W 0000 - secure.in.gov · TAG SUMMARY STATEMENT OF DEFICIENCIE ... 428 S 15TH ST 00 W 0000 ... (E,...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

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FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

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

(X4) ID

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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

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

RICHMOND, IN 47374

15G341 03/20/2018

VOCA CORPORATION OF INDIANA

428 S 15TH ST

00

W 0000

Bldg. 00

This visit was for the investigations of complaints

#IN00256090 and #IN00243877.

Complaint #IN00243877: Substantiated.

Federal/state deficiencies related to the

allegations are cited at W102, W104, W122, W149

and W186.

Complaint #IN00256090: Substantiated.

Federal/state deficiencies related to the

allegations are cited at W102, W104, W122, W149

and W186.

Unrelated deficiencies cited.

Survey Dates: March 15, 16, 19 and 20, 2018.

Facility Number: 000857

Provider Number: 15G341

AIMS Number: 100243690

These deficiencies also reflect state findings in

accordance with 460 IAC 9.

Quality Review of this report completed by #15068

on 3/29/18.

W 0000

483.410

GOVERNING BODY AND MANAGEMENT

The facility must ensure that specific

governing body and management

requirements are met.

W 0102

Bldg. 00

Based on observation, record review and

interview, the facility failed to meet the Condition

of Participation: Governing Body for 4 of 4

sampled clients (A, B, C and D), and 4 additional

clients (E, F, G and H). The governing body failed

W 0102 CORRECTION:

The facility must ensure that

specific governing body and

management requirements are

met. Specifically:

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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: E7F411 Facility ID: 000857

TITLE

If continuation sheet of 62

(X6) DATE




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to exercise general policy, budget and operating

direction over the facility to ensure the facility

implemented policies and procedures which

prohibited abuse/neglect/mistreatment of clients.

The governing body failed to exercise general

policy, budget and operating direction over the

facility to ensure there was sufficient staff to

implement client A's behavior management

protocols.

Findings include:

1. The facility's governing body failed to exercise

general policy, budget and operating direction

over the facility to ensure the facility met the

Condition of Participation: Client Protections. The

facility's governing body failed to exercise general


facility for 4 of 4 sampled clients (A, B, C and D),

and 4 additional clients (E, F, G and H), to ensure

the facility implemented policies and procedures

which prohibited abuse/neglect/mistreatment of

clients (client A's physical/verbal abuse toward

his peers). Please see W122.

2. The governing body failed to exercise general


facility to ensure the facility implemented policies

and procedures which prohibited

abuse/neglect/mistreatment of clients and failed to

ensure sufficient staff were available so behavior

management techniques, policies and procedures

were implemented for 4 of 4 sampled clients (A, B,

C and D), and 4 additional clients (E, F, G and H),

in regards to client A's physical and verbal

aggression. Please see W104.

This federal tag relates to Complaint #IN00243877.


Through ongoing assessment, the

interdisciplinary team determined

that client would be more

successful in a residential setting

with fewer housemates and

reduced external stimuli.

Therefore, the governing body, in

cooperation with the Bureau of

Developmental Disability Services,

has removed client A from the

home and assisted client A with

obtaining Medicaid Waiver

Services and he no longer resides

in the facility.

The Governing Body has directed

the facility to modify the staffing

matrix to assure that there are no

less than three staff on duty

between 6:00 AM and 9:00 AM to

provide active treatment during

morning medication

administration, morning hygiene

and breakfast. No less than three

staff will be on duty during evening

hours, with additional staffing

resources to be made available,

based on acute need. Day,

evening and night timeframes are

defined below. The governing body

has determined that based on the

current census at the facility (6),

combined with current assessed

behavioral and developmental

needs, single staffing on the

overnight shift is appropriate.

When incidents occur that require

enhanced supervision for any

clients, an additional staff will be

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E7F411 Facility ID: 000857 If continuation sheet of 62




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9-3-1(a) added to the overnight shift.

When direct support personnel are

unavailable to provide coverage as

described above, salaried

supervisory staff will fill in,

providing direct support as

needed.

Root Cause Analysis of why

corrections implemented after

the 7/28/17 survey have failed.

·The governing body failed to

assure appropriate staffing was in

place in the home to support an

aggressive client.

·The facility experienced a

staffing crisis due to inability to

hire qualified direct support staff.

·A majority of qualified direct

support candidate who declined

job offers indicated an

unwillingness to travel 60 miles for

the agency’s five-day new hire

orientation training program.

PERVENTION:

The Residential Manager will be

present, supervising active

treatment during no less than five

active treatment sessions per

week, on varied shifts to assist

with and monitor skills training

including but not limited to

including assuring behavior

supports are followed as written.

Members of the Operations Team

(comprised of the Executive

Director, Operations Managers,

Program Managers, Quality





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Assurance Manager, QIDP

Manager, Quality Assurance

Coordinators, Nurse Manger and

Registered Nurse) will review

facility support documents and

perform visual assessments of the

facility no less than three times

weekly for the next 30 days, and

after 30 days, will conduct

administrative observations no

less than weekly until all staff

demonstrate competence, as

determined by the Executive

Director and Regional Director

(Area Manager). At the conclusion

of this period of enhanced

administrative monitoring and

support, the Executive Director

and Regional Director will

determine the level of ongoing

support needed at the facility.

Active Treatment sessions to be

monitored are defined as:

Mornings: Beginning at 6:30 AM

and through morning transport and

including the following: Medication

administration, meal preparation

and breakfast, morning hygiene

and domestic skills training

through transport to work and day

service. Morning active treatment

monitoring will include staff from

both the day and overnight shifts.

Evenings: Beginning at

approximately 4:30 PM through

the evening meal and including the

following: domestic and hygiene

skills training, leisure skills





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training, medication


and dinner. Evening monitoring will

also include unannounced spot

checks later in the evening toward

bed time.

In addition to active treatment

observations, Operations Team

Members and/or the Residential

Manager will perform spot checks

at varied times on the overnight

shift no less than twice monthly

–more frequently if training issues

or problems are discovered.

Operations Team members have

been trained on monitoring

expectations. Specifically,

Administrative Monitoring is

defined as follows:

·The role of the administrative

monitor is not simply to observe &

Report.

·When opportunities for training

are observed, the monitor must

step in and provide the training

and document it.

·If gaps in active treatment are

observed the monitor is expected

to step in, and model the

appropriate provision of supports.

·Assuring the health and safety

of individuals receiving supports at

the time of the observation is the

top priority.

·Review all relevant

documentation, providing

documented coaching and training

as needed.





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The Executive Director and

Director of Operations/Regional

Manager (area manager) will

review documentation of

administrative level monitoring of

the facility –making

recommendations as appropriate.

As stated above, the Executive

Director will participate directly in

administrative monitoring of the

facility. Administrative support at

the home will include

·Assuring staff provide

continuous active treatment during

formal and informal opportunities,

including assessing the

effectiveness of behavior supports

and assuring behavior supports

are implemented as written.

·Assuring adequate direct

support staff are on duty to meet

the needs of all clients.

The Quality Assurance Manager

and QIDP Manager or other

designated Quality Assurance

staff will perform spot checks of

attendance records to assure

ongoing compliance. If

deficiencies are noted, the QA

staff will notify the Program

Manager, Operations Manager and

Executive Director to assure

prompt corrective action. Prior to

each schedule period, the

Operations Team will follow-up

verbally and via email to assure

that appropriate coverage has

been arranged.





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Preventative measures to be

implemented based on Root

Cause Analysis of why

corrections implemented after

the 7/28/17 survey have failed.

The governing body has

established a new hire orientation

training program in Wayne

County, Indiana to alleviate the

need to travel to receive initial

training certification. This program

has resolved the staffing crisis.

RESPONSIBLE PARTIES: QIDP,

Area Supervisor, Residential

Manager, Health Services Team,

Direct Support Staff, Operations

Team, BDDS Generalist, Regional

Director

483.410(a)(1)

GOVERNING BODY

The governing body must exercise general

policy, budget, and operating direction over

the facility.

W 0104

Bldg. 00


interview, the facility's governing body failed for 4

of 4 sampled clients (A, B, C and D), and 4

additional clients (E, F, G and H), to exercise


over the facility to ensure the facility implemented

policies and procedures which prohibited

abuse/neglect/mistreatment of clients (due to

client A's aggressive and threatening behaviors)

and failed to ensure sufficient staff was available

to implement behavior management techniques

and procedures.

W 0104 CORRECTION:


specific governing body and

management requirements are

met. Specifically:








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Findings include:

The facility's governing body failed to exercise


over the facility by neglecting to implement its

written policy and procedures to prevent abuse in

regard to the targeted aggression of clients by

client A. The governing body neglected to ensure

staff followed/implemented Behavior Support

Plans (BSP) to prevent the abuse and/or potential

abuse to clients by client A. The governing body

neglected to ensure sufficient staffing was

available and/or deployed in a way to implement

client A's BSP to keep clients safe. The governing

body neglected to ensure during the overnight

hours the home was provided with more than one

staff. Please see W149.

