PRINTED: 02/27/2018 DEPARTMENT OF HEALTH AND ...valid driver's license and she did not possess...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

PREFIX

TAG

IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

AURORA, IN 47001

15G326 02/08/2018

VOCA CORPORATION OF INDIANA

9 SUMMIT DR

00

W 0000

Bldg. 00

This visit was for a fundamental recertification

and state licensure survey.

Survey Dates: February 5, 6, 7 and 8, 2018

Facility Number: 000844

Provider Number: 15G326

AIM Number: 100243650

These deficiencies also reflect state findings in

accordance with 460 IAC 9.

Quality Review of this report completed by #15068

on 2/14/18.

W 0000

483.410(a)(1)

GOVERNING BODY

The governing body must exercise general

policy, budget, and operating direction over

the facility.

W 0104

Bldg. 00

Based on record review and interview for 8 of 8

clients living in the group home (#1, #2, #3, #4, #5,

#6, #7 and #8), the facility's governing body failed

to exercise operating direction over the facility by

failing to ensure staff #5 did not drive the group

home van due to not having a valid driver's

license.

Findings include:

On 2/5/18 at 1:20 PM, a review of the facility's

employee files was conducted. Staff #5's 12/14/17

MVR (motor vehicle record) Standard indicated

her license was suspended from 2/9/16 to 1/20/19.

On 12/21/17, staff #5 signed a Non-Driver

Acknowledgement indicating she did not have a

valid driver's license and she did not possess

automobile insurance. The acknowledgement

W 0104 W104: The governing body

must exercise general policy,

budget and operating

direction over the facility.

Corrective Action:

·Human Resources will

complete an Orientation

Spreadsheet on all new hires

and send to all Management

staff as new staff are hired.

There is a column on the

spreadsheet detailing any

02/26/2018 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: G7BP11 Facility ID: 000844

TITLE

If continuation sheet Page 1 of 22

(X6) DATE




02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00

included the following, "I Cannot Transport

clients or provide transportation services for

clients."

On 2/5/18 at 4:55 PM, the Area Supervisor (AS)

indicated staff #5 transported clients #1, #2, #3,

#4, #5, #6, #7 and #8 using the group home van.

The AS indicated she was not aware staff #5 had

a suspended license. The AS indicated neither

the office nor staff #5 informed her of staff #5's

suspended license. The AS indicated she

received a spreadsheet routinely indicating

whether or not staff could drive the group home

van. The AS indicated she did not recall staff #5

being unable to drive the clients in the van. The

AS indicated staff #5 drove herself to and from

work in her personal vehicle. The AS indicated

she was unaware of staff #5's suspended license.

On 2/7/18 at 11:49 AM, the Qualified Intellectual

Disabilities Professional assistant indicated in an

email, "I have verified with HR that [staff #5] does

not have a valid drivers license, in her file it does

show that she signed a job driving agreement

stating she would not drive. The driving policy is

in her file and signed by [name of Executive

Director]."

On 2/7/18 at 12:24 PM, the Human Resources

Specialist (HRS) indicated staff #5 was aware

when she hired in (on 12/21/17) she had a

suspended license. Staff #5 signed a non-driver

acknowledgement indicating she did not have a

valid license. The HRS indicated staff #5 should

not be driving the clients in the group home van

due to not having a current license. The HRS

stated although a spreadsheet was sent out

indicating the staff who was able to drive or not,

there was a "typo" indicating staff #5 could drive.

specifics Management

needs to know regarding the

new hire.


send an email to all

Management regarding any

restrictions for the new hires.

(Attachment A)

·All new hires with driving

restrictions will sign the

Non-Driver

Acknowledgement.

(Attachment B)

·Staff #5 received a

corrective disciplinary action

for signing the Non-Driver

Acknowledgement and

continuing to drive the

company

vehicle.(Attachment C)

How we will identify

others:


notify all Management via

email when a new hire has a

driving restriction.

