W 0000 #IN00258242.

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

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STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

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

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

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DEFICIENCY)

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ROCKVILLE, IN 47872

15G189 05/18/2018

CHILD ADULT RESOURCE SERVICES INC

220 S COLLEGE ST

00

W 0000

Bldg. 00

This visit was for the investigation of Complaint

#IN00258242.

Complaint #IN00258242: Substantiated, Federal

and state deficiencies related to the allegations are

cited at W149, W159, W192, W322, and W331.

Unrelated deficiencies cited.

Dates of Survey: May 16 and 18, 2018.

Facility Number: 000721

Provider Number: 15G189

AIMS Number: 100248840

These deficiencies also reflect state findings in

accordance with 460 IAC 9.

Quality Review of this report completed by #15068

on 5/31/18.

W 0000

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 interview and record review for 1 of 4

sample clients (A), the facility failed to implement

its written policy and procedures to prevent

neglect of client A in regards to multiple choking

incidents.

Findings include:

Bureau of Developmental Disabilities Services

(BDDS) reports and investigations were reviewed

on 5/16/18 at 10:30 AM. The review indicated the

W 0149 On June 7, 2018 – the SGL

Assistant Director trained all

residential staff on C.A.R.S.

Abuse-Neglect Policy &

Procedure in regards to examples

of abuse and neglect can be

defined as…”Alleged, suspected

or actual neglect which includes

but is not limited to: Failure to

provide appropriate supervision,

care, or training / Failure to provide

a safe, clean and sanitary

06/17/2018 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: 2LNN11 Facility ID: 000721

TITLE

If continuation sheet of 34

(X6) DATE




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00

following:

- BDDS report dated 3/8/18 at 11:35 AM indicated,

"Staff offered [client A] assistance warming up his

lunch in the microwave, he declined and as he

walked to the microwave [client A] reached into

his bowl and put a whole meatball in his mouth.

[Client A] then ran out of the room, (sic) staff

followed him, tried to communicate with [client A],

but he was unable to respond and began to turn

pale, grabbing his throat (sic). 7:15 PM,

Assessment of [client A] by [Registered Nurse

(RN) #1]. Discovered that [client A] continued to

refuse food or fluid all afternoon and throughout

the evening. He (client A) was trying to take

Tylenol when she (RN #1) arrived, and promptly

choked the water and Tylenol up (sic). [Client A]

stated he 'just didn't want to eat or drink,' and

'throat sore.' Temperature 99.5, heart rate 100,

respirations 24 even and essentially unlabored.

Chest auscultation revealed coarse rhonchi

(abnormal lung sounds) all fields. He continued to

complain of sore throat and kept spitting up

mucus. I (RN #1) elected at this time to take him,

with his consent, to [hospital #1 ER (Emergency

Room)]. X-Rays taken and diagnosis was

esophageal obstruction. Doctor explained that the

X-Ray results were not available due to a

computer malfunction. His oxygen saturation was

compromised at 88%, lower than [client A] has on

wellness checks...continued frequent coughing

and spitting of tan colored mucus (sic), It was

subsequently determined by ER physicians that

[client A] should be transferred to [hospital #2].

[Client A] refused to go by ambulance... [Client A

and RN #1] arrived after five hours in [hospital #1

ER] at [hospital #2]. He was admitted to

observation bed by [hospital #2]...".

"Plan to Resolve: Staff proceeded to do the

environment / Failure to provide

food and medical services as

needed / Failure to provide

medical supplies or safety

equipment as indicated in the

Individual Support Plan.

On May 24, 2018, Agency Nurse

sent out a guide for Client A’s

mechanical soft diet which

included general dietary guidelines

for Client A, Client A’s issues with

swallowing, encouragement to give

Client A while eating,

recommended foods, items to add

to soften or moistened foods and

foods to avoid. All appropriate

staff that work with Client A was

trained on these dietary guidelines

by their respective management

supervisor.

During the last week of May,

CEO, Agency Nurse and SGL

Assistant Director observed Client

A while medications were being

administered. Observations

revealed that Client A had difficulty

swallowing 2 large pills. As a

result on June 1, 2018, Agency

Nurse changed Client A’s Calcium

large tablet to Chewable Caltrate

600+Vitamin D and changed

Depakote large pill to liquid form.

On June 7, 2018, Agency Nurse

updated Client A’s High Risk Plan

to give further instructions for staff

to follow for Choking. QIDP

trained all residential staff on client

A’s plans…Objectives, Behavior

Plan, Personal Profile and High

Risk Plan which included steps to

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220 S COLLEGE ST

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Heimlich maneuver on [client A] having a small

piece of the meatball come up. Staff asked [client

A] a question and he was able to respond. Staff

notified [RN #1] of the incident and monitored

[client A] the rest of the day...".

Client A's record was reviewed on 5/16/18 at 12:15

PM. The review indicated the following:

- Client A's [Hospital #1's] Emergency Department

(ED) Discharge Summary (DS) dated 3/8/18 at

12:59 AM indicated the following:

"Arrival time: 3/7/18 at 7:55 PM."

"Discharge Diagnosis: Acute esophageal

obstruction."

"Discharge disposition: Transfer to another

facility."

- Client A's Admission History and Physical

(AHP) from [hospital #2] was dated 3/8/18 at 3:45

AM. The AHP indicated the following:

"History of present illness: Presenting as a

transfer from [hospital #1] after an episode of

choking on a meatball yesterday at lunch. The

Heimlich was performed and the meatball expelled

but he has continued throat discomfort as well as

refuses PO (oral) intake. He has pain with

swallowing and has a gurgling noise when he

speaks. His nurse reports desaturations into the

high 80's which only improved to the low 90's with

3 liters of oxygen. He has no oxygen requirement

at home...".

- Client A's CT of his chest dated 3/8/18 at 6:52

AM indicated, "Impression: Proximal (center)

esophageal (throat) retained ingested material.

take for a high risk of Choking.

Effective immediately the

Residential Management Team,

will oversee direct care staff to

ensure staff is preventing neglect

in regards to multiple choking

incidents.

Overseeing may include but is not

limited to: (a) Direct observation of

direct care staff while they are

performing direct care/active

treatment (b) Interviewing direct

care staff to analyze their

knowledge in preventing neglect in

regards to multiple choking

incident(s). Based on what

information the Residential

Management Team gathers by

overseeing direct care staff – it will

determine if staff person(s) need

further training on preventing

neglect in regards to multiple

choking incident(s)





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220 S COLLEGE ST

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Patchy bilateral (both sides) lung consolidations

are consistent with pneumonia...".

