Steps Toward Independence INC

The provider failed to ensure required health-services support for 3 of 4 sampled clients. Client 1 lacked documented repositioning and physical-therapy exercise tracking, missed an annual dental examination, and had unclear instructions for using albuterol inhaler and nebulizer medications. Clients 3 and 4 lacked documentation of medical follow-up and support, including follow-up after hospital or emergency-care visits, implementation of prescribed care, and medical documentation.

Client 2's MARs included a mirtazapine entry without frequency or December administration records, later entries without clear supporting documentation, and conflicting information regarding whether the medication was prescribed or discontinued.

MARs contained incomplete or inaccurate medication information, including unnamed medications, missing administration frequency, unclear medication instructions, and a mirabegron dose recorded as 500 mg instead of the prescribed 50 mg.

The provider failed to report alleged staff-to-client neglect and/or client-to-client verbal abuse to the Complaint Resolution Unit for three of four sampled clients. The incidents involved Clients 1, 3, and 4 and included alleged neglect, threats, verbal abuse, and potential financial exploitation.

Client 1's January 2026 MAR and Client 4's September 2024 and July 2025 MARs were missing. The provider could not produce the records when requested, preventing verification of medication administration.

The provider failed to obtain the Client 2 legal representative's signature on the most current individual financial plan dated 2025-03-06.

Client 1's property records did not include a complete list of possessions valued at $75 or more and/or identifying or serial numbers.

The provider failed to ensure Client 1's release-of-information forms specifically identified the records authorized for transfer or exchange.

The provider failed to ensure required home safety measures for 3 of 4 sampled clients. Client 1's household water temperatures exceeded the 120°F limit, and documentation was missing for move-in water-temperature checks and fire/evacuation drills for the household shared by Clients 3 and 4.

Twenty-five medication refusal forms for Client 2's progesterone were all dated 02/13/2026 rather than the individual dates refusals occurred. Staff acknowledged refusal documentation was not completed accurately.

The provider did not provide records and other relevant client information to department evaluators in a timely manner for all four sampled clients. Responses were delayed six to eleven working days and, in some cases, required prompting.

The provider failed to ensure dignity and consideration for three of four sampled clients and the co-tenants of Clients 3 and 4. Findings included inadequate follow-up, unaddressed home disrepair, and bedroom windows being frosted without documented necessity, creating potential psychosocial harm and rights violations.

Bedroom windows for Clients 3, 4, and 5 were fully covered with frost film even though the clients' support plans did not require frosted windows. The provider had difficulty removing the film, and portions remained on the windows.

Complete refusal plans were not documented for Clients 1, 3, and 4. Records lacked required descriptions of refusals, documented explanation of benefits and risks, provider efforts to obtain services, health or safety concerns, and required six-month reviews and signatures.

The provider failed to ensure Client 3's positive behavior support plan was implemented and contained clear required information. The plan lacked clear descriptions of actions staff should take to prevent target behaviors, and records did not document staff efforts to follow the plan during incidents involving supervision, sexual/personal boundaries, elopement, internet use, and potential financial exploitation.

PRN medications were marked as administered without documenting the reason given and/or the result or response for multiple clients and dates.

For 2 of 4 sampled clients (Clients 3 and 4), provider-managed client funds were not reconciled and/or verified monthly as required. Several food and cash ledgers were unsigned, lacked running balances, or contained undetected or uncorrected math errors.

The provider failed to reimburse Client 1 for three late fees incurred on bills paid from the provider-managed bank account.

The provider failed to obtain the Client 2 legal representative's signature on the provider-issued loan agreement dated 2025-03-01.

The provider failed to ensure required community protection home-site documentation was provided to DDA before Client 3 moved into the current home. Documentation addressing the home's suitability, restrictions, security precautions, and required approval was not shown to have been submitted or approved before the move.

The provider failed to implement Client 3's Community Protection Treatment Plan as written. A pet reptile was present and handled without documentation of prior treatment-team approval, and an exterior door alarm required by the plan was not functioning. The provider also lacked documentation of regular alarm testing.

Medication records for all four clients were missing one or more staff initials and corresponding full names in the identifier key, making staff who documented medication administration difficult or impossible to identify.

The provider failed to ensure IISPs were properly developed and maintained for Clients 1, 3, and 4. Plans lacked references to applicable support and service information and detailed instructions for providing health and safety, relationship-based social, protection, and exceptional-behavior supports.

For 2 of 4 sampled clients (Clients 3 and 4), the provider failed to maintain current running balances and/or retain receipts for purchases over $25. Client 3 had missing, inaccurate, or incomplete food and cash ledgers. Client 4 had inaccurate or incomplete monthly ledgers and missing receipts for purchases of $26.10 and $80.60.

PRN medication records lacked administration times and/or AM/PM identifiers, preventing verification that medications were administered within prescribed frequency limits.

Medication administration records for four clients frequently lacked staff initials for scheduled medications, often without an explanation. Interviews indicated staff forgot to document medication support and lacked consistent shift-change documentation checks.

Client 2's meloxicam administration was inconsistently documented. The medication was missing from the November 2025 MAR, and October 2025 MAR documentation did not show daily staff administration support from 10/17/2025 through 10/31/2025. No documentation explained the discrepancies.

The provider failed to maintain complete and accurate records of medications administered, assisted with, monitored, or refused for all four sampled clients. Records included missing staff initials, incomplete PRN documentation, missing medication administration record identifier keys and MARs, inaccurate refusal and administration documentation, undocumented medication-time changes, missing topical medication labels, and failure to document medication removal or missed doses.

For Client 1, the provider lacked documentation of informed decisions, current physician orders, and written staff instructions for safe use of the wheelchair safety belt, Hoyer lift, gait belt, and bed rails. This created potential safety risks.

For all 4 sampled clients, the provider lacked adequate medication-administration safeguards. Findings included medication administration outside prescribed time windows without appropriate health-professional approval, missing documentation for routine removal of medicated skin patches, medications administered without required support or contrary to prescriber instructions, and a prescribed medication lacking a pharmacy-prepared label.

Current background checks were not maintained within the required 36-month period for two of six sampled staff members, Staff A and Staff E. The provider identified the lapse during the evaluation and reran the checks.

The home shared by Clients 3 and 4 had a missing kitchen drawer front, missing kitchen cupboard door, missing hallway bathroom vanity mirror panel with exposed dried adhesive, and two upper-floor hallway ceiling light fixtures without covers. The provider could not document support for obtaining landlord or other assistance to address the repairs.

The provider failed to ensure 1 of 1 clients had a current Positive Behavior Support Plan (PBSP) on-site. Staff were using an outdated 04/16/2024 version instead of the current 04/10/2025 version, resulting in inaccurate support information available to staff and potential risk of unmet behavior management needs.

Provider failed to maintain safe water temperatures below 120F in homes of Client 1, 2, and 5; also noted maintenance issues including mold, missing caulk, torn carpet, and a missing floor tile.

Provider failed to ensure Client 1's Individual Financial Plan was signed and dated.

Provider failed to obtain current Release of Information (ROI) consents signed by Client 1.

Provider failed to ensure required alarms were functional on the door and window of a Community Protection Level-6 client (Client 7).

Provider failed to obtain written agreement/signatures for the IISP from three of six sampled clients (Client 2, 3, and 6).

Provider failed to ensure 3 of 3 clients requiring 24-hour supervision had the required staffing levels, placing clients at risk.