATION 6/2022)Clean and sanitary conditions shall be maintained in the home. The Property Manager cleaned the basement from all spiderwebs and cobwebs on 9/17/22. 09/17/2022 Implemented
6400.66There was a side entrance to the home which led to the basement steps and or a door into the kitchen. The exit door did not have a light to ensure safety.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The Property Manager installed a light fixture at the side entrance/exit on 9/17/22. 09/17/2022 Implemented
6400.67(a)At the time of inspection, the upstairs bathroom has a large hole behind the door which was partially covered and partially broken pieces of tile which was hazardous. The mirror above the sink as well as the window both had a lot of chipping paint which was not in good repair. (REPEAT VIOLATION 6/22)Floors, walls, ceilings and other surfaces shall be in good repair. The hole behind the door was fixed on 9/17/22 and the mirror above the sink & window was repainted by the Property Manager. 09/17/2022 Implemented
6400.72(a)Individual #5 had no screens in her bedroom windows. There were also no screens in the kitchen windows. The bathroom window also did not furnish a screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. The screens were affixed in the windows for the bedroom and bathrooms by the property manager on 9/17/22. Measurements were taken for the kitchen windows which are currently plexiglass and need to be replaced with windows that open to allow screens to be installed. This will be installed once the windows arrive by the Property Manager. 09/17/2022 Implemented
SIN-00206347 Renewal 06/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The caulking around the bathtub located in the upstairs main bathroom had a black substance resembling mold or mildew. (Repeat Violation 6/29/21)Clean and sanitary conditions shall be maintained in the home. The bathtub located in the upstairs main bathroom was recaulked by the property manager on 7/6/22. 07/06/2022 Implemented
6400.67(a)5 of the wooden blind slats located in the living room window were missing. Surfaces shall be in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. The wooden blinds were removed and replaced by curtains on 7/6/22 by the property manager. 07/06/2022 Implemented
6400.112(c)The 5/27/22 fire drill record did not document whether the fire alarms were operative as this section of the form was left blank.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The section that was left blank by error was filled in by the person that conducted the drill on 5/27/22 who attests to the smoke detectors being operable on that date. 07/06/2022 Implemented
6400.44(c)(3)Staff #3 who is the Program Specialist does not meet the specific qualifications. Staff #3 completed 34.5 credit hours from Fortis Institute and 22 credit hours from Luzerne County Community College for a total of 56.5 credit hours.A program specialist shall have one of the following groups of qualifications: An associate's degree or 60 credit hours from an accredited college or university and 4 years of work experience working directly with individuals with an intellectual disability or autism.Staff # 3 is currently enrolled in college and is taking 6 credits worth of classes in order to become a Program Specialist in the future. She will have the 6 credits completed on 08/11/2022 which will make her credit total 62.5 and will be able to resume her role as a Program Specialist. 07/05/2022 Implemented
6400.51(b)(1)Staff #3 did not receive orientation training on application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.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.Staff # 3 completed the person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships training on 6/10/22. The trainer also updated the orientation syllabus to include this training for future new hires. 06/10/2022 Implemented
SIN-00194540 Unannounced Monitoring 09/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The thermostat cover in the living room was broken off exposing wires and metal. The wall sconce light fixtures located on the enclosed front porch had been removed leaving the electrical boxes open and exposing wires. Both presented a hazard.Floors, walls, ceilings and other surfaces shall be in good repair. On 9/9/21, the property manager fixed the thermostat cover in the living room and covered the holes that were left from the broken wall sconce light fixtures. The property manager ensured that there are no exposed wires left uncovered to prevent any hazards. 09/09/2021 Implemented
6400.82(f)The two bathrooms located on the second floor of the home did not contain soap or individual towels.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. The Program Supervisor made sure to place paper-towels and soap by each sink of the upstairs bathrooms after discovering that they were not there. 09/09/2021 Implemented
6400.166(b)"Omeprazole 20mg Take 1 capsule by mouth twice a day 30 minutes before a meal" was present in the home and being administered to Individual #1. The medication and medication administrations were not recorded on the medication administration record (MAR) for Individual #1 as required.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Omeprazole 20 mg was added to the medication administration record by the Program Supervisor after the discovery that it was not on the monthly medication administration record for individual #1. 09/08/2021 Implemented
6400.186On the day of inspection, Staff #1 and Staff #2 left the home to go into the community with Individuals #1, #2 and #3. As written in their Individual Support Plans (ISP) Individual #1 and #3 are to be supervised as 1:1 while in the community. Individual #2 is to be line of sight while in the community. All supervision levels were not properly supported nor implemented as outlined in the ISPs while in the community as two staff could not properly provide 1:1 support to Individual #1 and Individual #3 while also providing supervision for Individual #2.The home shall implement the individual plan, including revisions.Provider contacted SC via email and asked that the 1:1 verbiage be removed from the ISP's to reflect the recent updates to both individuals' BSP's and the removal of staffing ratios. The changes were made in the respective ISP's on 9/17/21. 09/17/2021 Implemented
