Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.18(a)(7) | Individual #1, who could be in jeopardy if missing at all, eloped from the provider's supervision on 09/10/2022 and was unable to be located and retrieved by the provider until 09/16/2022. Although the provider reported the individual as a missing person to the local police department on 09/11/2022, the provider did not enter a missing person incident report into Department's information management system until 09/14/2022.
While evidence supports the provider's claim that they faced technical issues preventing digital entry of the incident within the regulatory time frame, the Incident Management Bulletin (IM Bulletin) outlines a procedure and provides a form for providers to utilize in such a scenario. Should technical issues occur that prevent digital entry of an incident, providers are instructed to complete and submit a physical "Services for Individuals with an Intellectual Disability or Autism Incident Report form" within the regulatory time frame and follow up by entering the incident digitally as soon as the technical issue is resolved. The provider did not complete and submit a "Services for Individuals with an Intellectual Disability or Autism Incident Report form" for this incident within 24 hours of discovery by a staff person as required. | 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:
An individual who is missing for more than 24 hours or who could be in jeopardy if missing at all. | Reporting incidents in timely manner is important for the safety of all our individuals and it creates awareness to all stakeholders at large. While it was evidentially true that there were technical difficulties with the EIM system on 09/10/2022 through till the problem was resolved on 09/14/2022, the incident should have been entered via paper version. The agency has added a second incidents point person as a backup to the incident manager on 09/27/2022 for contingency. The incidents manager has also printed out the paper version of the incidents forms so that incase of any technical difficulties they will be able to report via the form. |
10/14/2022
| Implemented |
6400.32(c) | The iteration of Individual #1's Individual Support Plan (ISP) that was in effect at the time of Individual #1's elopement on 09/10/2022 stated, "[Individual #1] HAS A HISTORY OF STEALING AND NEEDS EYE SIGHT [sic] SUPERVISION IN HIS HOME TO HELP AVOID SITUATIONS WHICH MAY CAUSE HIM TO BE ARRESTED." Individual #1 reports "ducking out" the back door while Staff #1 was assembling furniture in another room. Staff #1 reports that Individual #1 went to his bedroom, but did not respond to being called which was when Staff #1 noted Individual #1 was no longer in the home. Both Individual #1 and Staff #1 are in agreement that Individual #1 was out of Staff #1's line of sight at the time the elopement occurred. The provider's failure to provide the needed level of supervision for Individual #1 in the form of line-of-sight supervision in the home constitutes neglect of the individual. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | As the regulation stated that an individual may not be neglected, the safety and welfare of our individuals are the outmost priority of our agency. The staff person used his best judgements at the time of the incident by waiting for the individual to go to his room before he went to the staff bathroom. However, the individual was able to use that time to elope. The agency has taken immediate action to protect our individual agency wide. The team (ICL&P, SCo and Elder Care Solutions Inc.-legal guardian) met on 9/15/2022 to discuss measures our agency has recommended to protect the individual from future elopement. We wrote and emergency RPP, window and door alarms, and increased staffing to 2:1 ratio 24/7 to help prevent wandering and elopement. These measures can potentially help reduce the incidence and severity of elopements. |
09/27/2022
| Implemented |
6400.186 | The iteration of Individual #1's Individual Support Plan (ISP) that was in effect at the time of Individual #1's elopement on 09/10/2022 stated, "[Individual #1] HAS A HISTORY OF STEALING AND NEEDS EYE SIGHT [sic] SUPERVISION IN HIS HOME TO HELP AVOID SITUATIONS WHICH MAY CAUSE HIM TO BE ARRESTED." Individual #1 reports "ducking out" the back door while Staff #1 was assembling furniture in another room. Staff #1 reports that Individual #1 went to his bedroom, but did not respond to being called which was when Staff #1 noted Individual #1 was no longer in the home. Both Individual #1 and Staff #1 are in agreement that Individual #1 was out of Staff #1's line of sight at the time the elopement occurred. The provider's failure to provide the needed level of supervision for Individual #1 in the form of line-of-sight supervision in the home constitutes neglect of the individual. By allowing Individual #1 out of eyesight in the home, Staff #1 failed to implement the Individual Support Plan. | The home shall implement the individual plan, including revisions. | Implementation of the individual¿s plans are essential to the protection and safety of the individual. As the above regulation stated, our agency has taken immediate action to protect the safety and welfare of our individual. The staff person went to the bathroom, before going to the bathroom the individual went to his room and after he came out, he noticed that the individual was not in his room. We as provider and the rest of the individual teams (ICL&P, SCo and Elder Care Solutions Inc.-legal guardian) met on 9/15/2022 to discuss measures to protect the individual from future elopement. We wrote and emergency RPP, window and door alarms, and increased staffing to 2:1 ratio 24/7 to help prevent wandering and elopement. These measures can potentially help reduce the incidence and severity of elopements. |
09/27/2022
| Implemented |