- Client A's Speech Therapy Swallow Evaluation

dated 3/9/18 at 7:45 AM indicated the following:

"Diet: Mechanical Soft."

"Medication delivery: Whole, one pill at a time

with a puree (food)."

- Client A's Upper GI Endoscopy (throat tube with

light and camera)(EGD) dated 3/8/18 at 10:56 AM

indicated, "Findings: Food was found... removal

of food was accomplished...".

- Client A's [Hospital #2's] Discharge Summary

(DS) dated 3/9/18 at 4:43 PM indicated the

following:

"Discharge Diagnosis: Retained food bolus, CAP

(Community Acquired Pneumonia), Hypertension,

osteoarthritis, gastritis (stomach inflammation),

and esophagitis (esophagus inflammation)."

"Patient (client A) was admitted as a transfer from

[hospital #1] for throat pain and low oxygen

saturation. Patient had choked on a meatball on

date of admission and had continued to eat

following clearing of the meatball, then refused

meals that evening and was noted to be making a

'gurgling' sound when speaking. Neck and chest

CT scan showed a 4.3 CM (Centimeter) by 2.7 CM

by 1.6 CM retained food bolus lodged in the

proximal esophagus and compressing the upper

airway. Patient was started on supplemental

oxygen and admitted to the medical floor. That

morning patient was taken to Endoscopy where

EGD was performed and the food bolus was

cleared. EGD appeared to show esophagitis and





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moderate gastritis and biopsies were obtained.

During the procedure, the patient developed

respiratory distress and required intubation (tube

placed to aid breathing) and mechanical

ventilation. The patient was successfully

extubated (breathing tube removed) in PACU

(Post Anesthesia Care Unit) and returned to the

floor. IV antibiotics were started for treatment of

CAP seen on the CT chest. The patient's oxygen

was weaned that evening and patient had swallow

evaluation the following morning on 3/9/18...

Patient was then discharged back to his group

home."

"Follow up: Gastroenterologist (GI) in 2 weeks."

Client A's record review did not indicate client A

attended a GI specialist visit until 4/5/18.

- BDDS Incident Follow Up dated 3/9/18 indicated

the following:

"Was he monitored for signs and symptoms of

aspiration for 3-5 days after incident?"

"Yes, staff monitored [client A] for the remainder

of the day and communicated with [RN #1]

throughout the day by phone."

- Client A's Staff Shift Note (SSN) dated 3/9/18

was written by staff #2. Staff #2 indicated, "[Client

A] was having trouble sleeping all night. Told me

he couldn't breathe and his stomach hurt. I called

[Adult Services Director (ASD) #1] and [Executive

Director (ED) #1] came over to check on him. He

was assisted with taking his medications."

- Client A's SSN dated 3/11/18 was written by RN

#1. RN #1 indicated, "Nurse note: Assessment of

[client A]."





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15G189 05/18/2018


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- Client A's Primary Care Physician (PCP) visit

dated 3/13/18 at 8:00 AM indicated client A had

been seen as a follow up to his hospitalization.

The PCP Progress Notes (PN) indicated the

following:

" Diet Change: Modify to level 2 Dysphagia diet

due to recent pneumonia and esophageal

obstruction."

"Lungs: Clear to auscultation (listening with a

stethoscope) bilaterally...".

- Client A's Level 2 Dysphagia diet was undated.

The diet plan indicated the following:

"Level 2 Dysphagia Diet:"

"Avoid the following on Dysphagia Diet:"

"Chips... Cheese cubes or slices..

sandwiches...hard cooked eggs...".

"Preparing foods for diet: Regular house diet and

mechanical soft level 2."

"Meats should all be ground in food processor to

size of small grains of rice."

"Bread, crackers, cookies, and cakes have little

moisture. Provide a drink that the person can

'dunk' bread, crackers, cookies, cake in...".

"If serving ground lunchmeat, add mayonnaise or

other moist condiment and serve with crackers

that the meat mixture can be placed on top of the

cracker. This will add moisture to the cracker...".

- Client A's SSN dated 3/13/18 was written by Day





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Service Staff (DSS) #1. DSS #1 indicated, "Staff

assisted [client A] during lunch with helping him

warm up his food in the microwave and helping

him cut up his hot pocket into bite size pieces to

prevent choking."


#1. RN #1 indicated, "Reassess due to staff

concerns."

- Client A's SSN dated 3/21/18 was written by DSS

#1. DSS #1 indicated, "Staff also assisted [client

A] in the lunch room with cutting up his sandwich

into bite size pieces. Staff also assisted [client A]

during break time with opening up his string

cheese...".

- Client A's Nurse Documentation and Exam (NDE)

dated 3/23/18 was completed by RN #1. The NDE

indicated, "Respiratory: Breath sounds

congested. Cough."

- Client A's SSN dated 3/25/18 was written by staff

#9. Staff #9 indicated, "[Client A] ate breakfast

with Hand Over Hand (HOH) assistance in

portioning out his food and cutting up his

bacon...".

- BDDS report dated 3/28/18 indicated, "(On

3/27/18) Staff offered [client A] assistance with

cutting up his chicken at dinner to ensure his

mechanical soft diet #2 dietary recommendations

were followed, per his HRP (Health Risk Plan).

While staff was assisting him, he stated to staff

that he didn't want it that small (1/4 in. in size per

his plan). Staff reminded [client A] that his new

diet plan states what size the meat pieces are to

be, also reminding him of the health and safety

issues of aspiration and choking. Staff also

reminded him of his latest stay at the hospital due





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to aspiration pneumonia and choking. [Client A]

then agreed to the size of the pieces of meat.

While eating, staff monitored him to ensure

prompting to take drinks between small bites. As

staff turned their head away to check on another

client at the table, then they looked back, [client

A] put three small pieces of meat into his mouth,

disregarding staff encouragement for small bites,

one at a time, per his plan. After [client A]

swallowed the bite, he began coughing. Staff

encouraged him to continue to cough to ensure

air was getting through and attempted back blows

in an attempt to bring the meat up. [Client A]

stopped coughing, his face turned red, and the

food was still lodged. At this time, staff began

abdominal thrusts, and the food was brought up

and out of his mouth. [Client A] regained his

normal color and was able to resume eating his

dinner, one small bite at a time."

"Plan to Resolve: [Client A] continues to be

observed closely at meal times to ensure safety

from choking and aspiration as per his plan. Staff

will continue working with [client A] to ensure he

follows his dietary recommendations as well as

offering assistance with cutting his food up. Staff

will continue to monitor him closely to ensure

safety from choking and encouragement of taking

small bites and sips between each bite."