·New Hire will sign the

Non-Driver

acknowledgement upon hire.


send out the Orientation

Spreadsheet listing all new

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G7BP11 Facility ID: 000844 If continuation sheet Page 2 of 22




02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00

9-3-1(a) hires with any restrictions

noted for the new hire.

Measures to be put in

place:


send out the Orientation

Spreadsheet listing all new

hires with any restrictions

noted for the new hire.

·New hires with restrictions

will sign the Non-Driver

Acknowledgement form.


notify all Management via

email when a new hire has a

driving restriction.

Monitoring of Corrective

Action:


have the new hire sign the

Non-Driver

Acknowledgement form

upon hire and place it in the

new hire file.

·Human Resource

Coordinator will send out the

new hire Orientation

Spreadsheet to all





02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00

Management as new hires

are hired which will include

any driving restrictions the

new hire has.

·Human Resource

Coordinator will notify all

Management via email when

a new hire has a driving

restriction.

Completion Date: 2-26-18

483.420(d)(1)

STAFF TREATMENT OF CLIENTS

The facility must develop and implement

written policies and procedures that prohibit

mistreatment, neglect or abuse of the client.

W 0149

Bldg. 00


incident/investigative reports reviewed affecting

clients #1, #3, #4, #5, #6 and #8, the facility failed

to implement its policies and procedures to

prevent incidents of abuse and client to client

aggression.

Findings include:

W 0149 W149: The facility must

develop and implement

written policies and

procedures that prohibit

mistreatment, neglect or

abuse of the client.

02/26/2018 12:00:00AM





02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00

On 2/5/18 at 12:30 PM, a review of the facility's

incident/investigative reports was conducted and

indicated the following:

1) On 2/12/17 at 1:55 PM, staff #8 smacked client

#5 open handed on the right shoulder blade. No

injuries were noted.

An investigation was completed and staff #8 was

terminated due to a substantiated allegation of

physical abuse.

2) On 2/12/17 at 8:05 PM, client #6 walked by

client #3 and struck him on the upper back. No


3) On 3/20/17 at 8:00 AM, client #5 reported client

#4 reached over and touched his "bad spot" while

they were in the van on the way to the day

program. Client #5 was sitting next to client #4

and client #4 reached over and touched client #5

in the private area. Client #5 reported the incident

to staff after client #4 was dropped off at the day

program. No negative effects were noted. An

investigation was completed and indicated the

following: the seating arrangement in the van was

changed, client #5 was previously assessed as

making inappropriate sexual comments and had a

BSP (Behavior Support Plan) and goal to address,

and the team continued to monitor client #4 and

client #5.

4) On 6/20/17 at 11:30 AM, day program staff

reported client #3 yelled at a peer and threw his

walker and belongings at the peer. No injuries

were noted.

5) On 7/7/17 at 2:15 PM, day program staff

reported client #3 was struck by a peer twice. No


Corrective Action:

·All staff trained on the

Abuse/Neglect Policy and

Client Rights. (Attachment

D)

·At any time there is an

allegation of abuse, neglect

or mistreatment a reportable

incident is completed and

sent to the IDT, guardian,

APS and BDDS.

·Rescare policy states with

any allegation of abuse,

neglect or mistreatment staff

will be suspended

immediately and an

investigation is completed.

(Attachment E)

·All staff retrained on all

consumer’s Behavior

Support Plans.

(Attachment D)

·All day program/workshop

will be trained on Rescare’s

Abuse and Neglect Policy.

(Attachment F)






02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00

6) On 7/13/17 at 12:00 PM, while at day program,

client #3 yelled at client #1 telling him to get out of

his way. Client #3 stepped on client #1's foot.

Client #1 initially reported a sore ankle, but after

applying ice it was not sore.

