PRINTED: 04/11/2017 DEPARTMENT OF HEALTH AND …REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391

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 CODE

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(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

EVANSVILLE, IN 47713

15G137 12/09/2016

NORMAL LIFE OF INDIANA

8616 NORTHFIELD DR

00

W 0000

Bldg. 00

This visit was for a recertification and

state licensure survey. This visit included

the investigation of Complaint

#IN00214850.

Complaint #IN00214850: Substantiated.

Federal/state deficiencies related to the

allegation are cited at W149, W154 and

W157.

Dates of Survey: 12/1, 12/2, 12/5, 12/6,

12/7, 12/8 and 12/9, 2016.

Facility Number: 000674

Provider Number: 15G137

AIM Number: 100234390

These deficiencies reflect state findings

in accordance with 460 IAC 9.

Quality Review of this report completed

by #15068 on 12/22/16.

W 0000

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 determined that

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

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 disclosable 14

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: CX2X11 Facility ID: 000674

TITLE

If continuation sheet Page 1 of 37

(X6) DATE




04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

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

Based on record review and interview for

1 of 4 sampled clients (#1), the facility

failed to implement its policy and

procedures to prevent neglect of a client

regarding an allegation of neglect

involving a client who stole a can of dry

duster while shopping with staff at a

retail store.

Findings include:

The facility's Internal Incident reports,

BDDS (Bureau of Developmental

Disabilities Services) reports and

investigations were reviewed on 12/1/16

at 3:00 PM.

A BDDS report dated 11/11/16 indicated

"while at [name of retail store], [client

#1] stole a can of air duster and went to

the restroom and huffed it. [Client #1]

was found in the restroom sitting on the

W 0149 W149- The facility must

develop and implement written

policies and procedures that

prohibit mistreatment, neglect

or abuse of the client.

In order to correct the deficiency

with W149:

- The facility will ensure that

Client #1 Modification of Rights

and BSP are current to include

Line of Sight and Drug Abuse.

- Staff will be retrained on Client

#1 ISP/BSP/ with emphasis on

Line of Sight and drug abuse.

- RM will be retrained on Client #1

01/09/2017 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CX2X11 Facility ID: 000674 If continuation sheet Page 2 of 37




04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

floor huffing the dry duster by the [name

of retail store] cleaning staff. [Client #1]

was in line of sight and staff was waiting

outside of bathroom door on [client #1].

[Client #1] is safe. [Client #1] was

evaluated at [name of hospital] ER

(emergency room). He was diagnosed

with huffing. He had a chest x-ray,

alcohol screen, bmp (basic metabolic

panel - blood test), cbc (complete blood

count - blood test) done and were within

normal limits. A urine drug screen was

performed and results are pending, PCP

(primary care physician), psychiatrist and

counselor at [name of psychiatric facility]

notified. An investigation has been

initiated. Staff [name of staff] has been

placed on administrative leave."

An Investigative Summary completed on

11/12/16 indicated "Scope of

investigation: 1) To determine how

[client #1] acquired the air duster and 2)

to determine if [client #1] was ever out of

the line of sight of staff.

Investigative procedure: Interview client

and staff.

Summary of Interviews:

[Client #1] - [Client #1] stated that he

was with [staff #1] when they went to

[name of retail store] to look at [name of

video game]. They first went to [name of

ISP/BSP/ with emphasis on Line

of Sight and drug abuse.

- QIDP will be retrained on Client

#1 ISP/BSP/ with emphasis on

Line of Sight and drug abuse.

- Area Supervisor will be retrained

on Client #1 ISP/BSP with

emphasis on Line of Sight and

drug abuse.

- Program Manager will be

retrained on Client #1 ISP/BSP/

with emphasis on line of Sight

and drug abuse.

-IDT will be completed with Client

# 1 regarding importance of

following BSP regarding use of

inhalants (drug abuse)

-IDT will be completed with Client

#1 regarding Abuse & Neglect,

Client Rights and feeling Safe in

Home.

Persons Responsible: QIDP,





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

retail store] and they didn't have it and

[name of retail store] was closed. [Client

#1] and [staff #1] were in the CD

(compact disc) section at the east side

[retail store] trying to find it. He walked

to the next aisle and saw the air duster

and put it in his pocket. [Client #1] stated

that he could see [staff #1] and she could

see him. [Client #1] stated that he was

talking to her as he was stealing it so she

wouldn't know what he was doing.