The facility's governing body failed to exercise


over the facility by failing to ensure sufficient

staff was available to implement client A's

behavior management supervision to ensure

safety of his fellow housemates, for 4 of 4 sampled

clients (clients A, B, C and D) and 4 additional

clients (clients E, F, G and H). Please see W186.



9-3-1(a)







in the facility.

The Governing Body has directed

the facility to modify the staffing

matrix to assure that there are no

less than three staff on duty

between 6:00 AM and 9:00 AM to

provide active treatment during

morning medication

administration, morning hygiene

and breakfast. No less than three

staff will be on duty during evening

hours, with additional staffing

resources to be made available,

based on acute need. Day,

evening and night timeframes are

defined below. The governing body

has determined that based on the

current census at the facility (6),

combined with current assessed

behavioral and developmental

needs, single staffing on the

overnight shift is appropriate.

When incidents occur that require

enhanced supervision for any

clients, an additional staff will be

added to the overnight shift.






needed.





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PERVENTION:









































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bed time.













defined as follows:



Report.





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and document it.








top priority.




as needed.












the home will include

·Assuring staff provide

continuous active treatment during

formal and informal opportunities,

including assessing the

effectiveness of behavior supports

and assuring behavior supports

are implemented as written.

·Assuring adequate direct

support staff are on duty to meet

the needs of all clients.





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been arranged.






Director

483.420

CLIENT PROTECTIONS

The facility must ensure that specific client

protections requirements are met.

W 0122

Bldg. 00


interview for 4 of 4 sampled clients (A, B, C and

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

Condition of Participation: Client Protections was

not met. The facility neglected to implement

policies and procedures to ensure the rights of all

clients to be free of neglect and verbal, emotional

and physical abuse by failing to address client A's

property destruction and physical and verbal

aggression.

Findings include:

W 0122 CORRECTION:


specific client protections

requirements are met.

Specifically, the governing body

facilitated the following:






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interview, for 4 of 4 sampled clients (A, B, C and


facility neglected to implement policies and

procedures which prohibited

abuse/neglect/mistreatment of clients (due to

client A's aggressive and threatening behaviors).

Please see W149.


interview, for 4 of 4 sampled clients (A, B, C and


facility failed to ensure sufficient staff was

available to implement client A's behavior

management and supervision needs to ensure

safety of his fellow housemates. Please see

W186.



9-3-2(a)









in the facility.

PERVENTION:


































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bed time.













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defined as follows:



Report.




and document it.








top priority.




as needed.












the home will include assuring

staff provide continuous active

treatment during formal and

informal opportunities, including





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assessing the effectiveness of

behavior supports and assuring

behavior supports are

implemented as written.






Director

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


interview for 4 of 4 sampled clients (A, B, C and


facility failed to implement policies and

procedures to ensure the rights of all clients to be

free of neglect and verbal, emotional and physical

abuse by failing to address client A's property

destruction and physical and verbal aggression.

Findings include:

Observations were conducted at the facility on

the evening of 3/15/18 from 12:46 PM until 5:03

PM. Clients F and H were at the local

workshop/day service provider. Clients C, D, E,

and G were on an outing with staff #5 and #6.

Clients A, C, D, E, and G did not attend a

workshop or day program on a routine basis.

Client A was on a home visit with his

Grandmother. According to review of the daily

(client) census book (3/16/18 at 6:30 AM), client A

had been on leave of absence since 3/4/18.

W 0149 CORRECTION:

The facility must develop and

implement written policies and

procedures that prohibit

mistreatment, neglect or abuse of

the client. Specifically:














in the facility.

PERVENTION:

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The facility was a two story dwelling with two

stairways that had formerly been a duplex

apartment type building. The facility was home to

7 male clients with clients G and H having single

bedrooms on the first floor of the facility. Clients

A, B, D, E and F had single bedrooms on the

second floor of the facility.

An environmental tour of the facility on 3/15/18 at

1:00 PM was conducted. Client A's bedroom was

observed to have repairs to the bottom portion of

the bedroom door. The inside wall immediately to

the left of the bedroom door was observed to be

new wallboard with newly applied carpenter's

"mud" over the seamed/nailed areas of the

wallboard.

Interview with Maintenance staff #1 on 3/15/18 at

1:10 PM indicated a new door had been ordered

for client A's bedroom and the wall board needed

another coating of "mud" before paint would be

applied.

Client E's bedroom was observed at 1:15 PM and

was found to have gauges in the wallboard of two

walls. House Manager/HM #3 had alerted

maintenance staff the walls were in need of repair

on 3/14/18 according to Maintenance staff on

3/15/18 at 1:10 PM. It was unclear if client E had

damaged the walls or the former occupant of the

room, discharged client B, had damaged the walls.

Observations were also conducted on the

morning of 3/16/18 from 4:57 AM until 7:30 AM.

One staff (staff #10 Direct Support

Professional/DSP) was supervising clients C, D, E,

F, G and H. According to review of the staff

3/10-23/18 schedule at 5:00 AM on 3/16/18, staff

#10 and #11 were scheduled to work on 3/15/18.

One staff was scheduled to work from 6:00 PM

until 10:00 PM and the other staff was scheduled












































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to work from 6:00 PM until 10:00 PM on 3/15/18.

Interview with House Manager/HM staff #3 on

3/16/18 at 7:00 AM indicated the agency was in

the process of hiring/training a new staff to fill a

vacancy on third/overnight shift. Some nightshift

staff had been scheduled to work partial shifts

alone until the staff vacancy on nightshift was

filled.


the evening of 3/19/18 from 4:10 PM until 7:25 PM.

Client A was observed to be at the facility with his

peers, clients C, D, E, F, G and H.

Interview with client D was conducted on 3/15/18

at 2:17 PM. Client D stated "([Client A])

uses weapons and threatens people...stick from

room...came back from workshop and had (a) stick

in his hand went after [client C]. I told my

treatment team."

Review of HRC (Human Rights Committee)

minutes on 3/16/18 at 3:03 PM indicated client D

had indicated concerns regarding a housemate at

the 3/6/18 meeting: "Note: [Client D] stated to

HRC members that he was scared of his

housemate [client A] due to his behaviors. [Client

D] stated to HRC members that he told his Mom &

(and) dad that he was scared of his housemate

[client A]. [Client D] also stated that his parents

were gonna take care of it."

Client C stated (3/15/18 2:23 PM): "[Client A]

chased me around in circles up and down the

stairway. I ran out outside."

Interview with client D was continued on 3/15/18

at 2:50 PM. When asked how things were going at

the facility client D stated: "[Client E, newly

admitted to the facility 2/1/18)] comes into my


















bed time.













defined as follows:



Report.








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room (when) I'm sleeping...showed me his

possessions...I want to have peace in my room.

[Client E] needs to knock. I was in bed (and) said

'Dude I'm trying to sleep'."

When asked about any other concerns in the

facility, client D stated when another peer (client

A) had behaviors, "I went out (the) back door to

be safe." Client D was asked to explain his

concerns regarding client A, and client D stated:

"To be honest kind of nervous because he could

be doing the same kind of thing when he comes

back. (Client A was currently on leave of absence

from the facility.) Client D stated in regards to

client A's behavior, "Tearing up his room again.

Threatening people that kind of stuff." When

asked which people, client D stated: "Usually

goes after [peers living in the facility] [client C].

[Client G] gets scared. I get really scared. I go

downstairs. Most of the guys (clients) are scared

of him--one resident wanted to move out."

Review of reportable incidents/BDDS (Bureau of

Developmental Disabilities Services) reports,

investigations and internal incident reports from

10/1/2017 to the time of the survey was conducted

on 3/15/18 at 5:00 PM and 3/16/18 at 9:10 AM and

indicated the following.

1. A BDDS report filed by QIDP/Qualified

Intellectual Disabilities Professional #2 on 3/05/18

indicated an incident on 3/04/18 at 1:35 PM:

"[Client A] is [age] year- old male with a primary

diagnosis of Mild Intellectual Disability, who lives

in a supervised group living home with 7 other

men. [Client A] became upset after talking to his

girlfriend. [Client A] began to engage in property

destruction in his room. Staff attempted to

redirect him verbally without success. He broke

through a section of drywall and broke out a panel

on his bedroom door. [Client A] threatened to hit

and document it.








top priority.




as needed.












the home will include assuring

staff provide continuous active



assessing the effectiveness of

behavior supports and assuring

behavior supports are

implemented as written.



Manager, Direct Support Staff,

Operations Team, BDDS

Generalist, Regional Director





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a housemate with a piece of a mini-blind but was

(sic) staff positioned themselves between [client

A] and the housemate and prevented contact from

occurring. Neighbors heard [client A] yelling and

using profanity and called the police. [City] police

arrived and spoke with [client A] and left without

taking further action. [Client A] calmed and

assisted in cleaning his room."