7) On 7/18/17 at 2:00 PM, day program staff

reported client #3 became agitated and threw

shredded paper all over the floor. Client #3 struck

a peer in the stomach with a closed fist. Client #3

then struck staff in the arm three times. No


8) On 7/25/17 at 9:05 AM at the day program,

client #3 ran his walker into a peer's walker. The

peer struck client #3 on the buttocks with a closed

fist. Client #3 threw a spoon at the peer. No


9) On 8/30/17 at 1:30 PM at the day program,

client #1 was verbally aggressive towards a peer.

No injuries were noted.


client #3 walked past a peer and threatened him by

stomping his feet on the floor. Client #3 held his

fists up and swung and hit the peer in the

stomach. No injuries were noted.

11) On 10/5/17 at 5:30 PM, client #3 yelled at

client #8 to get out of the bedroom. Later, after

dinner, client #8 was preparing to take a shower

and forgot to lock the door. Client #3 went in to

the bathroom to wash his hands. Client #3 became

upset when client #8 told him to leave the

bathroom. Client #3 struck staff in the chest and

eye then dumped the trash can and continued the

verbal and physical aggression. Staff called 911

and client #3 was transported to the hospital due

to continued aggression.

others:

·Staff are trained monthly

on reporting policies of

Abuse, Neglect or

Mistreatment during monthly

staff meetings.


staff will be trained on

Rescare’s Abuse and

Neglect Policy.

·Human Resources will be

notified immediately when an

allegation is made and

accused staff will be

suspended pending an

investigation.

·Quality Assurance

department will complete an

investigation about the

allegation.

·Once the investigation is

complete and the allegation

is substantiated Human

Resources will terminate

employment for the accused

staff.

·QIDP-D will revise and

train all behavior Support

plans annually and as

needed.





02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00


client #3 struck a peer with his walker causing the

peer to fall to the floor.

13) On 11/6/17 at 5:15 PM, client #3 grabbed a

picture off of the wall and threw it causing the

glass to shatter. Client #3 pushed his walker into

client #8's stomach, leaving a red mark on client

#8's stomach. 911 was called and client #3 was

transported to the hospital due to continued

aggression.

On 2/5/18 at 1:07 PM, the Program Manager was

interviewed and she indicated client to client

aggression was abuse and the facility should

prevent abuse of the clients. The Program

Manager indicated the facility had a policy and

procedure prohibiting abuse of the clients.

On 2/5/18 at 12:19 PM, a review was conducted of

the facility's Abuse, Neglect, Exploitation

Operation Standard, dated 7/18/11. The policy

indicated, "CASC (Community Alternatives South

Central) staff actively advocate for the rights and

safety of all individuals... ResCare strictly

prohibits

abuse/neglect/exploitation/mistreatment...."

9-3-2(a)


place:

·All staff will follow Abuse,

Neglect reporting policy and

will be trained monthly on the

policy.

·Allegations will be

reported to BDDS, APS and

the IDT within 24 hours of the

allegation.

·Human Resources will be

notified immediately upon

receiving an allegation of

abuse, neglect or

mistreatment.

·Quality Assurance will

conduct an investigation on

the allegation.

· If an allegation is

substantiated the staff will be

terminated from

employment.

·QIDP-D will revise and

train all Behavior Support

Plans annually and as

needed.


staff trained and will follow

Rescare’s Abuse and

Neglect Policy.






02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00

Action:

·The Area Supervisor will

notify Human Resources

immediately when an

allegation is made.


suspend the alleged staff

immediately.


notify BDDS, APS and the

IDT within 24 hours of the

allegation.


conduct an investigation and

review with Program

Managers, AED, Human

Resource Manager and

Executive Director.

·All trainings on Behavior

Support Plans will be sent to

Training Coordinator and

Human Resources.

·QIDP-D will review Abuse

and Neglect Policy at day

program/workshop annually

and as needed.






02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00

483.460(a)(3)(i)

PHYSICIAN SERVICES

The facility must provide or obtain annual

physical examinations of each client that at a

minimum includes an evaluation of vision and

hearing.