SIN-00189358 Renewal 06/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At the time of the inspection, the backyard pool was being used by an individual and a staff person. The water in the pool was very cloudy and the bottom of the pool could not be seen. The owner of the home stated to another staff person that he had turned the pump/filter off and would turn it back on later. The pool was not filtered and maintained properly causing the water to become cloudy and dirty which is a health and safety risk to individuals using the pool.Clean and sanitary conditions shall be maintained in the home. On 7/8/21, a Pool Maintenance Professional came to inspect the pool and assist in maintaining it. He purchased new filter equipment and chemicals to help maintain the cleanliness of the pool. On 07/15/21, Administrative staff followed up to ensure that the pool remains clean and sanitary. 07/08/2021 Implemented
6400.73(a)The first three steps of the staircase leading from the kitchen to the basement did not have a handrail. (REPEAT VIOLATION, 9/29/2020) Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The Property Manager affixed the handrail back onto the wall on 07/08/21. 07/08/2021 Implemented
6400.81(i)The window facing the side of the house in Individual #2's bedroom did not have a window covering for privacy.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. On 7/8/21, glass frosting was applied to the window facing the side of the house in Individual #2¿s bedroom by the Program Supervisor. 07/08/2021 Implemented
6400.151(c)(4)Staff #1 had a physical examination dated 7/23/2020. The physical examination form did not document if staff has any medical problems or limitations.The physical examination shall include: Information of medical problems which might interfere with the health of the individuals.On 7/8/21, Administrative staff requested that Staff # 1 go back to the physician¿s office to have them evaluate her for medical problems & limitations. However, on 7/12/21, Staff # 1 resigned from her Direct Support Professional position at Independent Living LLC. 07/12/2021 Implemented
6400.32(h)An individual has the right to privacy of person and possessions, including the ability to be nude without being seen by others. At the time of the inspection, a video monitor, requested by and approved by individual #1's mother/legal guardian, was located on the kitchen counter in full view of staff, other individuals residing in the home and licensing staff. Individual #1 was nude in his bedroom and could be seen on the video monitor by anyone passing through the kitchen.An individual has the right to privacy of person and possessions.The staff that is working with Individual # 1 will have the video monitor in their possessions so that he has privacy instead of leaving the monitor on countertops where it is visible to everyone. 07/15/2021 Implemented
SIN-00177105 Renewal 09/29/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The window in the bathroom identified as used by Individual #6 had the bottom half of the window boarded up.Floors, walls, ceilings and other surfaces shall be in good repair. The property manager is replacing the window. A team meeting was held on October 8th 2020 in which we discussed options for plexi glass sheet coverings to be placed over all the windows to prevent further shattering of windows and injuries. A diagram will be created showing all of the windows that need plexi glass sheet coverings to prevent any injuries from occurring and will be submitted for review by the fire department and ODP Licensing before installation of the new plexi glass sheet coverings. The Program Specialist will continuously monitor the windows in the home and will immediately notify the property manager for repairs. 11/06/2020 Implemented
6400.73(a)The first 3 steps going down from the kitchen to the landing prior to descending into the basement does not have a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. A handrail was affixed to the wall where the 3 steps are going down from the kitchen to the landing prior to descending into the basement on 10/07/2020. 10/07/2020 Implemented
6400.101The back door exiting the kitchen had a deadbolt on the door that could only be opened using a key.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The deadbolt on the door that could only be opened using a key was replaced with a deadbolt that can be turned open with a knob on 10/7/2020. 10/07/2020 Implemented
6400.141(a)Individual #6 was admitted on 6/19/20. He did not have a physical completed until 9/15/20.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The CEO will request and receive documentation of physical examinations for individuals referred for residential services prior to being admitted in the future. If the individual does not have a current physical examination, the CEO will request one to be completed prior to the individual's move in date. 10/12/2020 Implemented
6400.141(c)(6)Individual #6 was admitted on 6/19/20. He did not have a TB completed until 9/17/20.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. The CEO will request and receive documentation of completed TB tests for individuals referred for residential services prior to being admitted in the future. If the individual does not have a current TB test, the CEO will request one to be completed prior to the individual's move in date. 10/12/2020 Implemented
6400.211(b)(3)There was no name, address and telephone number of the person able to give consent for emergency medical treatment in Individual #6's record.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. The Program Specialist is updating Individual # 6's records, including the Demographic form and the Emergency Medical Treatment Plan to include the person's contact information, including the name, address, and telephone number, to be able to give consent for emergency medical treatment. Individual # 6's ISP will be updated as well to include this information. 10/16/2020 Implemented
