The social services watchdog has criticised the HSE for its poor management and maintenance of a residential centre for adults with disabilities in Co Tipperary.
HIQA also found that Damien House in Clonmel failed in its duty to notify HIQA of two serious choking incidents which required residents to be hospitalised.
The HSE-run facility is home to twelve residents with moderate to severe intellectual disabilities.
The inspection on which today's report is based took place at short notice about a month before last Christmas.
HIQA found that the facility was in breach of thirteen of the sixteen regulations it checked.
Inspectors found that the service was not well governed or managed resulting in negative impacts on the residents' quality and safety of care.
A number of residents were keen to tell inspectors they were dissatisfied with the lack of transport to facilitate their preferred activities.
Staff reported requesting that the HSE address some maintenance issues, but HIQA found no evidence of management follow-up.
Not all interventions to restrict residents' freedom were logged, leading the inspectors to criticise the HSE for failing to demonstrate that the least restrictive interventions were in use for the shortest time required.
The report says that, for the most part, the number and skill- mix of available staff was adequate to meet resident's needs.
However, inappropriate deployment was found, for example, when neither of the two staff deemed necessary to attend to one resident was available.
Inspectors were informed that both had gone elsewhere to make the same resident's tea.
The report says the centre relied significantly on agency staff and that, while senior management had said the agency concerned had assured it that all the required documentation was in place for the personnel, the HSE management had not provided any evidence that garda vetting had been completed, for example.
HIQA also criticises that absence of a written protocol between the agency and the centre.
And it complains that the HSE failed in its duty to notify HIQA of two serious choking incidents not long before the inspection, which required residents to be hospitalised.