[Client #1] stated that he huffed the air

duster to get high because he did that all

the time when he lived alone. [Staff #1]

took him to the restroom close to the CD

section. She waited outside the restroom

door while he went inside the restroom.

Once he was in the restroom he went into

a stall, sat on the floor and started

huffing. He remembers the cleaning guy

finding him and his staff coming in to the

restroom to talk to him. [Client #1] stated

he knows he shouldn't have stole (sic) it

and huffed but he likes to get high. When

asked if he understands how dangerous it

is to huff, he stated 'yes but it makes me

feel happy.' [Client #1] does feel safe in

the home but once (sic) to live in

supported living back at home not in a

group home. [Client #1] stated that he

does like his staff."

"[Staff #1] - [Staff #1] stated that after

taking clients to [name of day program]

Area Supervisor, Program

Manager, Nurse, Director of

Health Services, and Executive

Director





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

she asked [client #1] if he wanted to go

look for the [name of video game] CD.

[Client #1] had been talking about it for

awhile so she thought it would be a nice

activity to see how much it cost and

where so (sic) that he could purchase it.

They first went to [name of retail store]

but they did not have it. [Client #1]

wanted to go to [name of retail store] but

they were closed. She stated that then she

took him to [name of retail store]. She

stated they walked side by side to the CD

department. We were both in the CD

aisle and couldn't find it. [Client #1]

walked over to the next aisle to see if it

was there. I could see him and we were

talking to one another. He looked like he

was just looking at the items in that aisle.

I followed him and then he said he

needed to use the restroom. I took him to

the restroom by the service desk in the

back of the store by the electronics

department. I sat on the bench right

outside the restroom. A maintenance man

went into the restroom to clean. He came

out a couple of minutes later and at that

time 2 managers were walking back

towards the restroom. I heard the

maintenance man tell the managers that

he (client #1) was sitting on the floor as

they walked into the restroom. The

managers had stated that they had called

911. I asked who they were talking about

because I had a client in the restroom.





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

They wouldn't let me go in at first but

after explaining I was his staff, they let

me in. I went in and [client #1] was

sitting on the floor in front of the toilet.

[Client #1] was conscious but would not

talk or answer any questions by [name of

retailer] staff. I crouched down next to

him and took his hand and asked if he

could get up and he shook his head yes

and replied 'yes'. The [name of retail

store] manager told [client #1] that he

was not pressing charges for theft against

[client #1]. He also told [client #1] that

he had seen someone die in that exact

same position and that he hoped he

learned from this situation. The

ambulance came and transported [client

#1] to [name of hospital]. I stayed with

[client #1] at the hospital until [name of

residential manager] arrived to take my

place.

[Name of Residential Manager] -

[Residential manager] stated that she

received a call from [staff #1] who was

very upset over [client #1] stealing and

huffing at [name of retail store]. Once I

arrived at the hospital, [staff #1] left.

[Client #1] would not talk about what

had happened. [Client #1] was released

from the hospital with no orders.

Factual findings:

--[Client #1] did steal air duster from





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

[name of retail store].

--[Client #1] did huff the air duster.

--[Client #1] was in line of sight of staff.

Conclusion: After review of all

statements and documentation the

investigative committee concludes that it

is substantiated that [client #1] stole air

duster and huffed it in the restroom at

[name of retail store]."

The investigative summary was signed by

the QA (quality assurance) manager and

dated 11/12/16.

An incident report completed on

11/11/16 at 4:30 PM indicated "after

leaving the hospital, [client #1] showed

staff the burn on (his) abdomen. ER

(emergency room) didn't catch it. Took

client to [name of urgent care clinic]."


"[client #1] is going to urgent care to be

evaluated for burn on his upper abdomen

with the coolant from today's incident

which is causing redness and blistering to

the aware (sic). [Client #1] is safe. His

diagnosis is 2nd degree burn abdomen.

Rx (prescription) Silvadene 2% (percent)

ointment BID (twice daily) for 5 - 7 days

ordered and Tylenol #3 (with codeine)

every 4 hours PRN (as needed) for pain.