- Client A's PCP's PN dated 3/28/18 indicated,

"May change level 2 mechanical soft regular

house diet to pureed regular house diet to ensure

individual's safety while eating."

- Client A's SSN dated 3/28/18 was written by

Assistant Director (AD) #1. AD #1 indicated,

"Staff also assisted him (client A) in packing his

lunch and he opened his sandwich container and

asked for assistance in cutting up his sandwich.





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Staff assisted in cutting it up with scissors...".

- Client A's High Risk Plan (HRP) dated April 2018

indicated client A had a HRP for choking. The

HRP for choking indicated the following:

"[Client A] is at risk for choking due to dental

issues... being a fast eater, impulsivity while

eating, taking too large of bites, and failing to

chew and swallow before taking another bite.

[Client A] is at increased risk of choking,

obstruction of esophagus by food and food

particles and aspiration pneumonia...".

"Prevention:"

"Regular house diet prepared according to

physician's order."

"Staff will assist [client A] in preparing foodstuffs

(sic) according to diet order per physician's

order."

"Staff will encourage [client A] to use posture

helpful for ease of swallowing. Encourage him to

sit up with back straight, squarely in chair,

shoulders back to facilitate correct position of

esophagus to ease swallowing without stress."

"Staff will remind [client A] during eating to take

small bites. Eat slowly. Take a bite, chew

thoroughly, swallow, and take sip of fluid prior to

loading another bite."

"[Client A] to sit upright for two hours following

meals or snacks to facilitate appropriate digestion,

and avoid reflux aspiration of foodstuffs (sic) or

particles."

"Signs and Symptoms:"





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"Persistent spitting food out of mouth."

"Face turning blue."

"Cannot cough, speak, or breathe."

"Showing universal sign for choking."

"Appears to be panicked."

"Note: Persistent coughing or gagging while

eating can lead to choking. Ask [client A] to stop

eating until cough has resolved."

"Protocol: During:"

"Observe for signs or symptoms of choking."

"Have [client A] stop eating or drinking."

"Follow standard first aid for choking. Use

Heimlich Maneuver if suspected food lodged on

esophagus or in airway."

"If [client A] exhibits symptoms of shortness of

breath, audible breathing and obstruction of

airway as evidenced by persistent cough or

signals that he is not able to breathe with ease,

seek immediate EMS (Emergency Medical

Services) intervention."

"Protocol: After:"

"Take vitals."

"Monitor client for adverse effects."

"Keep conscious client upright position for two

hours."





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"Report to:"

"Agency nurse via telephone when incident

occurs."

"House manager or designee verbally or in written

documentation."

"The director of adult services verbally or in a

written documentation."

- Client A's Speech Therapy Evaluation (STE)

dated 4/2/18 at 10:00 AM indicated, "Recommend

mechanical soft with ground meat and thin

liquids...".

- Email from RN #1 to [QIDP #1, AD #1, Office

Secretary (OS) #1, ASD #1, staff #10, #3, and #11,

day service, group home, and ED #1] was written

on 4/2/18 at 3:09 PM and reviewed on 5/16/18 at

12:15 PM. The email indicated the following,

"Took [client A] to speech therapy for evaluation

of swallowing. She ordered mechanical soft

regular house diet level 2 with ground meat. All

meats should be ground in food processor. Please

also grind raw vegetables... Please be sure to add

moisture to the ground foods... This does a lot by

adding moisture to allow him greater safety for

chewing and swallowing...Noticed at [day service]

he still is tending to 'load up the spoon' and trying

to chew too much at one time. Tried to encourage

small bite, chew, swallow, and sip. Please prompt

him regarding this."

- Email from RN #1 to [QIDP #1, AD #1, OS #1,

ASD #1, staff #10, #3, and #11, and day service]

was written on 4/2/18 at 4:16 PM and reviewed on

5/16/18 at 12:15 PM. The email indicated the

following, "Please continue to use the Oster food





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processor with the 2 sided blade to chop up the

meats to ground consistency, and any raw

vegetables should also be ground up. If you have

any questions, please just give me a call. The

chicken salad [client A] had for lunch today was

perfectly ground. The cauliflower salad, I had to

chop up much smaller to have ground

consistency. Don't forget to add moisture,

dressing, gravy, mayonnaise sauces, broth, or

meat juices, milk, etc. (sic). Most of our folks will

do better if dressing, sauce, etc. is added to meats,

etc. Easier to chew and to swallow. Very important

to make sure moisture is added to the ground

food."

- Client A's SSN dated 4/3/18 was written by ASD

#1. ASD #1 indicated, "Director (ASD #1) assisted

[client A] with his lunch food modification today

to be in compliance with his new dietary

guidelines, Regular house diet - Dysphasia Level

2 with ground meat. He came with a lunchmeat

sandwich, ham, cheese, mayo that was cut in half.

He also had regular potato chips as a side item,

listed on the avoid food list. [Client A] informed

director (ASD #1) that he had packed his own

food this morning and didn't want to have his

meat ground. Director (ASD #1) read his dietary

guidelines to him as a result of swallow study

conducted on 4/2/18. He read his own name on

the form. After education, he agreed to receive

assistance with the modification. He did not have

his food processor with him at day services today,

so director (ASD #1) assisted with meat into tiny,

ground-sized pieces. His bread was modified into

less than 1/4 inch sized pieces. Director (ASD #1)

asked [client A] to smash his chips with his hand

from outside of the baggie into chip crumbs.

Director (ASD #1) assisted with completion to

make sure all pieces were smashed. [Client A]

dumped the chip crumbs into his Tupperware





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container of ranch dressing and stirred to cover

with sauce. Director (ASD #1) verified that each

bite was covered with the sauce prior to his

consumption. Director (ASD #1) provided 1:1 (one

on one) supervision during his lunch meal. He

required verbal prompting to not overload his

utensil and to take sips of beverage between bites

to help wash down his food. He responded well to

prompting each time. Director (ASD #1)

coordinated via phone with [RN #1 and AD #1] to

make arrangements for staff to receive coaching

on modified diet while assisting [client A] with

packing his lunch. Director (ASD #1) also

coordinated for one of [client A's] food

processors to be sent to day services to keep on

site for assistance with meals."


#1. RN #1 indicated, "Demonstration to staff

appropriate chopping of meat for supper."

The facility's Community Residential Facility

Surveyor Worksheet (CRFSW) dated 5/16/18 was

reviewed on 5/16/18 at 8:00 AM. The CRFSW

indicated staff #1, #2, #3, #4, #5, #6, #7, and #8

were staff working in the home.