6400.32(r)Individual #6 does not have a lock on his bedroom door.An individual has the right to lock the individual's bedroom door.On 10/7/2020, a team meeting was held including Individual # 6's Supports Coordinator, family, Behavioral Specialist, Direct Support Staff, and Program Specialist. At this time, it was decided that it would be inappropriate to place a lock on Individual # 6's door because of his medical and behavioral needs due to safety concerns regarding his frequent seizures and his past attempts of climbing on to the roof. HIs ISP will be updated to reflect this as well. 10/07/2020 Implemented
6400.34(a)Individual #6 was admitted 6/19/2020. Individual was not educated on rights until 8/25/2020.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The CEO will ensure that each individual is educated on individual rights upon admission into services and annually thereafter. ((An admission checklist was developed to ensure compliance with the regulation. The responsibility to complete the checklist will be that of the CEO or Vice President -CH 10/29/20 as per email from Independent Living CEO)) 10/12/2020 Implemented
6400.166(a)(2)There was no name of the prescribing physician located on Individual #6's Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The Medication Administration Record was corrected to include the Name of the Prescriber by the Program Specialist/Medication Administration Instructor on 10/1/20 for Individual # 6. Also, the Program Supervisor will be monitoring the Medication Administration Log monthly to ensure that the name of the prescriber is listed. 10/01/2020 Implemented
6400.166(a)(10)Individual #6's Vimpat 100mg tabs did not have an administration time listed on the Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.The Program Specialist received written clarification of times to administer Individual # 6's medication by his prescribing doctor on 10/1/20. The Medication Administration Record was corrected on 10/1/20 by the Program Specialist. The Program Supervisor will monitor the Medication Administration Logs monthly upon delivery of her medications to ensure that they are correct. 10/01/2020 Implemented
6400.167(a)(4)Medication errors are occurring due to staff administering medications outside of the 1-hour window before or after the administration time. Individual #6 receives Ziprasidone and Divalproex at 10am and 7pm. Both of these medications were administered outside the 1 hour window on the following dates: 9/3/2020 (8am), 9/8/2020 (8am), 9/12/2020 (11:45am), 9/15/2020 (8:30am), 9/17/2020 (11:30am), 9/18/2020 (11:30am), 9/20/2020 (11:50am), 9/21/2020 (11:45am), 9/28/2020 (8am),9/9/2020 (10pm). Nicholas August receives Vimpat at 9:30am and 7:30pm. This medication was administered outside the 1-hour window on the following dates: 9/27/2020(11am), 9/28/2020(8am).Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time.An EIM was submitted by the Executive Director/Program Specialist on 10/01/2020 regarding all of the medication errors. The HCQU will be training all Direct Support Staff that work with Individual # 6 on 10/21/20 on proper medication administration techniques and protocols. Also, the doctor that prescribes Individual # 6's medications sent the Executive Director/Program Specialist written protocols which includes times of when the medication should be administered. The Executive Director/Program Specialist will continue to monitor that all Direct Support Staff are following the doctor's written protocol and that they are following the Medication Administration Training techniques and protocols. 10/21/2020 Implemented
6400.169(a)Even though staff are trained to pass medications, they are not administering medications to Individual #6 per the department approved Medication Training Course. Individual #6 is prescribed the following medications with no specific time of administration: Ziprasidone 40mg (1 capsule) twice a day, Divalproex Sod. 125mg 6 caps in the am and 8 caps in the pm, Vimpat 100mg (tabs) twice a day, Vimpat 100mg (1/2tab) twice a day, Vimpat 100mg (tab) Take ½ tab in the morning, 1 tab every evening. None of these medications have a specific time for them to be administered. Medications are being administered at various times from day to day which is not in accordance with the Department's Medication Administration Training course.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).All staff members that administer medication to Individual # 6 will be participating in a training session with the HCQU on proper medication administration techniques including times of administration on 10/21/20. The Program Supervisor will monitor monthly that staff are following all of the protocols relating to Medication Administration. 10/21/2020 Implemented
6400.213(1)(i)Individual #6 did not have height, weight, or eye color listed in the record.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number; (ii) the height, weight and eye colorIndividual # 6's demographic records was updated to include the height, weight, and eye color. 10/07/2020 Implemented
SIN-00173836 Unannounced Monitoring 06/25/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(f)The Social, Emotional, Environmental Needs Plan (SEEN) for Individual #1 does not meet the needs of Individual #1. Individual #1 exhibits self-abusive behaviors, specifically hitting himself in the head and banging his head against objects. This behavior causes bruising and abrasions. The SEEN dated 4/10/2020 and as written in the Individual Support Plan 7/1/2020-6/30/2021 does not include strategies to assist Individual #1 during these self-abusive behaviors.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.We have updated the Social, Emotional, Environmental Needs Plan to address Indiividual #1 self-abusive behaviors, specifically hitting himself in the head and banging his head against objects. The support team reviewed the plan to ensure that it is specific and meets his needs. 07/10/2020 Implemented