Community Living (yakima County)

Provider failed to implement policies by restricting a client from leaving their living room using a dresser as a physical barrier, violating client rights.

Provider failed to prevent the use of unauthorized restrictive procedures (barricading a client with a dresser) which was not listed in any support plans.

Provider failed to complete a functional assessment and positive behavior support plan including interventions for prevention of assaults or injuries to others for a client whose person-centered service plan indicated such support was necessary.

Provider failed to complete a functional assessment that included assault or injury to others for one client, resulting in staff not having instruction to prevent such behaviors despite the client's person-centered service plan indicating a need for extensive behavior supports.

The provider failed to update and implement an Individual Instruction and Support Plan (IISP) for a client who fell while being transported in a wheelchair because staff failed to secure the required lap belt.

The provider failed to update and implement an Individual Instruction and Support Plan (IISP) to include the use of a wheelchair lap belt. Consequently, staff failed to secure the belt, leading to the client falling out of the wheelchair and sustaining a fractured finger and bruising.

Provider failed to implement emergency policy and procedures for a client, resulting in a delay in recognizing a medical emergency and accessing 911 services, which contributed to the client's death.

Provider failed to implement 2-person staff assistance for a medical appointment and failed to revise/update the IISP regarding a client's chronic bowel condition and prescribed lactose-free diet.

Provider failed to immediately report alleged abuse or neglect for five sampled clients (Client 8, 9, 11, 13, and 14) to the Complaint Resolution Unit (CRU).

Provider failed to provide required health support, resulting in a duplicate medication dose for Client 8, excessive protein consumption for Client 11, and incomplete fluid intake tracking for Client 12.

Provider failed to complete a functional assessment for Client 12 within 45 days of identifying new target behaviors including burning property, trespassing/theft, and evading two-hour staff checks.

Provider failed to ensure a safe home environment; Client 11 had food safety issues and Client 12 had an inoperable smoke detector and fire hazards in the home.

Provider failed to implement and document support plans for Clients 11 and 12, specifically regarding two-hour checks, medication, and safety plans.

Provider failed to document required Refusal Plans for Client 12 regarding home cleanliness, safety with sharps, and the use of a smoke detector.

Provider failed to ensure clients' rights regarding privacy (removal of doors/curtains for Client 8), access to food (Client 11), and personal property (Client 14) were respected.

Provider failed to ensure the Positive Behavior Support Plan (PBSP) was clear and implemented regarding a restrictive sharps-securing program; staff were unsure which items required locking and a sharp tool was found unsecured.

Provider failed to ensure clients' rights were considered; interior doors were removed without consent, access to certain foods was restricted, and personal items were hidden by staff.

Provider failed to ensure safe/healthy environment for two clients, resulting in food safety concerns, fire safety concerns (non-operating smoke detector), and unattended household environment.

Provider failed to ensure requirements for IISP development/implementation, including lack of documentation for required support checks and failure to follow safety plans.

Provider failed to complete a functional assessment for Client 12 within 45 days of identifying new target behaviors including burning property, trespassing, theft, and misuse of sharps.

Provider failed to immediately report alleged abuse or neglect of five sampled clients to the Complaint Resolution Unit (CRU).

Provider failed to ensure the Positive Behavior Support Plan was clear and consistently implemented; staff were unsure of policy, and sharp objects were found unsecured in the home despite the plan.

Provider failed to ensure health service supports for three clients, resulting in medication errors, excessive protein consumption, and lack of tracking for fluid intake.

Provider failed to ensure requirements for client refusal were met regarding physical/safety services, including lack of Refusal Plans and failure to notify case manager.