The BDDS report's "Plan to Resolve (Immediate

and Long Term)" component written by QIDP #2

indicated: "[Client A] was not injured during the

incident. Verbal aggression and property

destruction are addressed in [client A's] Behavior

Support Plan. It should be noted the damages

were cleaned up and no health or safety hazards

are present. The damage will be repaired. Staff

swept [client A's] room for potentially harmful

items and he will remain on 15 minute checks for

safety. Staff will continue to follow the proactive

strategies in [client A's] plan to help reduce and

prevent further occurrences."

An IDT/Interdisciplinary Team Meeting regarding

the incident of 3/4/18, dated 3/16/18, was reviewed

on 3/16/18 at 3:40 PM. The IDT indicated client A

became upset and engaged in property damage to

his room. "He (client A) stated he was upset

about his girlfriend who lives in [city]. The team

has noticed a correlation between aggressive

behaviors and his girlfriend when he wants to go

visit. The incident (sic) have happened a day or

two before he is scheduled to go visit grandma

who lives in [same city]...Upon return to site (sic)

the team agrees to have one staff upstairs for at

least a week and if no further issues return to

normal staff duties. The team agrees to have one

staff upstairs a week before he is scheduled to go

home for safety due to co-relation (sic)...."

Client A's BSP/Behavior Support Plan dated





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5/12/17, was revised 3/16/18 and again on 3/19/18.

The 3/19/18 BSP (reviewed on 3/19/18 at 3:08 PM)

indicated: "...the following additional supports

have been implemented. Whenever [client A] has

engaged in physical aggression toward a

housemate or threatens to injure or harm a

housemate, staff are to initiate immediate

protective measures. These measures include

keeping [client A] in line of sight whenever he is

downstairs. At the 1st sign of agitation...staff will

move to within arm and a half's length of him and

assume a (YSIS) You're Safe, I'm Safe (facility

approved/taught behavior management

techniques) prepared stance....

When [client A] is upstairs in his bedroom or in a

housemate's bedroom, a staff is to remain upstairs

for safety. Staff will document on 15-minute check

sheets.

At the 1st sign of agitation while upstairs, staff

will move to within arm and a half's length of him

and assume a You're Safe, I'm Safe prepared

stance....

This will last at least a week and if after that time

he has not made any further threats to harm

others or engaged in physical aggression then the

protective measures will stop.

If [client A] does become agitated then staff will

maintain a calm approach at all times. [Client A]

will attempt to intimidate people to get what he

wants. As soon as [client A] senses fear, he will

escalate quickly towards potentially dangerous

violent behavior."

Interview with QIDP/Qualified Intellectual

Disabilities Professional #1 on 3/20/18 at 2:00 PM

indicated clients who exhibited physical

aggression had one or two person YSIS behavior

management techniques in their BSPs. The BSPs

also may have "enhanced supervision" for

aggressive behaviors, self injurious behaviors or





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elopement. Enhanced supervision was to be in

staff's line of sight for a time period determined by

the client's BSP or the IDT. The interview

indicated client A's current line of sight

supervision was 24 hours for 7 days. The Line of

sight supervision had commenced when client A

returned from his visit with family on 3/17/18 at

2:00 PM.







2. A BDDS report dated 3/10/18 indicated on

3/9/18 at 4:30 PM, client G eloped from the facility.

Staff picked up client G and he was returned to the

facility. Client G was out of line of sight for

"approximately 30 minutes." Client G "is on

enhanced supervision (line of sight during waking

hours and 15 minute checks at night) per the

post-elopement protocol in his Behavior Support

Plan."

3. A BDDS report dated 3/12/18 indicated client C

had left his assigned area on 3/11/18 at 2:30 PM.

Client C was listening to music, then stood up

from the dining table and told staff he was

leaving.

Client C walked out the front door. "Staff followed

[client C] for approximately 2 blocks, keeping him

in line of sight. Staff had (sic) one on one talk with

[client C] and he returned to the home with no

further issues...[Client C] has a history of leaving

his assigned area that is addressed in his support

plan...."

4. A BDDS report dated 2/25/18 indicated an





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incident on 2/24/18 at 12:30 PM. Client G

approached staff and told them he was upset and

had hit his head on the desk. Staff assessed client

G and after contacting the facility's nurse for

instructions, took client G to a local emergency

room/ER for evaluation of "possible head trauma."

The client was evaluated and no evidence of head

trauma was found. The BDDS report indicated

client G had a BSP which addressed

"self-injurious and attention seeking behavior...

[client G] was placed on enhanced

supervision-line of sight and 15 minute checks at

night for 24 hours, per his plan...."


incident on 2/24/18 at 1:30 PM. "Staff was

assisting in cleaning space on an electronic tablet

to which [client E] and his housemates have

access and came across sexually explicit pictures

that [client E] said he sent to a housemate's sister

through [name of social media.] Staff deleted the

explicit content and explained to [client E] that the

tablet is shared with housemates and discussed

the dangers of sending/posting explicit pictures

on social media...."


incident on 2/22/18 at 9:00 PM when staff

discovered sexually explicit pictures client E had

sent to a female he had met "through a dating

application" on an electronic tablet that was

shared by the clients in the facility. The BDDS

report indicated "[client E's] guardian has directed

the team to limit his access to pornography and to

restrict him from posting explicit contact on social

media. The interdisciplinary team will meet to

develop guidelines to assist [client E] in making

better choices and and (sic) to train him toward

safe use of social media."





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incident on 2/16/18 at 7:35 PM when staff went to

get client E for medications and "smelled smoke.

Staff noted remnants of burned paper and asked

[client E] what was burning and he said he wanted

to see how ink melted when burning and had lit a

piece of paper with a lighter. Staff asked [client E]

how he obtained the lighter and he said he found

it."

There were no injuries or property damage

according to the BDDS report. The report

indicated, "The

[IDT] will meet to create a plan for safety and add

fire starting to his [BSP]."


incident between clients E and F on 2/13/18 at 2:00

PM.

"[Client F] told staff he was upset with [client E].

[Client F] said that [client E] was outside his

bedroom door on the evening of 2/12/18 and when

[client F] opened the door, [client E] grabbed him

by the throat, with one hand, for approximately 2

seconds. [Client F] said [client E] went to his room

with no further incident." The BDDS report

indicated no injuries were noted and the team

would investigate to "verify the altercation

occurred...."


incident on 1/28/18 at 5:20 PM. "...[client A] was

threatening [(former client) B] with a stick and hit

him on the left forearm with the stick. [Client A]

remained agitated and kicked [client B's] bedroom

door, causing it to break. [Client A] punched

[client B] in the face causing his nose to bleed.

Staff was able to separate [client B] and [client A]

to difference (sic) area's (sic) of the home." Client

B was transported by staff to a local ER for

evaluation and x-rays which produced normal





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results. Client B was released and was transported

by staff back to the facility. "[Client B] sustained

a bloody nose and a 3 inch by 2.5 inch bruise to

his left mid forearm from where he was struck by

the stick. Staff will continue to monitor for further

marks, or bruising and offer emotional support to

[client B]." The BDDS report indicated both

clients had BSPs which addressed physical

aggression and client A was currently on

therapeutic leave with his grandmother. The

BDDS report indicated the IDT would meet to

develop "additional protective measures to be

incorporated into [client A's] plan."

The 1/29/18 IDT was reviewed on 3/19/18 at 9:00

PM. The IDT indicated "On 1-28-18 [client A]

became upset and punched a housemate in the

nose. [Client A] then hit him with a stick on his

arm.[Client A] stated he was upset with

housemate talking about going to waiver and

having alone time. [Client A] has a history of

physical aggression. Team agrees to have one

staff upstairs at night for safety in case needed.

This will last for 7 days and if no occurrences then

return to normal staffing routine. [Client A] was

scheduled to go visit his grandma and requested

to go a day early which she agreed to and he went

on 1-28-18."


incident of client to client aggression on 11/17/17

at 4:00 PM. "[Client A] received a text from his

girlfriend and became upset and walked out (sic)

the house. Staff followed and [client A] was

walking up and down the sidewalk carrying a

stick. [Client A] went into the house and became

verbally aggressive still carrying the stick. Staff

redirected house mates away and to the van.

[Client A] walked in and outside the house and

went to the van hitting the van with the stick.





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Staff redirected house mates to the back yard

while another staff drove the van around back. As

house mates were walking toward the van [client

A] came to the back yard, displaying verbally (sic)

aggression and heading towards house mates.

Staff went to redirect and [client A] ran and

jumped the fence and hit [client C] on the right

cheek with a closed fist. [Client A] continued to

run away down the alley and stopped. [Client C]

and house mates got into the van and went for a

drive. Another staff remained with [client A] who

continued to be verbally aggressive and holding a

stick. Staff encouraged [client A] to use his

coping skills and he refused. [Client A] walked to

the front of the house still carrying a stick and

staff verbally redirected to drop the stick before

coming in due to one house mate still being

inside. [Client A] refused and started hitting and

kicking the front door. When staff could no longer

assure safety, they called 911 and once police

arrived [client A] dropped the stick and sat on the

front porch talking to the Police. [Client A]

calmed and when Police left [client A] came inside

where he went to his room with no further issues."