His PCP (Primary Care Physician) is





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

aware and staff will continue to monitor."

Client #1's record was reviewed on

12/6/16 at 2:00 PM. Client #1's

Modification of Rights component of his

5/18/2016 Behavior Support Plan (BSP)

indicated client #1 should always be in

line of sight and when he is not, he

should be monitored with 15 minute

checks.

Interview with the Associate Executive

Director was completed on 12/9/16 at

3:30 PM. She stated "[client #1] should

always be in line of sight except when he

is in his room sleeping. Then he is on 15

minute checks. This was due to an

incident of elopement on 12/10/15."

Interview with staff #1 was completed on

12/8/16 at 11:45 AM. She stated "we

(client #1 and herself) went to [name of

retail store] to look for a [name of video

game] CD and I stayed in the same aisle

as [client #1] for the short period of time

we were in the store. He then said he had

to go to the bathroom. We went to the

men's restroom near the electronic

department. When [client #1] went inside

to use the restroom, I waited and sat on a

bench located near the door to the

restroom. After several minutes, a cleaner

went into the bathroom and no much

longer past that, I saw what looked like





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

two managers go in. I tried to find out

what was going on but only after I

explained I was his staff did they talk

with me. They told me that he had stolen

a can of air duster and was found huffing

it by the cleaning guy who then called the

managers. They (the managers) said due

to the situation with [client #1] being a

[name of facility] client, they wouldn't

press charges of stolen property. One of

the managers told us (me and [client #1])

that he had a similar incident happen one

time there and the person died from

huffing the can of air duster. The

managers had already called 911 and

[client #1] was taken by ambulance to the

hospital. I then called [residential

manager] and told her what had happened

and she met us at the hospital."

Review of the facility's undated

Abuse/Neglect/Exploitation policy was

completed on 12/08/16 at 4:30 PM. The

policy indicated "to ensure that all

allegations of abuse/neglect, exploitation

and death are reported and investigated as

required by regulations, local state,

federal and [Name of Facility] guidelines.

Although all staff are instructed and

encouraged to used the internal reporting

system outline within this procedure,

staff may contact APS (Adult Protective

Services] directly if at any time they

believe these procedures are not being





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

followed as required. Any act of

abuse/neglect/exploitation is strictly

prohibited and will not be tolerated. All

employees received training upon hire

regarding definitions of different types of

abuse/neglect, how to identify

abuse/neglect/exploitation, how to report

it and what to expect from an

investigation. All employees receive this

training upon hire and annually,

thereafter.

This federal tag relates to complaint

#IN00214850.

9-3-2(a)





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

483.420(d)(3) W 0154





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00


The facility must have evidence that all

alleged violations are thoroughly

investigated.

Bldg. 00



failed to conduct a thorough investigation

of an allegation of neglect. The facility

failed to determine in the investigation

why the client was not in "line of sight"

when his plan indicated he should be.

Findings include:





at 3:00 PM.
















W 0154 W154

- The facility must have evidence

that all alleged violations are

thoroughly investigated.

- QA will be retrained on

conducting a thorough

investigation in regards to all

alleged violations and assure

review within 5 days of the

incident.

- Program Manager will be

retrained on ensuring the QA’s

are conducting a thorough

investigation in regards to all

alleged violations and assure

review within 5 days of the

incident.

-The Executive Director shall

assure through review of

incidents and investigations to

assure proper documentation and

review occurs within 5 days. Any

issues shall be dealt with through

ResCare policy and procedure.

01/09/2017 12:00:00AM





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00
















and staff.




















Director





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00










huffing. He remembers the cleaning guy






is to huff, he stated 'yes but it makes me






"[Staff #1] - [Staff #1] stated that after
















04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00














outside the restroom. A maintenance man

went into the restroom to clean. He came
























04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00











place.










Factual findings:








is substantiated that [client #1] stole air







04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00



dated 11/12/16.






client to [name of urgent care clinic]."


"[client #1] is going to urgent care to be













12/6/16 at 2:00 PM. Client #1's




line of sight and when he is not, he

should be monitored with 15 minute

checks.