- Client A's Staff Training (ST) dated April 2018

did not indicate staff #6, #7, and #8 had been

trained on client A's updated HRP prior to

providing care in the home.

- Client A's PCP visit dated 4/3/18 indicated,

"History: Recently has had choking episodes.

Now being evaluated by speech therapy and on a

mechanical soft diet at this time."

- Client A's GI specialist PN's dated 4/5/18

indicated client A was seen as a follow up for his

hospitalization. The PN's indicated the following:





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OMB NO. 0938-039




A. BUILDING

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(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




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DEFICIENCY)

(X5)

COMPLETION


ROCKVILLE, IN 47872

15G189 05/18/2018


220 S COLLEGE ST

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"No complaints of gastric distress for last three

weeks."

"Special Instructions: Continue mechanical soft

diet, may have thin liquids."

"Follow reflux precautions."

- Client A's [hospital outpatient] chest X-Ray

dated 4/9/18 indicated, "Impression: Subtle

haziness in the left lower lobe is likely due to

atelectasis (lung collapse) or resolving infiltrates

(infection)."

- BDDS report dated 4/13/18 indicated, "[Staff #12]

encouraged [client A] to allow him to assist him in

grinding up his sausage at breakfast, per

Dysphagia level 2 dietary orders. [Client A]

responded by asking why he needed to cut up his

breakfast sausage. Staff explained that it is easier

for him to eat and it is his dietary recommendation.

[Client A] stated that this plan for him is stupid,

and he didn't want to do this... he began eating

the meat that was not cut not pieces per his

dietary plan. He began to gag on his food, and

staff attempted to assist him... He continued to

yell at staff, while attempting to eat the food that

was not per his plan again. He began to gag once

again and staff attempted to help him... After the

deep breathing, [client A] attempted to eat again,

accepting some assistance in cutting up his food

for a few moments, (sic) but then refused to allow

assistance and refused to cut his own food. He

began coughing again, due to the bites he was

attempting...".

"Plan to Resolve: [Client A] has a new dietary

plan (Dysphagia level 2) due to two recent

incidents of choking while dining. One in which





06/14/2018PRINTED:

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OMB NO. 0938-039




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ROCKVILLE, IN 47872

15G189 05/18/2018


220 S COLLEGE ST

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resulted in hospitalization. Results of a swallow

study resulted in his new dietary orders. [Client

A] is still acclimating to his new modified diet and

gets upset about not have (sic) the same dietary

plan that he had prior to choking incidents. Staff

will continue to support [client A] with his current

dining protocols, providing encouragement prior

to and during meal times to cope with his feelings.

An IDT (Interdisciplinary Team) meeting was held

on 4/13/18 to review [client A's] behavior plan. No

changes to the plan were recommended at this

time. [ED #1, QIDP #1, AD #1, and ASD #1]

resolved to add additional staffing supports to

morning meal preparation and supervision of

breakfast, ensuring that morning shift DSP's

(Direct Support Professionals) will be available to

provide more individual time with [client A] to

help him prepare his food to his liking within

dietary plan guidelines in attempt to prevent

future incidents."

- Client A's Recertification Form (RF) was

completed by client A's PCP on 4/16/18. The RF

indicated, "Regular house diet mechanical soft

level 2 with ground meat...".


#4. Staff #4 indicated, "Staff assisted [client A]

with putting snacks into baggies, (sic) [client A]

put his chicken and cheese in the food processor

for lunch tomorrow, (sic) and eggs, he fixed his

lunch telling staff what he wanted to bring."


#1. Staff #1 indicated, "[Client A] was assisted in

his morning medications. When given his (client

A's) medications he choked on one of the pills

(sic) back blows were given and then it came up

and he was fine. During lunch he (client A) was

assisted in grinding his food and his chicken was





06/14/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




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(X3) DATE SURVEY

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ROCKVILLE, IN 47872

15G189 05/18/2018


220 S COLLEGE ST

00

shredded (sic) he then choked on his chicken and

after he got it up on his own went to the bathroom

and threw up. Afterwards I (staff #1) was giving

him (client A's) his noon medications and he

choked again needing back blows to help it come

up. It came up and we called the nurse and we

checked his blood pressure was high."

- BDDS report dated 4/29/18 indicated an incident

date of 4/28/18 at 7:00 AM indicated, "During

morning medication administration, one of [client

A's] pills got stuck in his throat when he

attempted to swallow it with a drink of water. He

was unable to cough it up and his face turned red.

Staff completed physical assistance via back

blows, which successfully dislodged the

medication. He then swallowed the pill without

further incident."


date of 4/28/18 at 12:00 PM indicated, "During

12:00 PM medication administration, one of [client







further incident."


#11. Staff #11 indicated, "Staff verbally reminded

him (client A) to remember to take sips of water

between bites of egg salad ...".

- Client A's Nutrition Assessment dated 5/5/18

indicated the following:

"HRP choking. Diet changed to mechanical soft

with ground meat on 4/18/18... Monitored for





06/14/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




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ROCKVILLE, IN 47872

15G189 05/18/2018


220 S COLLEGE ST

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chewing and swallowing problems."

"Recommendations: To continue with mechanical

soft diet with ground meat... Continue with HRP

for choking. Monitor for tolerance of current diet."

Registered Nurse (RN) #1 was interviewed on

5/18/18 at 9:25 AM. RN #1 indicated

recommendations from specialists should be

implemented. RN #1 indicated client A had a HRP

for choking due to a history of aspiration

pneumonia and food obstruction. RN #1 indicated

client A has had several instances of choking on

his food and medications in the past few months.

RN #1 indicated client A's current diet was

mechanical soft. RN #1 indicated client A's meat

should be ground in a food processor. RN #1

indicated staff should follow client A's mechanical

soft diet including avoiding foods on the

restricted list. RN #1 indicated she provides

training to staff in order to implement client A's

dietary plans and restrictions.

ED #1 was interviewed on 5/16/18 at 4:00 PM. ED

#1 indicated recommendations from specialists

should be implemented. ED #1 indicated client A

has had several health issues in the past few

months in regards to swallowing. ED #1 indicated

client A's diet was changed due to the issues. ED

#1 indicated client A's current diet is mechanical

soft. ED #1 indicated client A has a HRP for

choking due to these issues. ED #1 indicated the

client A's risk plan and dietary restrictions should

be followed as written. ED #1 indicated the

facility's abuse and neglect policy should be

followed as written.

The facility's policy for Abuse and Neglect dated

1/2018 was reviewed on 5/18/18 at 2:00 PM. The

policy indicated,





06/14/2018PRINTED:

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OMB NO. 0938-039




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ROCKVILLE, IN 47872

15G189 05/18/2018


220 S COLLEGE ST

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"Alleged, suspected, or actual neglect which

includes but is not limited to: Failure to provide

appropriate supervision, care, or training...".

