| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | At 12:10PM, there were not screens in the windows in Individual #1's bedroom. | Screens, windows and doors shall be in good repair. | The Maintenance Director replaced the screen that had been pushed out of the window, by the individual in residence on morning of the unannounced inspection upon notification, immediately. The Clinical Director will submit photographic proof via email of the screen installation upon submission of this Plan of Correction to the Licensing Representative.
The House Manager and Assistant House Manager will receive instruction from the Maintenance Director on the proper installation of window screens and will be trained on the 6400.72(b) regulation requirement and agency expectation of compliance by the Clinical Director and proof of this training will be emailed to the Licensing Representative upon completion. |
08/04/2023
| Implemented |
| 6400.18(a)(5) | On 6/2/23, multiple agency staff members including direct service workers and administration staff became aware of an allegation of neglect, for exposure to marijuana and not following supervision levels. The incident of neglect was not reported in the Enterprise Incident Management, the Department's information management system, until 6/15/2023. In June 2023, multiple agency staff became aware of a suspected violation of individual rights, when Individual #1 was reportedly upset following Direct Service Worker #4 assisting Individual #1 with hair cutting and grooming. As of 7/14/2023, the allegation has not been reported in the Enterprise Incident Management, the Department's information 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.
| The allegation of neglect ¿ failure to provide protection from hazards in relation to suspected marijuana use was filed in Enterprise Incident Management on 6/15/2023 (Incident #9232986) when Liberty Holding Company administration was first made aware of the allegation from Administrative Entity staff. This incident was investigated thoroughly, and the administrative review was completed on 6/29/2023 with an ¿inconclusive¿ determination. This determination was verbally substantiated during a virtual meeting conducted on 7/25/2023 with the AE Director of ID/DD programs, the AE Incident Management Coordinator and the representative from Adult Protective Services. The corrective action for this investigation ¿ to permanently separate the identified target from Liberty Holding Co¿s employment was carried out on 6/29/2023.
The allegation of neglect ¿ failure to provide needed supervision was filed in Enterprise Incident Management on 6/15/2023 (Incident #9232981) when Liberty Holding Company administration was first made aware of the allegation from Administrative Entity staff. This incident was investigated thoroughly, and the administrative review was completed on 6/29/2023 with a ¿confirmed¿ determination. This determination was verbally substantiated during a virtual meeting conducted on 7/25/2023 with the AE Director of ID/DD programs, the AE Incident Management Coordinator and the representative from Adult Protective Services. The corrective action for this investigation ¿ to educate Individual #1 on his right to live in a trauma free environment to include the right to notify staff/administrators immediately if/when he¿s ever in a situation where he feels unsafe or scared was completed by the Program Specialist on 7/5/2023. Additionally, all currently assigned staff to Individual #1 were retrained on his supervision care needs as outlined in his ISP, restrictive procedure and accompanying fade plan as well as documentation expectations by the Program Specialist on 7/7/2023.
The allegation of a rights violation ¿ privacy, was filed in Enterprise Incident Management on 7/14/2023 (Incident #9247635) as soon as ODP personnel informed the Clinical Director of the evidence found in a service note in the earlier part of June 2023. This allegation is still currently under investigation and the determination and corrective action will be shared with the Licensing Representative once the provider administrative review is completed and corrective action carried out. |
08/09/2023
| Implemented |
| 6400.32(c) | Individual #1's Individual Plan, updated 5/17/23, reads; "Staffing supports are 2:1 to ensure Health/safety needs are being met. [Individual #1] has a history of eloping and taking objects that do not belong to him. [Individual #1] should never be left home alone or unsupervised. Throughout, May 2023 and June 2023, reportedly, Individual #1, was permitted to walk around the block of his home, including on 5/25/2023, during a "house meeting" when Individual #1 was walking around the block unsupervised for three minutes. On 6/2/23, Direct Service Worker #1 transported Individual #1 to an Adult Gaming Center where Direct Service Worker #1 was the only staff person providing supervision to Individual #1 from approximately 12:00AM to 7:00AM. In addition, during this time, Direct Service Worker #1 left Individual #1 unsupervised in the agency vehicle while Direct Service Worker #1 met with unknown persons outside of the Adult Gaming Center. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | The Residential Program Specialist retrained all currently assigned house staff on individual #1¿s supervision care needs as outlined in his ISP, restrictive procedure plan and accompanying fade plan as well as documentation expectations by 7/7/2023 ¿ proof of this training will be emailed to the Licensing Representative upon submission of this Plan of Correction. |
08/11/2023
| Implemented |
| 6400.166(a)(10) | Omeprazole Dr 40mg., Aripiprazole 20mg., Clonazepam .5 mg., Divalproex Dr 500mg., Loratadine Tab 100mg., and Propranolol 20mg., prescribed to Individual #1, were initialed by Direct Service Worker #2 as being administered at 8:00AM on 6/2/2023; however, these medications were administered by Direct Service Worker #2 at 9:30AM on 6/2/2023. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Direct Service Worker #2 amended the Medication Administration Record to accurately reflect the time of medication administration on 6/2/2023 and proof of that record will be scanned and emailed to the Licensing Representative upon submission of this Plan of Correction. Direct Service Worker #2 is also being retrained on the Medication Administration curriculum and proof of that training will also be submitted to the Licensing Representative upon completion. |
08/11/2023
| Implemented |
| 6400.166(b) | Omeprazole Dr 40mg., Aripiprazole 20mg., Clonazepam .5 mg., Divalproex Dr 500mg., Loratadine Tab 100mg., and Propranolol 20mg., prescribed to Individual #1, were initialed by Direct Service Worker #2 as being administered at 8:00AM on 6/2/2023; however, these medications were administered by Direct Service Worker #2 at 9:30AM on 6/2/2023. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Direct Service Worker #2 amended the Medication Administration Record to accurately reflect the time of medication administration on 6/2/2023 and proof of that record will be scanned and emailed to the Licensing Representative upon submission of this Plan of Correction. Direct Service Worker #2 is also being retrained on the Medication Administration curriculum and proof of that training will also be submitted to the Licensing Representative upon completion. |
08/11/2023
| Implemented |