Clear in Home Care, Pllc (king)

Client 1's Individual Instruction and Support Plan (IISP) lacked documented instructions for transfers, infectious disease prevention, and pica support.

Functional Assessment (FA) was not completed regarding emotional outbursts, assault, or specific physical restraint holds used on the client.

Provider failed to ensure documented monitoring of physical restraints, failed to record duration of each instance of restraint, and failed to provide documented instruction for continuous observation during physical restraint.

Provider did not have a documented refusal plan in place for intermittent medication refusal.

Provider failed to maintain Incident Reports for two emergency room visits related to self-injurious behavior.

Provider failed to ensure a physical-intervention training curriculum and a system for appropriate staff training were in place for interventions used on Client 1.

Provider failed to document that the client's legal representative was provided with information about anticipated benefits and safety risks of using medical devices (stroller/wheelchair belt, gait trainer strap, arm splints).

Provider failed to ensure national fingerprint background checks were completed for three sampled staff members.

Provider failed to document proposed intervention strategies and obtain necessary approvals before implementing restrictive procedures/physical restraints for Client 1.

Provider failed to ensure physical interventions were only used after less restrictive techniques were proven insufficient and documented as required for Client 1.

Provider failed to report injury of unknown origin (3-inch scratch) and alleged neglect (inadequate hygiene/care) to the Complaint Resolution Unit (CRU).

Provider failed to document twice-daily environment checks for a client with a history of pica, despite requirements in their support plan.

Provider failed to document proposed intervention strategies, termination criteria, or documentation plans before implementing restrictive procedures (arm splints and physical holds).

Provider failed to ensure their physical intervention techniques system included all required components, resulting in implemented physical interventions lacking proper documentation and oversight.

Provider failed to document restrictive physical interventions prior to implementation and failed to determine/document client's legal representative notification preferences.