This federal tag relates to complaint #IN00258242.

9-3-2(a)

483.420(d)(2)


The facility must ensure that all allegations of

mistreatment, neglect or abuse, as well as

injuries of unknown source, are reported

immediately to the administrator or to other

officials in accordance with State law through

established procedures.

W 0153

Bldg. 00

Based on record review and interview for 1 of 9

allegations of abuse, neglect and mistreatment

reviewed, the facility failed to report an incident of

client to client Physical Aggression (PA) between

clients D and H to Bureau of Developmental

Disabilities Services (BDDS) within 24 hours of

the alleged incident.

Findings include:

BDDS reports were reviewed on 5/16/18 at 10:30

AM. The review indicated the following:

- BDDS report dated 3/1/18 indicated, "As [client

D] and [client H] passed one another as they

walked thru (sic) the dining room, [client D] kicked

[client H] because she was in his way."

The report indicated the incident date was 2/27/18.

The date of administrative knowledge is listed as

2/27/18. The BDDS reported date is listed as

3/1/18.

W 0153 On June 7, 2018 – the Residential

Management Team trained all

residential direct care staff about

submitting incident reports.

Training included…completing

incident reports for all instances of

client to client physical

aggression, following on-call

procedures for notification of

incident reports, completing an

incident report in AccelTrax and

completing an incident report

before the end of his/her shift.

AccelTrax is an electronic data

collection system that allows

employees the ability to report

time and services rendered 24

hours a day / 7 days a week.

C.A.R.S. had been using

AccelTrax solely to collect

information regarding services

rendered and employee

timekeeping.

06/17/2018 12:00:00AM





06/14/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




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B. WING

(X3) DATE SURVEY

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(X5)

COMPLETION


ROCKVILLE, IN 47872

15G189 05/18/2018


220 S COLLEGE ST

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Executive Director (ED) #1 was interviewed on

5/16/18 at 4:00 PM. ED #1 indicated staff should

report all client to client PA to administration

immediately. ED #1 indicated these events should

be reported to BDDS within 24 hours of

administrative knowledge.

9-3-2(a)

On May 10, 2018 – C.A.R.S.

started utilizing AccelTrax to

submit internal incident reports.

Staff is responsible for completing

an incident report through

AccelTrax which includes all

instances of client to client

physical aggression. As soon as

the incident report is submitted,

the system is set up to send an

automatic email to the IDT team

regarding the incident report. This

allows all IDT members and the

administrator to review the incident

report immediately. This in turn

allows the incident report including

all instances of client to client

physical aggression to be

submitted to the state within

24-hours of the alleged incident.

In the past, during non-office hours

(evenings, weekends, holidays),

the Director of SGL & Waiver

Services and Quality Assurance

Coordinator was responsible for

submitting incident reports to the

state within 24 hours of the

alleged incident. On May 10,

2018 – the SGL Assistant Director

was added as one more person to

be responsible for submitting

incident reports to the state during

non-office hours.

483.420(d)(3)


The facility must have evidence that all

alleged violations are thoroughly investigated.

W 0154

Bldg. 00


allegations of abuse, neglect and mistreatment W 0154 On June 7, 2018 – Director of SGL

& Waiver Services emailed out 06/17/2018 12:00:00AM





06/14/2018PRINTED:

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OMB NO. 0938-039




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ROCKVILLE, IN 47872

15G189 05/18/2018


220 S COLLEGE ST

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reviewed, the facility failed to thoroughly

investigate an incident of client to client Physical

Aggression (PA) between clients D and H, and

client C's injury of unknown origin.

Findings include:

The facility's BDDS (Bureau of Developmental

Disabilities Services) reports and investigations

were reviewed on 5/16/18 at 10:30 AM. The review


1. BDDS report dated 3/1/18 indicated, "As [client

D] and [client H] passed one another as they

walked thru (sic) the dining room, [client D] kicked

[client H] because she was in his way."

"Plan to Resolve: Staff counseled [client D] to

utilize coping skills and patience with others.

House Manager (HM) to conduct internal

investigation due to peer to peer PA."

- The Investigation Report (IR) dated 3/6/18


"Completed by [HM #1]."

"This investigation was completed due to PA

from one client to another. [Staff #4, #8, and HM

#1] was (sic) present in the home during the

aggression and intervened...".

"The RM (Residential Manager (HM #1))

completing this investigation was present in the

home at the time of the alleged incident of PA."


5/16/18 at 4:00 PM. ED #1 indicated all allegations

of abuse, neglect, and mistreatment should be

investigated thoroughly. ED #1 indicated all

protocols to the Adult

Management Team regarding

initiating an investigation for

incidents such as client to client

physical aggression and unknown

injuries. Protocols included…[1]

who is allowed to be an

investigator [2] who is not allowed

to be an investigator [3] how

investigation interviews can be

completed [4] who is primarily

responsible for overseeing that

group home investigations are

completed in a timely manner [5]

who will be assigned to complete

an investigation on the day of the

incident [5] who is to receive the

completed investigation report.










timekeeping.

On May 10, 2018 – C.A.R.S.



Staff will be responsible for

completing an incident report

through AccelTrax which includes

all instances of client to client


injuries. As soon as the incident

report is submitted, the system is

set up to send an automatic email

to the IDT team regarding the





06/14/2018PRINTED:

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15G189 05/18/2018


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potential witnesses should in interviewed during

an investigation. ED #1 indicated a potential

witness should not be the investigator of the

same incident.

2. BDDS report dated 4/18/18 indicated, "As staff

was assisting [client C] with putting her pajamas

on, it was found that [client C] had a bruise on her

upper right shoulder blasd (sic) on her back that

was 1 Inch (IN) in diameter and 3 dime size bruises

on her right knee cap. An investigation was

completed by the Assistant Director (AD) and the

conclusion of the investigation was discovered

that recently [client C] had sat down on her knees

on the van, (sic) when staff was assisting her onto

the van. Instead of sitting on the seat, she sat on

her knees on the floorboard, and had leaned back

against the seat for several minutes before she

allowed staff to assist her to her feet (sic)."

"Plan to Resolve: Staff checked [client C] for any

other bruises. None found. Staff will continue

assisting [client C] per HRP (Health Risk Plan),

during times she is mobile (sic), due to her

unsteady gait (sic), and will continue using her

gait belt during these times. Staff will continue to

redirect her when she is getting on and off the

van."