W 0323

Bldg. 00


clients in the sample (#3 and #4), the facility failed

to ensure the clients had annual evaluations of

their hearing.

Findings include:

On 2/6/18 at 12:29 PM, a review of client #3's

record was conducted. Client #3's record did not

include documentation his hearing was evaluated

during the past 12 months (January 2017 to

January 2018).

On 2/6/18 at 1:32 PM, a review of client #4's record

was conducted. Client #4's record did not include

documentation his hearing was evaluated during

the past 12 months (January 2017 to January

2018).

On 2/6/18 at 2:23 PM, the Qualified Intellectual

Disabilities Professional (QIDP) indicated the

clients should have had a hearing evaluation

upon admission and every 2-3 years or as

recommended by the audiologist.

9-3-6(a)


provide or obtain annual

physical examinations of

each client that at a minimum

includes and evaluation of

vision and hearing.

Corrective Action:

·Nurse scheduled a

hearing evaluation for client

(3) (Attachment G)

·Nurse scheduled a

hearing evaluation for client

(4) (Attachment H)


others:

·Weekly checks are

completed by the Nurse to

ensure all appointments are

in compliance. (Attachment

I)

02/26/2018 12:00:00AM





02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00


place:

·Site Supervisor will ensure

all appointments are

scheduled according to

client need.

·Nurse will complete a

weekly check during visits to

the home to ensure all

appointments are scheduled

and completed as

scheduled.

·Site Supervisor will send

all appointments scheduled

to the Area Supervisor for

monitoring of completion.

·Area Supervisor will send

all appointments scheduled

to the Program Manager for

monitoring of completion.


Action:


all clients are taken to

appointments as scheduled.

·Area Supervisor will

monitor all upcoming

appointments and remind

the Site Supervisor.

·Nurse will send weekly





02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00

check to the Nurse Manager,

Area Supervisor and

Program Manager for

monitoring and to ensure

completion.


483.460(f)(2)

COMPREHENSIVE DENTAL DIAGNOSTIC

SERVICE

Comprehensive dental diagnostic services

include periodic examination and diagnosis

performed at least annually.

W 0352

Bldg. 00


clients in the sample (#4), the facility failed to

ensure client #4 had an annual dental examination.

Findings include:


was conducted. Client #4's most recent dental

examination was conducted on 10/25/16. In the

Return Visit section, the dentist documented, "Pt.

(patient) may need a root canal treatment." There

was no documentation client #4 had another

dental examination since 10/25/16.


Disabilities Professional (QIDP) stated client #4

"should have been" back to the dentist. The

QIDP indicated she was not sure why a follow up

appointment was not conducted. The QIDP

stated client #4 should have dental examinations

"at least annually."

9-3-6(a)


ensure comprehensive

dental treatment services

that include dental care

needed for relief of pain and

infections, restoration of

teeth and maintenance of

dental health.

Corrective Action:


all appointments are

02/26/2018 12:00:00AM





02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00

scheduled in a timely

fashion.

·Nurse completes weekly

audits to ensure all medical

appointments are scheduled.

(Attachment I)

·QIDP-D will update IDT on

routine and referral

appointments and follow ups

via email.

·Nurse scheduled dental

visit for client (4)

(Attachment J)

·QIDP-D will review


while completing monthly

summaries on all

consumers. (Attachment K)


others:

·Site Supervisor will

schedule all routine and

referral appointments in a

timely fashion.

·Nurse will complete

weekly checklist.

·QIDP-D will update the

IDT on routine and referral


via email.






02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00



summaries on all consumers


place:

·All appointments will be

scheduled timely by the Site

Supervisor.

·Nurse Manager will

complete weekly checklist to

ensure all appointments

have been scheduled and

completed.


IDT and guardian on routine

and referral appointments

upon completion.


appointments at follow ups


summaries on all

consumers.