The BDDS report indicated "Through the night,

one staff remained upstairs beside the bedrooms

during sleeping hours to assure safety."

The 11/17/2017 IDT was reviewed on 3/19/18 at

9:00 PM. The IDT indicated "[Client A] became

upset when his girlfriend broke up with him. He

became physically aggressive toward house mate

who [client A] stated 'looked like the guy she left

him (sic) for.' To help prevent further occurrences

for (sic) the team agrees to have one staff upstairs

when [client A] is upstairs including sleeping

hours. This will last at least a week and if no

issues after that time then staff can return to

normal routine."





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11. A BDDS report dated 10/17/17 indicated client

F had eloped on 10/16/17 at 7:40 PM. The BDDS

report indicated, " Staff received a call from an

unknown person, that there may have been a

client seen walking down the street. Staff went to

check and found [client F] not in the home. Staff

discovered that the alarm to the fire escape had

been shut off. Staff began searching the

community for [client F] and when he was not

found informed the police. Staff continued to

search and after 3 hours staff found [client F]

walking down the alley coming back to the house.

[Client F] returned to the home and was placed on

fifteen minute checks for safety. [Client F] went to

bed with no further issues." The BDDS report

indicated client F had a history of leaving

assigned area but elopement was removed as a

targeted behavior at his annual program plan

review. The BDDS report indicated the team was

"currently researching door alarms that will be

more difficult to circumvent."

The 10/19/17 follow-up BDDS report indicated

client F was out staff's of line of sight for "5 hours

and 30 minutes" and he did not have alone time

addressed in his support plan.


A had eloped on 10/16/17 at 7:40 PM. The BDDS

report indicated, "Staff received a call from an

unknown person, who said that they saw a client

walking down (sic) street. Staff investigated and

noticed [client A] was not in his room. Staff

searched and [client A] came to the front door.

Staff asked what he was doing and he stated that

a house mate went through his room and out the

fire escape door. Staff asked about the door alarm

and [client A] stated he had shut it off. [Client A]

stated that he followed house mate to try to get

him to come back to the house. [Client A] had no





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further issues." The BDDS report indicated the

team was "currently researching door alarms that

will be more difficult to circumvent."


client A was out staff's of line of sight for one

hour and he did not have alone time in his support

plan.

The agency's "Abuse, Neglect, Exploitation,

Mistreatment" policy dated 12/07/10 (revision),

02/26/11 (revision), and 2/26/18 (revision) was

reviewed on 3/15/18 at 8:30 PM and indicated the

agency prohibited abuse, neglect, exploitation and

mistreatment of clients served.

"Policy: RESCARE staff actively advocate for the

rights and safety of all individuals. All allegations

or occurrences of abuse, neglect, exploitation, or

mistreatment shall be reported to the appropriate

authorities through the appropriate supervisory

channels and will be thoroughly investigated

under the policies of RESCARE, Rescare, and

local, state and federal guidelines."

The policy indicated, in part, the following:

"2. Definitions:

Physical abuse: the act or failure to act that results

or could result in physical injury to an individual.

Non-accidental injury inflicted by another person

or persons.

Verbal abuse: the act of insulting or profane

language or gestures directed toward an

individual that subjects him/her to humiliation or

degradation. Coarse, loud tone or language that is

perceived by an individual as offending or

threatening.

Intimidation/emotional abuse: the act or failure to

act that results or could result in emotional injury





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to an individual. The act of insulting or coarse

language or gestures directed toward an

individual that subject him/her to humiliation or

degradation. Discouraging or inhibiting behavior

by threatening both actual or implied. Attitudes or

acts that interfere with the psychological and

social well being of an individual.

Emotional/physical neglect: failure to provide

goods and/or services necessary for the

individual to avoid physical harm. Failure to

provide the support necessary to an individual's

psychological and social well being. Failure to

meet the basic need requirements such as food,

drink, shelter, clothing and to provide a safe

environment.

Program intervention neglect: failure to provide

goods and/or services necessary for the

individual to avoid physical harm. Failure to

implement a support plan, inappropriate

application of intervention with out (sic) a

qualified person notification/review."



9-3-2(a)

483.430(d)(1-2)

DIRECT CARE STAFF

The facility must provide sufficient direct care

staff to manage and supervise clients in

accordance with their individual program

plans.

Direct care staff are defined as the present

on-duty staff calculated over all shifts in a

24-hour period for each defined residential

living unit.

W 0186

Bldg. 00





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interview for 4 of 4 sampled clients (clients A, B, C

and D) and 4 additional clients (clients E, F, G and

H), the facility failed to ensure sufficient staff was

available to implement client A's behavior

management supervision to ensure safety of his

fellow house mates.

Findings include:


the evening of 3/15/18 from 12:46 PM until 5:03

PM. Clients F and H were at the local

workshop/day service provider. Clients C, D, E,

and G were on an outing with staff #5 and #6.

Clients A, C, D, E, and G did not attend a

workshop or day program on a routine basis.

[client A] was on a home visit with his

Grandmother. According to review of the daily

(client) census book (3/16/18 at 6:30 AM), client A

had been on leave of absence since 3/4/18.

The facility was a two story dwelling with two

stairways that had formerly been a duplex

apartment type building. The facility was home to

7 male clients with clients G and H having single

bedrooms on the first floor of the facility. Clients

A, B, D, E and F had single bedrooms on the

second floor of the facility.

An environmental tour of the facility on 3/15/18 at

1:00 PM was conducted. Client A's bedroom was

observed to have repairs to the bottom portion of

the bedroom door. The inside wall immediately to

the left of the bedroom door was observed to be

new wallboard with newly applied carpenter's

"mud" over the seamed/nailed areas of the

wallboard. Interview with Maintenance staff #1 on

3/15/18 at 1:10 PM indicated a new door had been

ordered for client A's bedroom and the wall board

needed another coating of "mud" before paint

W 0186 CORRECTION:

The facility must provide sufficient

direct care staff to manage and

supervise clients in accordance

with their individual program plans.

Specifically, the Governing Body

has directed the facility to modify

the staffing matrix to assure that

there are no less than three staff

on duty between 6:00 AM and

9:00 AM to provide active

treatment during morning

medication administration,

morning hygiene and breakfast.

No less than three staff will be on

duty during evening hours, with

additional staffing resources to be

made available, based on acute

need. Day, evening and night

timeframes are defined below. The

governing body has determined

that based on the current census

at the facility (6), combined with

current assessed behavioral and

developmental needs, single

staffing on the overnight shift is

appropriate. When incidents occur

that require enhanced supervision

for any clients, an additional staff

will be added to the overnight shift.






needed.

PREVENTION:

The Residential Manager and Area

04/19/2018 12:00:00AM





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would be applied. Client E's bedroom was

observed at 1:15 PM and was found to have

gauges in the wallboard of two walls. House

Manager/HM #3 had alerted maintenance staff

(interview with Maintenance staff on 3/15/18 at

1:10 PM) the walls were in need of repair on

3/14/18. It was unclear if client E had damaged the

walls or the former occupant of the room,

discharged client B, had damaged the walls.

Observations were also conducted on the

morning of 3/16/18 from 4:57 AM until 7:30 AM.

One staff (staff #10 Direct Support

Professional/DSP) was supervising clients C, D, E,

F, G and H. According to review of the staff

3/10-23/18 schedule at 5:00 AM on 3/16/18, staff

#10 and #11 were scheduled to work on 3/15/18.

One staff was scheduled to work from 6:00 PM

until 10:00 PM and the other staff was scheduled

to work from 6:00 PM until 10:00 PM on 3/15/18.

Interview with House Manager/HM staff #3 on

3/16/18 at 7:00 AM indicated the agency was in

the process of hiring/training a new staff to fill a

vacancy on third/overnight shift. Some nightshift

staff had been scheduled to work partial shifts

alone until the staff vacancy on nightshift was

filled.


the evening of 3/19/18 from 4:10 PM until 7:25 PM.

Client A was observed to be at the facility with his

peers clients C, D, E, F, G and H. Staff #5 was

preparing to pass medications. Client A came

downstairs and obtained a glass of water without

staff in attendance at 4:40 PM. Client A went back

upstairs to his bedroom saying "be right back"

without staff at 4:42 PM. Staff #5 and #6 were in

the kitchen at 4:43 PM while client A came

downstairs and was in the living room and dining

room without being in staff's line of sight. [client

Supervisor will submit schedule

revisions to Program Manager for

approval prior to implementation.















less than weekly until all staff and

supervisors demonstrate

competence. At the conclusion of

this period of enhanced






















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A] went upstairs without staff at 4:46 PM where

clients E and F were. Client A came back

downstairs at 4:47 PM saying he put away his

tablet (electronic device). At 4:49 PM, staff #6

went upstairs and client A was not in staff's line

of sight while in the dining room.