- The Incident Report Form (IRF) dated 4/17/18

indicated [AD #1] completed the IRF. The IRF


"Other staff present: [Staff #4 and #5]."

"First aid given by: [Staff #4]."

- The Investigation Report (IR) dated 4/18/18


incident report. This allows all IDT

members and the administrator to

review the incident report

immediately. This will also allow

appropriate management team

members to immediately initiate

an internal investigation for all

instances of client to client


injuries.

The CEO and Director of SGL &

Waiver Services will review all final

investigation reports to verify the

investigation and the final report

has been completed appropriately

as well as initiating any needed

follow-ups as a result of the

investigation such as correction

actions.





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FORM APPROVED

OMB NO. 0938-039




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ROCKVILLE, IN 47872

15G189 05/18/2018


220 S COLLEGE ST

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"This investigation is in response to an on-call

notification from [staff #5 and #4] to [AD #1] via

phone call regarding bruises found on [client C]

while assisting her with putting her pajamas on

during the evening of 4/17/18."

The IR indicated [AD #1] completed the IR.

The IR indicated AD #1 interviewed Registered

Nurse (RN) #1 and Qualified Intellectual

Disabilities Professional (QIDP) #1 during her

investigation. The investigation did not indicate

staff #4 or #5 were interviewed. The investigation

did not indicate the staff who was assisting client

C when she sat on her knees on the van for an

extended time were interviewed for the

investigation.

ED #1 was interviewed on 5/16/18 at 4:00 PM. ED

#1 indicated all injuries of unknown origin should

be investigated thoroughly. ED #1 indicated all

potential witnesses should in interviewed during

an investigation.

9-3-2(a)

483.430(a)

QIDP

Each client's active treatment program must

be integrated, coordinated and monitored by

a qualified intellectual disability professional.

W 0159

Bldg. 00

Based on observation, record review and

interview for 4 of 4 sample clients (A, B, C, and D),

plus 4 additional clients (E, F, G, and H), the QIDP

(Qualified Intellectual Disabilities Professional)

failed to implement the facility's written policy and

procedures to prevent neglect of client A in

regards to multiple choking incidents, failed to

ensure staff were sufficiently trained to implement

client A's health care protocols, and failed to


Assistant Director trained the

QIDP and all residential staff on

C.A.R.S. Abuse-Neglect Policy &

Procedure in regards to examples

of abuse and neglect can be

defined as…”Alleged, suspected

or actual neglect which includes

but is not limited to: Failure to

06/17/2018 12:00:00AM





06/14/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




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15G189 05/18/2018


220 S COLLEGE ST

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ensure staff implemented the prescribed menu

plan for clients A, B, C, D, E, F, G, and H during

mealtime.

Findings include:

1. The QIDP failed to implement the facility's

written policy and procedures to prevent neglect

of client A in regards to multiple choking

incidents. Please see W149.

2. The QIDP failed ensure staff were sufficiently

trained to implement client A's health care

protocols. Please see W192.

3. The QIDP failed to ensure staff implemented the

prescribed menu plan for clients A, B, C, D, E, F,

G, and H during mealtime. Please see W460.


9-3-3(a)

provide appropriate supervision,

care, or training / Failure to provide

a safe, clean and sanitary

environment / Failure to provide

food and medical services as

needed / Failure to provide

medical supplies or safety

equipment as indicated in the

Individual Support Plan.

On June 7, 2018 – QIDP trained

all residential staff on client A’s

plans…Objectives, Behavior Plan,

Personal Profile and High Risk

Plan which included steps to take

for a high risk of Choking.

On June 7, 2018 – QIDP trained

all residential staff on menus

which included…ensuring a menu

is posted in the kitchen at all

times, following the menu each

day for each meal, documenting

changes on the menu.

Effective immediately, the QIDP

will oversee direct care staff to

ensure staff is sufficiently trained

on client’s health care protocols

and to ensure staff is

implementing menu plans during

mealtimes.







knowledge in regards to health

care protocols and menu plans.

Based on what information the

QIDP gathers by overseeing direct

care staff – it will determine if staff





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15G189 05/18/2018


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person(s) need further training on

client’s health care protocols and

menu plans.

483.430(e)(2)

STAFF TRAINING PROGRAM

For employees who work with clients, training

must focus on skills and competencies

directed toward clients' health needs.

W 0192

Bldg. 00


sampled clients (A), the facility failed ensure staff

were sufficiently trained to implement client A's

health care protocols.

Findings include:

The facility's Community Residential Facility

Surveyor Worksheet (CRFSW) dated 5/16/18 was

reviewed on 5/16/18 at 8:00 AM. The CRFSW

indicated staff #1, #2, #3, #4, #5, #6, #7, and #8

were staff working in the home.


PM.

- Client A's Staff Training (ST) dated April 2018

did not indicate staff #6, #7, and #8 had been

trained on client A's updated High Risk Plan

(HRP) prior to providing care in the home.

- Client A's Individual Support Plan (ISP) dated

2/21/18 indicated client A is at an increased risk

for choking. The ISP indicated, "Current HRP in

place for choking. Plan in place to improve dining

skills. Level 2 dysphagia (difficulty swallowing)

diet."

- Client A's High Risk Plan (HRP) dated April 2018

indicated client A had a HRP for choking. The

W 0192 On June 7, 2018 – QIDP trained

all residential staff on client A’s

plans…Objectives, Behavior Plan,

Personal Profile and High Risk

Plan which included steps to take

for a high risk of Choking.


will ensure each staff person is

trained on client’s plans before the

staff person fills in at a different

group home they normally work

at. The QIDP will attend each

monthly house staff meeting and

ensure all staff is trained on all

appropriate client plans. The

QIDP will also attend each

monthly residential in-service and

ensure all staff is trained on all

appropriate client plans. If

training of staff is required between

monthly house meetings and

residential in-services, the QIDP

will schedule 1-on-1 staff training

as deemed necessary.


along with the Residential

Management Team will oversee

direct care staff to ensure staff is

sufficiently trained on client’s

health care protocols.


06/17/2018 12:00:00AM





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ROCKVILLE, IN 47872

15G189 05/18/2018


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HRP for choking indicated the following:

"[Client A] is at risk for choking due to dental

issues... being a fast eater, impulsivity while

eating, taking too large of bites, and failing to

chew and swallow before taking another bite.

[Client A] is at increased risk of choking,

obstruction of esophagus by food and food

particles and aspiration pneumonia...".

"Report to:"

"Agency nurse (RN #1) via telephone when

incident occurs."




following:










further incident."