·Dental exam is scheduled

for client (4) (Attachment J)


Action:





02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00


checklist to the Nurse

Manager, Area Supervisor

and Program Manager

weekly upon completion.

·Program Manager will be

included on all

communication about

appointments.

·Nurse Manager will be

included on all

communication about

appointments.

·Site Supervisor will send

monthly calendar of

appointments to the Area

Supervisor for monitoring

and to ensure completion.

·QIDP-D will send

completed monthly

summaries to the Program

Manager for review.






02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00

483.460(g)(2)

COMPREHENSIVE DENTAL TREATMENT

The facility must ensure comprehensive

dental treatment services that include dental

care needed for relief of pain and infections,

restoration of teeth, and maintenance of

dental health.

W 0356

Bldg. 00


clients in the sample (#2 and #4), the facility failed

to ensure clients #2 and #4 received dental care as

recommended by the dentist.

Findings include:

1) On 2/6/18 at 1:32 PM, a review of client #4's

record was conducted. Client #4's most recent

dental examination was conducted on 10/25/16. In

the Return Visit section, the dentist documented,

"Pt. (patient) may need a root canal treatment."

There was no documentation client #4 had

another dental examination since 10/25/16.


Disabilities Professional (QIDP) stated client #4

"should have been" back to the dentist. The

QIDP indicated she was not sure why a follow up

appointment was not conducted.

On 2/7/18 at 11:15 AM, the QIDP indicated there

was no documentation the root canal was

completed.

2) On 2/6/18 at 12:30 PM, a review of client #2's

record was conducted. Client #2's 9/21/17

ResCare Consultation Report indicated client #2

needed to be placed on a three month periodontal

maintenance recall to maintain his oral health. The

report indicated an appointment for a cleaning

was to be scheduled in three months. There was

writing on the form indicating an appointment was


ensure comprehensive

dental treatment services

that include dental care

needed for relief of pain and

infections, restoration of

teeth and maintenance of

dental health.

Corrective Action:


all appointments and follow

ups are scheduled in a timely

fashion.

·Nurse completes weekly

audits to ensure all medical

appointments are scheduled.

(Attachment I)

·QIDP-D will update IDT on

routine and referral


via email.


02/26/2018 12:00:00AM





02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00

scheduled for 3/26/18 at 11:00 AM. There was no

documentation in the record indicating client #2

returned to the dentist for a three month follow-up

appointment as recommended by the dentist.

On 2/6/18 at 2:45 PM, the QIDP (Qualified

Intellectual Disabilities Professional) indicated

client #2 should have returned to the dentist in

December 2017. The QIDP indicated client #2 did

not have the recommended follow-up

appointment.

9-3-6(a)

exam for client (4) for

(Attachment J)


exam for client (2) for

(Attachment L)

·QIDP-D will review all



summaries on all

consumers. (Attachment K)


others:


schedule all routine and

follow up appointments in a

timely fashion.

·Nurse will complete

weekly checklist to ensure all


are current and scheduled.


IDT on routine and referral


via email.




summaries on all

consumers.





02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00


place:

·All appointments and

follow ups will be scheduled

timely by the Site Supervisor.

·Nurse Manager will

complete weekly checklist to

ensure all appointments

have been scheduled and

completed.


IDT and guardian on routine,

follow up and referral

appointments upon

completion.




summaries on all

consumers.


Action:


checklist to the Nurse

Manager, Area Supervisor

and Program Manager

weekly upon completion.

·Program Manager will be

included on all

communication about





02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00

appointments.

·Nurse Manager will be

included on all

communication about

appointments.

·QIDP-D will send

completed monthly

summaries to the Program

Manager for review.


483.460(k)(2)

DRUG ADMINISTRATION

The system for drug administration must

assure that all drugs, including those that are

self-administered, are administered without

error.