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00



3:30 PM. She stated "[client #1] should









game] CD and I stayed in the same aisle

as [client #1] for the short period of time

we were in the store. He then said he had

to go to the bathroom. We went to the

men's restroom near the electronic





went into the bathroom and no much
















04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00










The QA (Quality Assurance) Manager

was interviewed on 12/8/16 at 3:00 PM.

When asked why she indicated client #1

was in line of sight during the entire

11/11/16 huffing incident involving

client #1, she stated "I realized after I

completed the investigation he (client #1)

was in line of sight only during the time

when he and staff were shopping for the

game CD. I just realized that he wasn't in

line of sight while he was in the men's

bathroom huffing the air duster."


#IN00214850.

9-3-2(a)





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

483.420(d)(4)


If the alleged violation is verified, appropriate

corrective action must be taken.

W 0157

Bldg. 00



failed to take appropriate corrective

action in regards to preventing potential

future incidents of huffing.

Findings include:



W 0157 W157: If the alleged violation is

verified, appropriate corrective

action must be taken.

In order to correct the deficiency

with W157:

- All staff will be retrained on the

01/09/2017 12:00:00AM





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00



at 3:00 PM.






























Abuse Neglect Exploitation Policy

and Procedures.

- QA Coordinators will be

retrained on the initiating

investigations and having them

completed within 5 business days

and the final investigation will be

sent to the Executive Director.

- QA Managers will be retrained

on ensuring all approved

recommendations are completed

or submitted to HR for corrective

action.

- The QA Manager will follow up

with the QA Coordinator at least

weekly to ensure that all incidents

that require and investigation are

initiated and completed within 5

business days.

- The QA Manager will ensure the

QA Coordinator submits all

finalized investigations to the

Executive Director for review of

any recommendations.

- All investigations will be

provided to the Executive Director

upon completion for review.





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00


and staff.

























huffing, He remembers the cleaning guy






Persons Responsible: QA

Coordinator, QA Manager, and

Executive Director.





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

is to huff, he stated 'yes' but it makes me






[Staff #1] - [Staff #1] stated that after

























outside the restroom, A maintenance man

were into the restroom to clean. He came





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00






























place.








04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00







Factual findings:








is substantiated that [client #1] stole aid





dated 11/12/16.






client to [name of urgent care clinic].


[client #1] is going to urgent care to be






04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00












12/6/16 at 2:00 PM. Client #1's




line of sight and when he is not (sleeping

only), he should be monitored with 15

minute checks. Client #1's BSP did not

indicate huffing was a behavior to

monitor and/or decrease. Client #1's BSP

did not indicate how staff should keep

him in line of sight during future trips to

retail stores in regards to him having to

use the restroom.



3:30 PM. She stated "[client #1 should









04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00





game] CD and she stayed in the same

aisle as [client #1] for the short period of

time they were in the store. He then said

he had to go to the bathroom. We went to

the men's restroom near the electronic





went into the bathroom and not much

























04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

The QA (Quality Assurance) Manager

was interviewed on 12/8/16 at 3:00 PM.

When asked why she indicated client #1

was in line of sight during the entire

11/11/16 huffing incident involving

client #1, she stated "I realized after I

completed the investigation he (client #1)

was in line of sight only during the time

when he and staff were shopping for the

game CD. I just realized that he wasn't in

line of sight while he was in the men's

bathroom huffing the air duster."

During interview with the Qualified

Intellectual Disabilities Professional

(QIDP) on 12/7/16 at 11:00 AM, she

stated "the Interdisciplinary Team (IDT)

has not yet met to discuss or revise[client

#1's] plan to specify how staff should

handle future incidents while shopping

with [client #1], especially in regards to

him having to use the restroom while

shopping at retail stores."

At the conclusion of the

annual/complaint survey, client 1's BSP

(Behavior Support Plan) had not been

updated to indicate how staff should deal

with client #1 in regard to shopping with

him and maintaining line of sight when

he needs to utilize the men's room.






04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

#IN00214850.

9-3-2(a)





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

483.440(f)(3)(i)

PROGRAM MONITORING & CHANGE

The committee should review, approve, and

monitor individual programs designed to

manage inappropriate behavior and other

programs that, in the opinion of the

committee, involve risks to client protection

and rights.

W 0262

Bldg. 00


1 of 4 sampled clients (#4) who took a

behavior control medication, the facility

failed to obtain approval/review from the

Human Rights Committee for the

medication.