The Incident Report (IR) for the 4/28/18 incident at

7:00 AM indicated RN #1 was notified via text

message on 4/29/18 at 12:30 PM regarding client

A's choking incident.










knowledge in regards to health

care protocols. Based on what

information the QIDP and

Residential Management Team

gathers by overseeing direct care

staff – it will determine if staff

person(s) need further training on

client’s health care protocols.





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further incident."

The IR for the 4/28/18 incident at 12:00 PM

indicated RN #1 was notified via text message on

4/29/18 at 12:30 PM regarding client A's choking

incident.


5/16/18 at 4:00 PM. ED #1 indicated staff working

in the home should be trained on HRP's prior to

providing care for client A. ED #1 indicated client

A has a risk plan for choking. ED #1 indicated the

client A's risk plan should be followed as written.


9-3-3(a)

483.460(a)(3)

PHYSICIAN SERVICES

The facility must provide or obtain preventive

and general medical care.

W 0322

Bldg. 00


sample clients (A), the facility failed to ensure

client A followed recommendations for a specialist

visit following a hospitalization.

Findings include:


PM. Client A's record indicated the following:

- Client A's Discharge Summary Note (DSN) dated

3/9/18 indicated client A had been hospitalized.

The DSN indicated the following:

W 0322 Client A was discharged from the

hospital on 3/9/2018. Client A’s

discharge summary note indicated

a follow up visit with a

Gastroenterologist (GI) in 2

weeks. The Agency Nurse called

the Gastroenterologist office the

morning of 3/11/2018 and

explained Client A’s status.

Agency Nurse explained that

Client A needed to be seen by the

Gastroenterologist within 2 weeks

based on hospital discharge

06/17/2018 12:00:00AM





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15G189 05/18/2018


220 S COLLEGE ST

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"Discharge diagnosis: Retained food bolus,

community acquired pneumonia, hypertension

(high blood pressure), osteoarthritis, gastritis

(stomach inflammation), and esophagitis

(esophagus inflammation)."

"Follow up: Gastroenterologist (GI) in 2 weeks."

- Client A's record review did not indicate client A

attended a GI specialist visit until 4/5/18.




followed.


9-3-6(a)

instructions. The

Gastroenterologist office’s earliest

available appointment for Client A

was on 4/5/2018 at 11:00am.

When a client receives a

recommendation to see a

specialist from a physician and/or

per hospital discharge instructions

the Agency Nurse will call and

make the appointment within one

business day. The Agency Nurse

will call and schedule the earliest

available appointment for the

client. When a scheduled

appointment is made outside a

recommended timeframe, the

Agency Nurse will document the

reasoning of the late scheduled

appointment within Nurse’s

Notes.

483.460(c)

NURSING SERVICES

The facility must provide clients with nursing

services in accordance with their needs.

W 0331

Bldg. 00


sample clients (A), the facility nursing services

failed to ensure client A's medication

administration modifications recommended by

specialists were implemented.

Findings include:


PM. The review indicated the following:

- Client A's Speech Therapy Swallow Evaluation

dated 3/9/18 at 7:45 AM indicated, "Medication

delivery: Whole, one pill at a time with a puree

(food)."

W 0331 Agency Nurse reviewed the

3/9/2018 Speech Therapy Swallow

Evaluation as soon as it was faxed

to C.A.R.S. on 3/30/2018 at

1:16pm. Agency Nurse’s

impression was that the

Medication Delivery instructions

for whole, one pill at a time with

puree was a recommendation

while Client A was in the hospital

as opposed to a discharge

instruction to follow at the group

home.

On May 24, 2018, Agency Nurse

sent out a guide for Client A’s

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following:










further incident."










further incident."




followed. RN #1 indicated client A takes his

medications whole with sips of water. RN #1

indicated client A does not use a puree to assist

with medication administration.


9-3-6(a)

mechanical soft diet which

included general dietary guidelines

for Client A, Client A’s issues with

swallowing, encouragement to give

Client A while eating,

recommended foods, items to add

to soften or moistened foods and

foods to avoid. All appropriate

staff that work with Client A was

trained on these dietary guidelines

by their respective management

supervisor.

During the last week of May,

CEO, Agency Nurse and SGL

Assistant Director observed Client

A while medications were being

administered. Observations

revealed that Client A had difficulty

swallowing 2 large pills. As a

result on June 1, 2018, Agency

Nurse changed Client A’s Calcium

large tablet to Chewable Caltrate

600+Vitamin D and changed

Depakote large pill to liquid form.

On June 7, 2018, Agency Nurse

updated Client A’s High Risk Plan

to give further instructions for staff

to follow for Choking. QIDP

trained all residential staff on client

A’s plans…Objectives, Behavior

Plan, Personal Profile and High

Risk Plan which included steps to

take for a high risk of Choking.

Effective immediately, when a

client receives a recommendation

from a physician, specialist and/or

per hospital discharge instructions

the Agency Nurse will follow up

with the respective entity to clarify

the recommendation as deemed





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necessary.

Agency Nurse will work with the

Residential Management Team to

ensure that all staff are trained on

the recommendation and follow

through on the recommendation.

Effective immediately the Agency

Nurse, along with the Residential

Management Team, will oversee


sufficiently following all

recommendations.







knowledge in regards to the

recommendation(s). Based on

what information the Agency

Nurse and Residential




further training on

recommendation(s).

483.460(k)(1)

DRUG ADMINISTRATION

The system for drug administration must

assure that all drugs are administered in

compliance with the physician's orders.

W 0368

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sample clients (A and D), the facility failed to

administer clients A and D's medication as

ordered by a physician.

Findings include:


Assistant Director and Agency

Nurse trained all residential staff

on Med Errors in regards to proper

medication administration

protocols, Med Buddy

responsibilities and proper

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The facility's BDDS (Bureau of Developmental

Disabilities Services) reports were reviewed on

5/16/18 at 10:30 AM. The review indicated the

following:

1. BDDS report dated 3/8/18 indicated, "Staff

discovered that [client A] did not receive his 7:00

PM medications on 3/6/18. Divalproex Sodium ER

(Extended Release) (personality disorder) 500 MG

(Milligram) tablet... Clonazepam (personality

disorder) 0.5 MG tablet... Calcium 600 MG plus

Vitamin D 800 (osteoporosis)...".


PM. Client A's Recertification Form (RF) dated

4/16/18 was completed by client A's Primary Care

Physician (PCP). The RF indicated,

- "Divalproex Sodium ER 500 MG tablet: Take 1

tablet by mouth twice daily."

- "Clonazepam 0.5 MG tablet: Take 1 tablet by

mouth in the morning. Take 1/2 tablet by mouth at

bedtime."