Review of client A's record was completed on

3/19/18 at 4:15 PM. The progress notes dated

3/17/18 indicated he was at the facility at 2:00 PM

on 3/17/18. The record indicated a body scan form

completed with client A on 3/17/18 at 2:30 PM by

staff #7 after his return from leave of absence with

his grandmother.

Review of staff's time cards was completed with

the Area Supervisor/AD #1 on 3/20/18 at 2:15 PM.

The review indicated staff #10's schedule for

3/17/18 was in at 5:59 PM and out at 12:00 AM on

3/18/18. On 3/18/18 in at 5:59 PM and out at 12:00

AM on 3/19/18.

Staff #11's time records indicated clocking in on

3/17/18 at 5:56 PM until 12:00 AM 3/18/18. Staff

#11 clocked back in 3/18/18 from 12:00 AM until

6:03 AM when staff #11 clocked out. Staff #11

worked alone for 6 hours the morning 3/18/18.

Staff #11 clocked in on 3/18/18 at 6:03 PM until

12:00 AM 3/19/18. AS #1 stated staff #11

"probably" clocked back in from 12:AM until 6:00

AM 3/19/18 as she had on 3/18/18. Staff #11

worked alone for 6 hours the mornings of 3/18/18

and 3/19/18.

















bed time.













defined as follows:



Report.




and document it.











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For [client A]:

1. A BDDS report filed by QIDP/Qualified

Intellectual Disabilities Professional #2 on 3/05/18

indicated an incident on 3/04/18 at 1:35 PM:

"[Client A] is [age] year- old male with a primary

diagnosis of Mild Intellectual Disability, who lives

in a supervised group living home with 7 other

men. [Client A] became upset after talking to his

girlfriend. [client A] began to engage in property

destruction in his room. Staff attempted to

redirect him verbally without success. He broke

through a section of drywall and broke out a panel

on his bedroom door. [[client A]] threatened to hit

a housemate with a piece of a mini-blind but was

(sic) staff positioned themselves between [[client

A]] and the housemate and prevented contact

from occurring. Neighbors heard [client A] yelling

and using profanity and called the police. [City]

police arrived and spoke with [client A] and left

without taking further action. [Client A] calmed

and assisted in cleaning his room."

The BDDS report's "Plan to Resolve (Immediate

and Long Term)" component written by QIDP #2

indicated: "[Client A] was not injured during the

incident. Verbal aggression and property

destruction are addressed in [client A's] Behavior

Support Plan. It should be noted the damages

were cleaned up and no health or safety hazards

are present. The damage will be repaired. Staff

swept [client A's] room for potentially harmful

items and he will remain on 15 minute checks for

safety. Staff will continue to follow the proactive

strategies in [client A's] plan to help reduce and

prevent further occurrences."


incident on 1/28/18 at 5:20 PM. "...[client A] was

threatening [(former client) B] with a stick and hit

him on the left forearm with the stick. [Client A]

remained agitated and kicked [client B's] bedroom


top priority.




as needed.











facility.

Administrative support at the

home will include assuring

adequate direct support staff are

on duty to meet the needs of all

clients.




















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door, causing it to break. [Client A] punched

[client B] in the face causing his nose to bleed.

Staff was able to separate [client B] and [client A]

to difference (sic) area's of the home." Client B

was transported by staff to a local ER for

evaluation and x-rays which produced normal

results. Client B was released and was transported

by staff back to the facility. "[Client B] sustained

a bloody nose and a 3 inch by 2.5 inch bruise to

his left mid forearm from where he was struck by

the stick. Staff will continue to monitor for further

marks, or bruising and offer emotional support to

[client B]." The BDDS report in indicated both

clients had BSPs which addressed physical

aggression and [client A] was currently on

therapeutic leave with his grandmother. The

BDDS report indicated the IDT would meet to

develop "additional protective measures to be

incorporated into [client A's] plan."

The 1/29/18 IDT was reviewed on 3/19/18 at 9:00

PM. The IDT indicated "On 1-28-18 [client A]

became upset and punched a housemate in the

nose. [Client A] then hit him with a stick on his

arm.

[client A] stated he was upset with housemate

talking about going to waiver and having alone

time. [Client A] has a history of physical

aggression. Team agrees to have one staff

upstairs at night for safety in case needed. This

will last for 7 days and if no occurrences then

return to normal staffing routine. [Client A] was

scheduled to go visit his grandma and requested

to go a day early which she agreed to and he went

on 1-28-18."


incident of client to [client A] aggression on

11/17/17 at 4:00 PM. "[Client A] received a text

from his girlfriend and became upset and walked

been arranged.










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out (sic) the house. Staff followed and [client A]

was walking up and down the sidewalk carrying a

stick. [Client A] went into the house and became

verbally aggressive still carrying the stick. Staff

redirected house mates away and to the van.

[Client A] walked in and outside the house and

went to the van hitting the van with the stick.

Staff redirected house mates to the back yard

while another staff drove the van around back. As

house mates were walking toward the van [client

A] came to the back yard, displaying verbally (sic)

aggression and heading towards house mates.

Staff went to redirect and [client A] ran and

jumped the fence and hit [client C] on the right

cheek with a closed fist. [[client A]] continued to

run away down the alley and stopped. [Client C]

and house mates got into the van and went for a

drive. Another staff remained with [client A] who

continued to be verbally aggressive and holding a

stick. Staff encouraged [client A] to use his

coping skills and he refused. [Client A] walked to

the front of the house still carrying a stick and

staff verbally redirected to drop the stick before

coming in due to one house mate still being

inside. [Client A] refused and started hitting and

kicking the front door. When staff could no longer

assure safety, they called 911 and once police

arrived [client A] dropped the stick and sat on the

front porch talking to the Police. [Client A]

calmed and when Police left [client A] came inside

where he went to his room with no further issues."

The BDDS report indicated "Through the night,

one staff remained upstairs beside the bedrooms

during sleeping hours to assure safety."

The 11/17/2017 IDT was reviewed on 3/19/18 at

9:00 PM. The IDT indicated "[Client A] became

upset when his girlfriend broke up with him. He

became physically aggressive toward house mate

who [client A] stated 'looked like the guy she left





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him (sic) for.' To help prevent further occurrences

for (sic) the team agrees to have one staff upstairs

when [client A] is upstairs including sleeping

hours. This will last at least a week and if no

issues after that time then staff can return to

normal routine."

4. A BDDS report dated 10/17/17 indicated [client

A] had eloped on 10/16/17 at 7:40 PM. The BDDS


unknown person, who said that they saw a client

walking down (sic) street. Staff investigated and

noticed [client A] was not in his room. Staff

searched and [client A] came to the front door.

Staff asked what he was doing and he stated that

a house mate went through his room and out the

fire escape door. Staff asked about the door alarm

and [client A] stated he had shut it off. [Client A]

stated that he followed house mate to try to get

him to come back to the house. [Client A] had no

further issues." The BDDS report indicated the

team was "currently researching door alarms that

will be more difficult to circumvent."


[client A] was out staff's of line of sight for one

hour and he did not have alone time in his support

plan.

An IDT/Interdisciplinary Team Meeting regarding

the incident of 3/4/18, dated 3/16/18, was reviewed

on 3/16/18 at 3:40 PM. The IDT indicated [client

A] became upset and engaged in property damage

to his room. "He (client A) stated he was upset

about his girlfriend who lives in [city]. The team

has noticed a correlation between aggressive

behaviors and his girlfriend when he wants to go

visit. The incident (sic) have happened a day or

two before he is scheduled to go visit grandma

who lives in [same city]...Upon return to site (sic)

the team agrees to have one staff upstairs for at





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least a week and if no further issues return to

normal staff duties. The team agrees to have one

staff upstairs a week before he is scheduled to go

home for safety due to co-relation (sic)...."

For client G:

1. A BDDS report dated 3/10/18 indicated on

3/9/18 at 4:30 PM, client G eloped from the facility.

Staff picked up client G and he was returned to the

facility. Client G was out of line of sight for

"approximately 30 minutes." Client G "is on

enhanced supervision (line of sight during waking

hours and 15 minute checks at night) per the

post-elopement protocol in his Behavior Support

Plan."


incident on 2/24/18 at 12:30 PM. Client G

approached staff and told them he was upset and

had hit his head on the desk. Staff assessed client

G and after contacting the facility's nurse for

instructions, took client G to a local emergency

room/ER for evaluation of "possible head trauma."

The client was evaluated and no evidence of head

trauma was found. The BDDS report indicated

client G had a BSP which addressed

"self-injurious and attention seeking behavior...

[client G] was placed on enhanced

supervision-line of sight and 15 minute checks at

night for 24 hours, per his plan...."