Findings include:

Review of client #4's record was

completed on 12/7/16 at 11:45 AM. The

physician's orders dated 11/1 - 11/30/16

indicated client #1 received "Lithium 150

mg (milligrams) BID (twice daily) for

bipolar disorder." A note from the client's

psychiatrist on 8/26/16 indicated "slowly

decrease Trileptal - add Lithium

(antipsychotic) 300 mg BID. Lithium

level in 5 days." Review of client #1's

record did not indicate approval from the

Human Rights committee for the original

prescription of Lithium.

Interview with the facility's Qualified


(QIDP) was completed on 12/8/16 at

10:00 AM. She stated "the team should

W 0262 The committee should review,

approve, and monitor individual

programs designed to manage

inappropriate behavior and other

programs that, in the opinion of

the committee, involve risks to

client protection and rights.

-QIDP will be retrained on

completing team meeting and

obtaining Human Rights

Committee approval before

beginning a medication.

-Area Supervisor will be retrained

on completing team meeting and



beginning a medication.

-Program Manager will be

retrained on completing a team

meeting and obtaining Human

Rights Committee approval

before beginning a medication

01/09/2017 12:00:00AM





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

have met after [client #4's] appointment

with [Name of Psychiatrist] when he

prescribed the new medication (Lithium)

to discuss and approve it. We should

have obtained guardian approval. Then it

should have gone to the Human Rights

Committee for their approval."

9-3-4(a)

-Nurse will be retrained on



beginning a medication

-Specifically for Client #4, an IDT

will be completed to discuss

increase in behavior medication

-Nurse, QIDP, and Program

Manager will monitor through

quarterly audits of clients’ charts

- QIDP and Program Manager will

monitor monthly during home

audits

-Nurse will monitor monthly

during check of Physicians

Orders





Director





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

483.440(f)(3)(ii)

PROGRAM MONITORING & CHANGE

The committee should insure that these

programs are conducted only with the

written informed consent of the client,

parents (if the client is a minor) or legal

guardian.

W 0263

Bldg. 00


1 of 4 sampled clients (client #4) with

restrictive programs, the facility failed to

obtain written informed consent from the

legal guardian for client #4's restrictive

program that included the use of Lithium.

Findings include:



physician's orders dated 11/1 - 11/30/16

indicated client #4 received "Lithium 150

mg (milligrams) BID (twice daily) for

bipolar disorder." A note from the client's

psychiatrist on 8/26/16 indicated "slowly

decrease Trileptal - add Lithium

(antipsychotic) 300 mg BID. Lithium

level in 5 days." Review of client #4's

record did not indicate guardian approval

for the original prescription of Lithium.

The facility provided a surveyor

worksheet dated 12/1/16 (reviewed

12/1/16 at 3:00 PM) which indicated

client #4 had a guardian on record.

Interview with the facility's Qualified


W 0263 The committee should insure that

these programs are conducted

only with the written informed

consent of the client, parents or

legal guardian.

The QIDP will ensure that all

guardians are notified of any

recommendations for medication

changes prior to getting HRC

approvals

The QIDP will ensure all phone

interview forms are mailed to the

appropriate party for signatures

using certified mail.

Area Supervisor, will conduct

periodic reviews to ensure

restrictive programs are sent

to the guardian for consent and

are filed in each client’s file.

Program Manager, will conduct

periodic reviews to ensure

01/09/2017 12:00:00AM





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

(QIDP) was completed on 12/8/16 at

10:00 AM. She stated "the team should

have met after [client #4's] appointment

with [Name of Psychiatrist] when he

prescribed the new medication (Lithium)

to discuss and it. After that we should

have received guardian approval. We

made several attempts but not not get a

response."

9-3-4(a)

restrictive programs are sent

to the guardian for consent and

are filed in each client’s file.

Nurse will ensure no medications

are started without appropriate

approvals.





Director

483.450(e)(2)

DRUG USAGE

Drugs used for control of inappropriate

behavior must be used only as an integral

part of the client's individual program plan

that is directed specifically towards the

reduction of and eventual elimination of the

behaviors for which the drugs are employed.