W 0369

Bldg. 00

Based on observation, record review and

interview for 2 of 19 medications administered to

clients #4 and #8, the facility failed to ensure the

clients' medications were administered as

prescribed by the physician.

Findings include:

1) On 2/5/18 during the 3:25 PM to 5:40 PM

observation in the group home, staff #7

W 0369 W369: The facility for drug

administration must assure

that all drugs, including those

that are self-administered

are administered without

error.

02/26/2018 12:00:00AM





02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00

administered client #4's Ziprasidone (for anxiety)

40mg (milligram) pill at 4:20 PM. On 2/5/18 during

the 3:25 PM to 5:40 PM observation in the group

home, client #4 was not observed to eat food at

any time.

On 2/5/18 at 4:20 PM, client #4's February 2018

MAR (medication administration record) was

reviewed. The MAR indicated client #4's

Ziprasidone was to be administered with food.


was conducted. Client #4's 12/20/17 physician's

orders were reviewed. The order indicated one

Ziprasidone 40 mg capsule was to be given with

food at 4:00 PM.

On 2/6/18 at 1:42 PM, the QIDP (Qualified

Intellectual Disabilities Professional) Assistant

was interviewed. The QIDP Assistant indicated

the physician's orders needed to be followed and

the medication should be administered as written.

2) On 2/6/18 during the 5:55 AM to 7:45 AM

observation in the group home, staff #3

administered client #8's Omeprazole (for

GERD/gastroesophageal reflux disease) 40 mg pill

at 6:15 AM.

On 2/6/18 from 5:55 AM to 7:45 AM, an

observation was conducted in the group home.

At 5:55 AM, client #8 was observed sitting at the

dining room table eating a bowl of cereal.

On 2/6/18 at 6:15 AM, client #8's February 2018

MAR was reviewed and indicated Omeprazole 40

mg was to be administered every morning before

breakfast.


Corrective Action:

·All staff retrained on

medication administration.

(Attachment M)

·All staff trained on Client

(4) medication and

directions on administering

his Ziprasidone.

(Attachment M & D)

·All staff trained on Client

(8) medication and

directions on administering

his Omeprazole.

(Attachment M & D)


medication error.

(Attachment N)


medication error.

(Attachment O)


observe 2 med passes a

week.


observe 1 med pass per

week.

·Nurse will observe 1 med

pass per week.


others:





02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00

was conducted. Client #8's 1/2/18 physician's

orders were reviewed and indicated the following:

give one capsule by mouth every morning before

breakfast for GERD.

On 2/6/18 at 6:50 AM, staff #3 indicated client #8's

Omeprazole should have been administered prior

to breakfast. She indicated it was a hectic

morning and she forgot to give it to him before he

ate.

On 2/6/18 at 1:42 PM, the QIDP Assistant was

interviewed. The QIDP Assistant indicated the

physician's orders needed to be followed and the

medication should be administered as written.

9-3-6(a)


conduct med pass

observations.



week.


pass per week.

·Nurse trained all staff on

proper medication

administration.


place:


conduct med pass

observations.

·All staff trained on

medication administration

and directions for

administering


conduct med pass

observations.



week.


pass per week.





02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00


Action:


conduct med pass

observations 2 times a week

for no less than 30 days.


complete med pass

observations 1 time a week

for no less than 30 days.

·Nurse will complete med

pass observations 1 time a

week for no less than 30

days.

·Site Supervisor will report

any issues with medication

administration to the Area

Supervisor, Program

Manager and Nurse

immediately.

·Nurse retrained all staff on

medication administration,

training sent to the Program

Manager.






02/27/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


AURORA, IN 47001

15G326 02/08/2018


9 SUMMIT DR

00


Date post:	26-Mar-2021
Category:	Documents
Upload:	others
View:	1 times
Download:	0 times

PRINTED: 02/27/2018 DEPARTMENT OF HEALTH AND ...valid driver's license and she did not possess...

Documents