For client E:


incident on 2/24/18 at 1:30 PM. "Staff was

assisting in cleaning space on an electronic tablet

to which [client E] and his housemates have

access and came across sexually explicit pictures

that [client E] said he sent to a housemate's sister

through [name of social media.] Staff deleted the

explicit content and explained to [client E] that the





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tablet is shared with housemates and discussed

the dangers of sending/posting explicit pictures

on social media...."


incident on 2/22/18 at 9:00 PM when staff

discovered sexually explicit pictures client E had

sent to a female he had met "through a dating

application" on an electronic tablet that was

shared by the clients in the facility. The BDDS

report indicated "[client E's] guardian has directed

the team to limit his access to pornography and to

restrict him from posting explicit contact on social

media. The interdisciplinary team will meet to

develop guidelines to assist [client E] in making

better choices and and (sic) to train him toward

safe use of social media."


incident on 2/16/18 at 7:35 PM when staff went to

get client E for medications and "smelled smoke.

Staff noted remnants of burned paper and asked

[client E] what was burning and he said he wanted

to see how ink melted when burning and had lit a

piece of paper with a lighter. Staff asked [client E]

how he obtained the lighter and he said he found

it."

There were no injuries or property damage

according to the BDDS report. The report

indicated, "The

[IDT] will meet to create a plan for safety and add

fire starting to his [BSP]."



PM.

"[Client F] told staff he was upset with [client E].








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occurred...."

For client F:



PM.

"[Client F] told staff he was upset with [client E] .









occurred...."


F had eloped on 10/16/17 at 7:40 PM. The BDDS


unknown person, that there may have been a

client seen walking down the street. Staff went to

check and found [client F] not in the home. Staff

discovered that the alarm to the fire escape had

been shut off. Staff began searching the

community for [client F] and when he was not

found informed the police. Staff continued to

search and after 3 hours staff found [client F]

walking down the alley coming back to the house.

[Client F] returned to the home and was placed on

fifteen minute checks for safety. [Client F] went to

bed with no further issues." The BDDS report

indicated client F had a history of leaving

assigned area but elopement was removed as a





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targeted behavior at his annual program plan

review. The BDDS report indicated the team was

"currently researching door alarms that will be

more difficult to circumvent."


client F was out staff's of line of sight for "5 hours

and 30 minutes" and he did not have alone time

addressed in his support plan.

[Client A]'s BSP/Behavior Support Plan dated


















sheets.




stance....












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violent behavior."

Client A's 5/12/17 BSP was reviewed on 3/16/18 at

3:16 PM and indicated the following:

"TARGET BEHAVIORS AND GOALS

Physical Aggression: any time [client A] strikes,

spits, grabs, kicks, bites, pinches, is threatening,

and throwing objects at others, uses his hands

(open or closed) that have the potential to cause

injury.

o Goal: [client A] will exhibit no more than 5

episodes of physical aggression per month across

12 consecutive months by 5/2018.

Verbal Aggression: any time [client A] engages in

shouting in a manner that is louder than his

normal speaking tone (using profanity or racial

slurs).


episodes of verbal aggression per month across

12 consecutive months by 5/2018.

Property Disruption/Destruction: any time [client

A] throws objects, slams doors, and/or otherwise

manipulating property such that it no longer

functions in the manner it was intended that make

an audible sound loud enough to be heard in the

next room. This includes setting fire to objects.


episodes of property disruption/destruction per

month across 12 consecutive months by 5/2018.

Threats to Harm Others: any time [client A] makes

a statement that she (sic) will harm staff and/or

peers (kill them in their sleep, burn the house

down, break their knee) or refers to events in her





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(sic) past when she (sic) has harmed others.

o . Goal: [client A] will exhibit no more than 5

episodes of threats to harm others per month

across 12 consecutive months by 5/2018.

PSYCHIATRIC DIAGNOSES

Axis I: Oppositional Defiant Disorder

Axis II: Mild Intellectual Disorder

Axis III: Attention Deficit/Hyperactivity

Disorder."

[Client A]'s BSP/Behavior Support Plan dated


















sheets.




stance....











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violent behavior."

Client G's BSP/Behavior Support Plan dated

7/15/17, revision date of 8/16/17 was reviewed on

3/16/18 at 9:30 AM and indicated the following

measures to be taken if the client eloped or

exhibited other behaviors.

"Elopement:

Staff will follow [client G] and initially keep

some distance between him and themselves (no

more than 10 feet).

o Immediately notify the Residential Manager

and QIDP.

o Let the Residential Manager and QIDP know

what is going on and follow his/her instructions

o Staff is to Call [name] Hospital, The [name]

Hospital, and [name] Office once [client G] has

eloped from the Group Home.

o These are places that [client G] will go to and

staff are to call and notify them that if [client G]

comes there, for them to call the Group Home

and/or [city] Police Department.

o The team feels that it is in the best interest

that [client G] remains in line of sight at all times to

ensure his safety.

" Let him know that you are there to talk to him

and help him problem solve what is upsetting him.

" Let him know that once he returns back to the

home you and he will talk about what is upsetting

him and help him come up with a solution.

" If [client G] elopes from the Group Home and

staff cannot find him, one staff will go look for him

and the other staff will call 911 to report him

missing from the Group Home.

911 Emergency System may ONLY be used when





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individual behaviors jeopardize the safety and

well-being of peers, community members and staff

and ONLY when all Rescare-Indianapolis/ICF and

Human Rights Committee approved de-escalation

and redirection techniques have been utilized and

exhausted Residential Manager and QIDP are to

be notified IMMEDIATELY once the call is

placed.

Upon arrival of emergency personnel, residential

staff will intercede on behalf of the individual to

coordinate police intervention, according to

individual's current behavior status. If the

individual is sitting or standing alone with no

weapon, making no threats and causing no harm,

staff must explain to emergency personnel the

individual is not currently threatening and verbal

intervention will be more beneficial than physical

intervention.

Threats to Harm Others/Self:

Immediately ensure [client G] is safe.

o Immediately scan the room for items that can

be used as a potential weapon by [client G]

against himself or others.

o If there are items in the immediate area that

could be used as weapons that [client G] could

use, in a subtle manner remove the weapons from

the home.

o Staff then will keep [client G] within line of

sight and ensure that all sharps are locked up.

[Client G] will then be placed on 15 minute checks

for 48 hours.

" Do not overreact to what [client G] is saying.

" Let [client G] know you are here to help him

and if there is anything he wants or needs he

should ask.

" If [client G] asks staff to leave, do so but

maintain sight of him.

" Attempt to redirect others in the immediate





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environment to other areas of the home.

" Attempt to redirect [client G] to an area where

he can calm down.

o Let [client G] know that if he would like to talk

to you about what is upsetting him you will be

happy to talk to him once he is calm.

o Let him know that he can talk to his

Residential Manager and QIDP

o Provide him with praise for following through

with requests to discuss other topics.

" Phone call addendum:

o Staffs are to be within listening range when

[client G] is on the phone due to history of

self-injurious behavior after phone calls.

o [Client G] is to remain within staff's line of

sight for 2 hours after phone calls with his family.

[Client G] has a history of going to his room and

engaging in self-injurious behavior after phone

calls with his family.

o After 2 hours if [client G] has not made any

self-injurious statements or attempts at self-harm

then he will be placed on 15 minute checks for 12

hours.

o After 12 hours if [client G] has not made any

self-injurious statements or attempts, then

enhanced supervision will stop. If [client G] does

make a statement or attempt then enhanced

supervision will continue.

911 Emergency System may ONLY be used when

individual behaviors jeopardize the safety and

well-being of the individual, the individuals' peers,

community members, staff or others in the

immediate environment and ONLY when all

Rescare-Indianapolis/ICF and Human Rights

Committee approved de-escalation and redirection

techniques have been utilized and exhausted.

Clinical Specialist and QIDP are to be notified

IMMEDIATELY once the call is placed.

Upon arrival of emergency personnel, residential





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staff will intercede on behalf of the individual to




weapon, making no threats and causing no harm,

staff must explain to emergency personnel the

individual is not currently threatening and verbal

intervention will be more beneficial than physical

intervention."

Client E's BSP dated 1/26/18, revised 3/2/18 was

reviewed at 10:00 AM on 3/16/18.

"TARGET BEHAVIORS AND GOALS

Physical Aggression: any time [client E] strikes,

spits, grabs, kicks, bites, pinches, is threatening,

and throwing objects at others that have the

potential to cause injury.

o Goal: [client E] will exhibit no more than 5

episodes of physical aggression per month across

12 consecutive months by 3.2019.

Verbal Aggression: any time [client E] shouts

and/or screams at peers and/or staff to include

insults, vulgar comments, obscenities and

demeaning comments.


episodes of verbal aggression per month across

12 consecutive months by 3.2019.

Property Disruption/Destruction: any time [client

E] bangs on the walls or windows or doors,

pushes chairs, clears tables, dumps food, slams

doors and throws objects that make an audible

sound loud enough to be heard in the next room.

This also includes falsely activating the fire alarm.


episodes of property disruption/destruction per

month across 12 consecutive months by 3.2019.