W 0312

Bldg. 00

Based on record review and interview for W 0312 W 312 01/09/2017 12:00:00AM





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

1 of 4 sampled clients (#4) who took a

behavior control medication, the facility

failed to ensure the medication Lithium

was part of the client's Behavioral

Support Plan (BSP).

Findings include:


completed on 12/7/16 at 11:45 AM.

Client #4's Individual Support Plan (ISP)

dated 5/10/16 indicated client #4's

diagnoses included, but were not limited

to impulse control disorder, ADHD

(Attention Deficit Hyperactivity

Disorder), bipolar disorder, mild mental

retardation, vitamin D deficiency and

HTN (Hypertension - high blood

pressure). Client #4's 11/1/16 physician's

orders indicated client #4 received

"Lithium 300 mg (milligram) twice daily

and Lithium 150 mg twice daily." Client

#4's ISP indicated client #4 took

Bupropion, Vyvanse, Ziprasidone. Client

#4's ISP did not indicate he took the

medication Lithium.

Interview with the QIDP (Qualified

Intellectual Disabilities Professional) was


QIDP stated "[client #4] takes Lithium

for bipolar disorder. It should have been

addressed in his plan."

Drugs used for control of

inappropriate behavior must be

used only as an integral part of

the client’s individual program

plan that is directed specifically

towards the reduction of and

eventual elimination of the

behaviors for which the drugs are

employed.

QIDP will ensure that all of the

client’s BSP’s will be reviewed to

ensure that specific medication

plans of reduction are included.

The QIDP will review the BSP’s

monthly to ensure that all

prescribed psychotropic

medications are included in each

resident’s plans.

The Area Supervisor will monitor

bi-monthly as they complete their

supervisory visits update the

BSP’s after the resident’s

psychiatry appointments when

medication changes have taken

place.

The Program Manager will

review the BSP’s quarterly to





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

9-3-5(a) ensure that all prescribed

psychotropic medications are

included in each resident’s plans.·

The Director of Nursing will

review the BSP’s Quarterly to

ensure that all prescribed

psychotropic medications are

included in each resident’s plans.





Director





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

483.470(i)(1)

EVACUATION DRILLS

The facility must hold evacuation drills at

least quarterly for each shift of personnel.

W 0440

Bldg. 00


4 of 4 sampled clients (#1, #2, #3 and #4)

and 3 additional clients (#5, #6 and #7),

the facility failed to ensure fire

evacuation drills were conducted at least

quarterly for all shifts of personnel.

Findings include:

Fire evacuation drills from 10/1/15 until

W 0440 W 440

The facility must hold evacuation

drills at least quarterly for each

shift of personnel. Based on

record review and interview, the

facility failed to hold evacuation

drills at least quarterly for all shifts

of personnel.

01/09/2017 12:00:00AM





04/11/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G137 12/09/2016


8616 NORTHFIELD DR

00

the time of the survey with clients #1, #2,

#3, #4, #5, #6 and #7 as participants were

reviewed on 12/6/16 at 6:20 PM. The

review indicated no fire evacuation drills

were completed for the day shift for the

4th quarter (October, November and

December) of 2015.

During interview with the residential

manager (RM) on 12/6/16 at 7:00 PM,

she stated "I have only been the

residential manager since the spring and

at that time, I reviewed all the fire drills

and could not locate one (drill) in the fire

drill binder. [Name of Project Manager]

was also helping me to get things in order

and asked me if I had located one for the

day shift for the 4th quarter of last year. I

told her I did not."

9-3-7(a)

A schedule identifying when each

emergency drill should be ran has

been implemented.

The RM will receive training on

the emergency drill tracking and

importance of ensuring

emergency drills are ran each

month

The QIDP will receive training on

the emergency drill tracking and

the importance of ensuring

emergency drills are ran each

month according to the schedule.

The Area Supervisor will receive

training on the emergency drill

tracking and the importance of

ensuring emergency drills are ran

each month according to the

schedule

The Program Manager will

receive training on the emergency

drill tracking and the importance

of ensuring emergency drills are

ran each month according to the

schedule.


Date post:	27-Jun-2020
Category:	Documents
Upload:	others
View:	0 times
Download:	0 times

PRINTED: 04/11/2017 DEPARTMENT OF HEALTH AND …REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX...

Documents