- "Calcium 600 MG plus Vitamin D tablet: Take 1

tablet by mouth twice daily."

2. BDDS report dated 3/8/18 indicated, "On 3/7/18,

staff discovered that [client D] had not received

his 7:00 AM Risperidone (psychosis) 0.5 MG

tablet on 3/6/18. No adverse effects were noted

due to the error."

Client D's record was reviewed on 5/16/18 at 2:15

PM. Client D's RF dated 4/16/18 was completed by

client D's PCP. The RF indicated,

- "Risperidone 0.5 MG tablet: Take 1 tablet by

procedures for re-ordering

medications in a timely manner so

medications are available for

administration.

Effective immediately, the Agency


Management team will continue to

complete random supervised med

passes on both new and

seasoned staff throughout the

month. The Agency Nurse and


will be required to increase the

frequency of random supervised

med passes on both new and

seasoned staff throughout each

month.

Effective immediately, the Agency



staff to (1) ensure staff is able to

demonstrate continuous

competency in medication

administration (2) assess staff’s

ongoing training needs in regards

to medication administration.


limited to (a) direct observation of


administering medication (b)

conducting a review of all

medication error reports that have

been submitted by direct care staff

(c) observing direct care staff

during medication administration

to analyze their knowledge in

regards to medication

administration. Based on what

information the Agency Nurse and






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mouth twice daily."

3. BDDS report dated 4/16/18 indicated, "[Client

D] did not receive his Biotene (oral dryness)

mouth rinse due to staff didn't (sic) complete an

order fill as indicated on shift checklist."




- "Biotene Oral Rinse: Swish 1 tablespoon in

mouth for thirty seconds as needed up to five

times daily."

4. BDDS report dated 4/27/18 indicated, "During

9:00 PM medication administration on 4/26/18,

staff noted that one of the two capsules of

Levetiracetam (seizures) 500 MG was stuck to the

packaging adhesive on the back side of the

medication card from the previous evening

4/25/18. [Client D] only received one of two

capsules of his prescribed dose on 4/25/18."




- "Levetiracetam 500 MG tablet: Take 2 tablets by

mouth twice daily."


5/18/18 at 9:25 AM. RN #1 indicated clients A and

D's medication should be given as ordered by the

physician.

9-3-6(a)

has gathered by overseeing staff –

it will determine if staff person(s)

need further training in medication

administration

483.480(a)(1)

FOOD AND NUTRITION SERVICES

W 0460





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Each client must receive a nourishing,

well-balanced diet including modified and

specially-prescribed diets.

Bldg. 00

Based on observation, record review, and

interview for 4 of 4 sample clients (A, B, C, and D),

plus 4 additional clients (E, F, G, and H) the facility

failed to ensure staff implemented the prescribed

menu plan for clients A, B, C, D, E, F, G, and H

during mealtime.

Findings include:

Observations were done at the home on 5/16/18

from 6:05 AM to 6:55 AM. At 6:27 AM, clients A,

B, C, D, E, F, G, and H's breakfast was set on the

table. The breakfast consisted of cereal, toast, and

scrambled eggs.

Clients A, B, C, D, E, F, G, and H's menu dated

Week 1 was reviewed on 5/16/18 at 6:25 AM. The

menu was posted on the home's refrigerator. The

menu indicated the following:

- "Wednesday: Two apple cinnamon pancakes,

two turkey bacon pieces, and 1 orange."

Staff #2 was interviewed on 5/16/18 at 6:39 AM.

Staff #2 indicated the menu for the home was

posted on the refrigerator. Staff #2 indicated the

menu should be followed as written. Staff #2

indicated she was unsure of why the menu was

not followed this morning.


5/16/18 at 4:00 PM. ED #1 indicated the posted

menu should be followed. ED #1 indicated if

variations are made from the menu, the alternative

should be from the same food group.

9-3-8(a)

W 0460 On June 7, 2018 – QIDP trained

all residential staff on menus

which included…ensuring a menu

is posted in the kitchen at all

times, following the menu each

day for each meal, documenting

changes on the menu.


along with the Residential



implementing menu plans during

mealtimes.







knowledge in regards to menu

plans. Based on what information

the QIDP and the Residential




further training on menu plans.

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W 9999

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STATE FINDINGS:

The following Community Residential Facilities for

Persons with Developmental Disabilities Rule was

not met.

460 IAC 9-3-1 Governing Body

(b) The residential provider shall report the

following circumstances to the division by

telephone no later than the first business day

followed by written summaries as requested by

division. (15.) A fall resulting in injury, regardless

of the severity of the injury.

THIS STATE RULE WAS NOT MET AS

EVIDENCED BY:


incidents of falls resulting in injury, the facility

failed to immediately report client C's fall with

injury to BDDS (Bureau of Developmental

Disabilities Services).

Findings include:

BDDS reports were reviewed on 5/16/18 at 10:30

AM. The review indicated the following:

- BDDS report dated 4/2/18 indicated, "While staff

assisted [client C] out of the van, by holding onto

gait belt and her arm, [client C] was rushing and

fell onto her side (sic) resulting in 2 1/2 IN (Inch)

by 1 1/2 IN and 1 IN by 1 IN scrapes in left knee."

The report indicated the incident date was 3/30/18.

The date of administrative knowledge is listed as

W 9999 On June 7, 2018 – the Residential

Management Team trained all

residential direct care staff about

submitting incident reports.

Training included…completing

incident reports for all instances of

falls, following on-call procedures

for notification of incident reports,

completing an incident report in

AccelTrax and completing an

incident report before the end of

his/her shift.










timekeeping.

On May 10, 2018 – C.A.R.S.



Staff is responsible for completing

an incident report through

AccelTrax which includes all

instances of falls. As soon as

the incident report is submitted,

the system is set up to send an

automatic email to the IDT team

regarding the incident report. This

allows all IDT members and the

administrator to review the incident

report immediately. This in turn

allows the incident report including

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3/30/18. The BDDS reported date is listed as

4/2/18.


5/16/18 at 4:00 PM. ED #1 indicated client C's falls

should be reported to BDDS within 24 hours of

administrative knowledge.

9-3-1(b)

all instances of falls to be

submitted to the state within

24-hours of the alleged incident.

In the past, during non-office hours

(evenings, weekends, holidays),

the Director of Adult Services and

Quality Assurance Coordinator

was responsible for submitting

incident reports to the state within

24 hours of the alleged incident.

On May 10, 2018 – the SGL

Assistant Director was added as

one more person to be responsible

for submitting incident reports to

the state during non-office hours.


W 0000 #IN00258242.

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