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Non-Compliance: Health: any time [client E]

refuses and does not take his scheduled

medications and medical treatments, refuses to eat

a meal or meal substitute or refuses to follow

medical/health/safety directions (including

appointments) as indicated on the physician's and

dietary orders.


episodes of non-compliance: Health per month

across 12 consecutive months by 3.2019.

Withdrawal/isolating behavior: any time [client E]

demonstrates an unwillingness to get into or stay

with a conversation or activity. This includes

when [client E] remains with the person in the

same room and drops his head and refuses to

acknowledge the person; when [client E] stares at

the person but will not talk or respond to

questions; when [client E] gets up and leaves the

room and refuses to acknowledge the person;

when [client E] becomes quiet or shuts down and

quickly agrees to something (or says "never

mind") in order to end the conversation/activity

with no real intent to follow through; when [client

E] isolates himself in his room during waking

hours and is unwilling to engage in activities in

his room (watch TV, listen to music, talk with

staff), in the house or in the community.


episodes of withdrawal/inattentive behavior per

month across 12 consecutive months by 3.2019.

Making weapons out of objects: anytime [client

E] makes an object into a weapon, such as folding

a piece of paper into the shape of a gun. [client E]

has not used these against anyone.


episode of weapon making per month across

o 12 consecutive months by 3.2019.





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Socially offensive behavior: any time [client E]

engages in actions in the proximity of others that

are typically considered offensive actions. This

includes sexually inappropriate comments,

gestures or actions (exposing himself, grabbing

female staff chest, putting head on male/female

staff shoulder/chest,)

Goal: [client E] will exhibit no more than 8

episodes of socially offensive behavior per month

across 12 consecutive months by 3.2019.

Fire Starting: any time [client E] attempts or does

start a fire. [client E] has a fascination with fire

starting.


episodes of fire starting per month across 12

consecutive months by 3.2019.

Stealing: any time [client E] acquires an item(s)

that he did not pay for or have permission to have

is considered stealing.


episodes of stealing per month across 12

consecutive months by 3.2019.

PSYCHIATRIC DIAGNOSES

Axis I: Reactive Attachment Disorder, Inhibited

Type; Intermittent Explosive Disorder

Axis II: Mild Intellectual Disability

Axis III: Attention-Deficit/Hyperactivity Disorder,

Combined Type;

When [client E] engages in physical aggression,

him tendency is to lash out in every direction with

him hands/fists and him feet to attack anyone in

him reach. Staff must provide personal space to

him and must insure the environment surrounding

[client E] is clear of obstructions and that [client

E] is given plenty of space to maneuver.

Physical Aggression





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" Do not over react; try to maintain a calm and

emotionless demeanor.

" Immediately ensure the health and safety of

everybody in the immediate area.

" In a firm and polite voice ask him to stop the

behavior, and redirect him to a quieter area away

from others, redirect him outside (back patio) or to

his room.

o Encourage him to use him calming strategies

(alone time; journaling; listening to music; writing

letters; writing and telling funny stories.)

" Throughout this process minimize verbal

interactions with him and never get into a power

str

uggle." If the behavior persists and he is

placing himself or others in immediate danger

implement You're Safe I'm Safe (YSIS)

(facility approved/taught behavior

management techniques).o Position yourself

between [client E] and his peers." In a

calm but firm voice verbally redirect [client

E] to a different location/area/activity."

Block physical aggression and property

destruction." If [client E] is continuing to

place himself or others in jeopardy, use the

YSIS procedures in the following order:"

Physically redirect." One person hold."

Two person hold." When using these

holds, be aware that [client E] may attempt

to bite, hit or struggle, position yourself so

that you are safe." If needed have his peers

move to a safe location where [client E]

cannot aggress towards them.o Let him

know what you are doing but do not engage

in conversations with him.ONE PERSON





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STANDING RESTRAINT/ESCORT: this

technique should be used when only one

staff member is available to intervene or for

short duration. Maintaining this technique

should be for no more than a few minutes.

Once the technique is effectively in place, the

staff can escort or move the person a short

distance as required (moving away from

dangerous objects, away from vulnerable

people, away from otherwise reinforcing

situations). 1. Staff should approach from

behind the person if possible (or from the

side). 2. Staff member should slide one arm

across the individual's back to grasp their

arms at the forearm in an overhand grip. At

the same time, staff member should move

forward a bit so their hip is securely touching

the person's hip. 3. Staff reaches across

their own body to grasp the person's

forearm in an underhand grip. 4. Once the

person is securely held, staff can escort the

person a short distance to safety or away

from a reinforcing situation.TWO PERSON

STANDING RESTRAINT/ESCORT: 1.

Approach the individual - one staff on each

side. One staff member should assume the

lead role, directing their movements as they

apply the technique. 2. One at a time, staff

members reach across the individual's back

to grasp the individual's outside forearm,

using an overhand grip. 3. Each staff

member reaches across their own body to





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grasp the individual's wrist (that is closest to

them), using an underhand grip. Both staff

member's hips should be snuggly up against

the individual's hips to provide

security/stability. 4. Draw the individual's

elbow backward over your hip a bit, using

your shoulder to support; provide as much

support as possible, the hold should feel

snug. 5. Again, hips of both staff should be

snug against the individual's hips.When using

these holds, be aware that [client E] may

attempt to punch, kick, scratch and struggle;

position yourself so that you are safe. If

needed have [client E]'s peers move to a

safe location where [client E] cannot aggress

towards them. Throughout this process

minimize verbal interactions with [client E]

and never get into a power struggle. Let

[client E] know what you are doing, but do

not engage in conversations with him.911

Emergency System may ONLY be used

when individual behaviors jeopardize the

safety and well-being of peers, community

members and staff and ONLY when all

Rescare-Indianapolis/ICF and Human

Rights Committee approved de-escalation

and redirection techniques have been utilized

and exhausted. Clinical Supervisor and

QIDP are to be notified IMMEDIATELY

once the call is placed. Upon arrival of

emergency personnel, residential staff will

intercede on behalf of the individual to





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weapon, making no threats and causing no

harm, staff must explain to emergency

personnel the individual is not currently

threatening and verbal intervention will be

more beneficial than physical intervention."

Client F's BSP dated 5/26/17 was reviewed

on 3/20/18 at 9:15 AM and indicated

elopement was not among his targeted

behaviors."TARGET BEHAVIORS AND

GOALSProcrastination: any time [client F]

is carrying out common daily activities such

as personal hygiene, household chores,

completing his laundry on his designated

day, he will instead watch TV, text family

and friends, play games on his phone, and

give excuses as to why he can't do it at the

given time. o Goal: [client F] will exhibit

no more than 5 episodes of Procrastination

per month across 12 consecutive months by

05/2018.Lying to others/Not telling the

Truth: this occurs when [client F] wants to

blame-shift others or situations for his

problems, actions and behaviors. He lies to

get attention and reaction from others.o

Goal: [client F] will exhibit no more than

5 episodes of Lying to Others per month

across 12 consecutive months by

05/2018.SIB: Skin Picking: this occurs

anytime [client F's] anxieties are in control of





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his behaviors. He will sit and pick and bite at

lip and skin around his finger nails.o Goal:

[client F] will exhibit no more than 3

episodes of SIB: Skin Picking per month


05/2018.Contraband: anytime [client F]

returns from workshop with cigarette butts

or any other items that do not belong to

him.o Goal: [client F] will exhibit no more

than 3 episodes of contraband per month


05/2018.PSYCHIATRIC DIAGNOSES

and DRUG REDUCTION PLANAxis I:

Williams Syndrome (genetic

developmental disorder), DepressionAxis II:

Mild Mental Retardation; Axis III: Mild

Cerebral Palsy; Pre-Diabetic,

Accommodative Insufficiency (inability of the

eyes to focus on objects), Slight Gum

Disease, Seasonal Allergies." Interview with

client D was conducted on 3/15/18 at 2:17

PM. Client D stated "[client A]uses

weapons and threatens people...stick from

room...came back from workshop and had

(a) stick in his hand went after [client C]. I

told my treatment team."Review of HRC

(Human Rights Committee) minutes on

3/16/18 at 3:03 PM indicated client D had

indicated concerns regarding a housemate at

the 3/6/18 meeting: "Note: [Client D]

stated to HRC members that he was scared

of his housemate [client A] due to his





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behaviors. [Client D] stated to HRC

members that he told his Mom & (and) dad

that he was scared of his housemate [client

A]. [Client D] also stated that his parents

were gonna take care of it."Client C stated

(3/15/18 2:23 PM): "[Client A] chased me

around in circles up and down the stairway.

I ran outside."Interview with client D was

continued on 3/15/18 at 2:50 PM. When

asked how things were going at the facility

client D stated: "[Client E, (newly admitted

to the facility 2/1/18)] comes into my room

(when) I'm sleeping...showed me his

possessions...I want to have peace in my

room. [Client E] needs to knock. I was in

bed (and) said 'Dude I'm trying to

sleep'."When asked about any other

concerns in the facility, client D stated when

another peer, (client A), had behaviors, "I

went out (the) back door to be safe." Client

D was asked to explain his concerns

regarding client A, and client D stated: "To

be honest kind of nervous because he could

be doing the same kind of thing when he

comes back. Client A was currently on leave

of absence from the facility. Client D stated

in regards to client A's behavior, "Tearing up

his room again. Threatening people that kind

of stuff." When asked which people, client

D stated: "Usually goes after [peers living in

the facility] [client C]. [Client G] gets scared.

I get really scared. I go downstairs. Most of





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the guys (clients) are scared of him--one

resident wanted to move out."Interview with

QIDP/Qualified Intellectual Disabilities

Professional #1 on 3/20/18 at 2:00 PM

indicated clients who exhibited physical

aggression had one or two person YSIS

behavior management techniques in their

BSPs. The BSPs also may have "enhanced

supervision" for aggressive behaviors, self

injurious behaviors or elopement. Enhanced

supervision was to be in staff's line of sight

for a time period determined by the client's

BSP or the IDT. The interview indicated

client A's current line of sight supervision

was 24 hours for 7 days. The line of sight

supervision had commenced when client A

returned from his visit with family on 3/17/18

at 2:00 PM. This federal tag relates to

Complaint #IN00243877.This federal tag

relates to Complaint #IN00256090.9-3-

3(a)

483.480(a)(1)

FOOD AND NUTRITION SERVICES

Each client must receive a nourishing,

well-balanced diet including modified and

specially-prescribed diets.

W 0460

Bldg. 00


interview for 3 of 4 sampled clients (clients A, C


H), the facility failed to ensure clients received

their menued meal items or equivalent

substitutions.

Findings include:

W 0460 CORRECTION:

Each client must receive a

nourishing, well-balanced diet

including modified and

specially-prescribed diets.

Specifically, staff will be trained on

proper implantation of the rotating

menus including but not limited to

following the menu. Additionally,

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Observations were conducted of clients A, C, D,

E, F, G and H at the facility on the evening of

3/19/18 from 4:10 PM until 7:25 PM. Staff #6 was in

the kitchen with client C preparing a meal of baked

fish and steak fries in the facility's oven at 4:43

PM. The clients (A, C, D, E, F and G) went into

the kitchen and filled their plates with fries and

fish. Clients H's plate of food and apple juice were

prepared for him and placed on the table by staff

#5. Clients began eating at 4:49 PM.

Client D placed tartar sauce and relish onto the

dining room table. Client E obtained barbeque

sauce and placed it onto the table. The tableware

setting consisted of glasses, dinner plates and

forks. The food was not served on the table and

passed from individual to individual in a family

style manner.

Client A was observed to eat the fish and fries

with his fingers/hands. Clients E and G ate the fish

and fries with their fingers/hands. Client C placed

the fish between two slices of bread. Client C

dipped the sandwich into barbeque sauce and ate

it with his hands. He did not use his fork. Client D

ate a fish sandwich and fries with his fingers.

Clients F and H were observed to use their forks

during the meal. After the meal, staff #6 washed

cookie sheets and finished loading the

dishwasher. Client C was prompted to clean the

dining table at 5:10 PM.

Clients did not have milk, a vegetable or fruit

offered during the evening meal.

Review of the menu for the evening meal on

3/19/18 was conducted on 3/20/18 at 1:45 PM.

The menu consisted of vegetable lasagna 3

ounces, steamed broccoli 1/2 cup, Italian bread 1

slice, chilled watermelon 1 cup, skim milk 8 fluid

ounces, and margarine 1 teaspoon.

Interview with staff #6 on 3/20/18 at 1:30 PM

staff will be retrained toward

provision and documentation of

nutritious substitutions.

PREVENTION:


expected to observe no less than

five active treatment sessions per

week to assess direct support

staff interaction with clients and to

provide hands on coaching and

training including but not limited

assuring staff assist clients with

preparing meals according to the

established menus, with

appropriate portion sizes and

textures, as recommended by the

dietician and other medical

professionals and documenting

nutritious substitutions, when

indicated.

Members of the Operations Team,






Coordinators, and Nurse Manager)

as well as the QIDP will conduct


less than three times weekly for

the next 30 days, and no less

than twice weekly until all staff

demonstrate competence. At the

conclusion of this period of

intensive administrative monitoring

and support, the Executive

Director and Regional director

(area manager) will determine the





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indicated the evening meal on 3/19/18 consisted

of fish, steak fries, apple juice, bread and

condiments.

Interview with Area Supervisor/AS #1 on 3/20/18

at 2:00 PM indicated it was the policy of the

facility to substitute foods and document the

equivalent substitutions. The interview indicated

no food substitutions had been documented for

the 3/19/18 evening meal. The interview indicated

clients should have been offered a vegetable, fruit

and milk during the evening meal on 3/19/18.

9-3-8(a)

level of ongoing support needed at

the facility. Active Treatment

sessions to be monitored are

defined as:





















bed time.
















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defined as follows:



Report.




and document it.








top priority.




as needed.











facility.

Administrative support will include

but not limited assuring staff

assist clients with preparing meals

according to the established

menus, with appropriate portion

sizes and textures, as





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recommended by the dietician and

other medical professionals and

documenting nutritious

substitutions, when indicated.






483.480(d)(4)

DINING AREAS AND SERVICE

The facility must assure that each client eats

in a manner consistent with his or her

developmental level.

W 0488

Bldg. 00


interview for 3 of 4 sampled clients (clients A, C


H), the facility failed to ensure clients participated

in family style dining and ate in a manner in

accordance with their capabilities.

Findings include:

Observations were conducted of clients A, C, D,

E, F, G and H at the facility on the evening of

3/19/18 from 4:10 PM until 7:25 PM. Staff #6 was in

the kitchen with client C preparing a meal of baked

fish and steak fries in the facility's oven at 4:43

PM. The clients (A, C, D, E, F and G) went into the

kitchen and filled their plates with fries and fish.

Clients H's plate of food and apple juice were

prepared for him and placed on the table by staff

#5. Clients began eating at 4:49 PM.

Client D placed tartar sauce and relish onto the

dining room table. Client E obtained barbeque

sauce and placed it onto the table. The tableware

setting consisted of glasses, dinner plates and

forks. The food was not served on the table and

W 0488 CORRECTION:

The facility must assure that each

client eats in a manner consistent

with his or her developmental

level. Specifically, staff will be

retrained regarding the need to

assure all clients participate in all

aspects of meal preparation to the

extent of their capabilities, as well

as staff participation in family style

dining, including but not limited to

training toward and modeling

appropriate mealtime behavior.

PREVENTION:


expected to participate in no less

than five active treatment sessions

per week, on varied shifts to assist


including but not limited to meal

preparation and family style

dining, providing coaching and

training to staff as needed.

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passed from individual to individual in a family

style manner.

Client A was observed to eat the fish and fries

with his fingers/hands. Clients E and G ate the fish

and fries with their fingers/hands. Client C placed

the fish between two slices of bread. Client C

dipped the sandwich into barbeque sauce and ate

it with his hands. He did not use his fork. Client D

ate a fish sandwich and fries with his fingers.

Clients F and H were observed to use their forks

during the meal. After the meal, staff #6 washed

cookie sheets and finished loading the

dishwasher. Client C was prompted to clean the

dining table at 5:10 PM.

Review of client A's record was conducted on

3/19/18 at 4:15 PM. The review indicated an ISP

dated 5/2017. The ISP contained an objective to

prepare an item to be cooked in the microwave.

Client C's record was reviewed on 3/19/18 at 6:43

PM and indicated a program plan of 3/2018. The

program plan contained an objective to prepare

meals with verbal prompting.

Client D's record was reviewed on 3/19/18 at 6:27

PM. The record indicated a program plan dated

11/2017. The record review indicated no

contraindication for client D's participation in

mealtime preparation or dining skills.

Interview with Area Supervisor/AS #1 on 3/20/18

at 2:00 PM indicated all clients were capable of

participating in meal preparation and clean up

tasks. The interview indicated the clients should

be redirected to eat with good table manners

(using utensils and napkins). The interview

indicated clients should participate in mealtime

skills in accordance with their capabilities.

Members of the Operations Team,






Coordinators, and Nurse Manager)

as well as the QIDP will conduct


less than three times weekly for

the next 30 days, and no less

than twice weekly until all staff

demonstrate competence. At the

conclusion of this period of

intensive administrative monitoring

and support, the Executive

Director and Regional director

(area manager) will determine the

level of ongoing support needed at

the facility. Active Treatment

sessions to be monitored are

defined as:




















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9-3-8(a) training, medication





bed time.













defined as follows:



Report.




and document it.








top priority.




as needed.





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facility.

Administrative support at the

home will include assuring staff

provide continuous active



but not limited to meal preparation

and family style dining.




Operations Team, Regional

Director


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