PRINTED: 12/28/2016 DEPARTMENT OF HEALTH AND ...If continuation sheet Page 1 of 23 (X6) DATE (X1)...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

12/28/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

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

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIES

(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

INDIANAPOLIS, IN 46254

15G378 08/12/2016

REM-INDIANA INC

4002 N MOLLER RD

00

W 0000

Bldg. 00

This visit was for a recertification and

state licensure survey.

Survey Date: August 9, 10, 11, 12, 2016

Facility Number: 000892

Aim Number: 100244290

Provider Number: 15G378

These deficiencies also reflect state findings in

accordance with 460 IAC 9.

Quality Review of this report completed by

#15068 on 8/22/16.

W 0000

483.420(a)(4)

PROTECTION OF CLIENTS RIGHTS

The facility must ensure the rights of all

clients. Therefore, the facility must allow

individual clients to manage their financial

affairs and teach them to do so to the extent

of their capabilities.

W 0126

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Based on record review and interview the

facility failed for 3 of 5 clients residing in

the group home (#3, #4, #5) to allow

spending opportunities for the clients.

Findings include:

Clients' finances were reviewed on

8/10/16 at 12:52p.m. with staff #1 and

W 0126 The Program Coordinator was

retrained on client’s rights

anddignity regarding community

outings. This training included the

completion of aplanned out

activities calendar for the entire

month, with no less than

eightitems planned out in the

community.

The Direct Support Staff were

retrained on client outings.

Thisincluded offering choices,

09/11/2016 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 determined that

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

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

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

continued program participation.

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

_____________________________________________________________________________________________________Event ID: 8W5M11 Facility ID: 000892

TITLE

If continuation sheet of 23

(X6) DATE




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15G378 08/12/2016

REM-INDIANA INC

4002 N MOLLER RD

00

staff #3. Clients' "Individual Cash On

Hand" ledgers for 5/16 through 8/9/16

were reviewed. There were no August

2016 "Individual Cash on Hand" ledgers

for clients #3, #4 and #5. The ledgers

indicated clients #3 and #4 had one cash

transaction each since 5/1/16. Client #5's

ledgers indicated she had 2 cash

transactions since 5/1/16.

Staff #1 was interviewed on 8/10/16 at

12:52p.m. Staff #1 indicated, per the

financial documentation, the facility had

not provided clients #3, #4 and #5 the

opportunity to spend their money during

the past 3 months. Staff #1 indicated the

clients should get the opportunity to

make purchases when on outings and

when shopping.

9-3-2(a)

and doing activities that the

clients would like todo in their free

time. They were also retrained on

client dignity and rightsfor

community inclusion.

The direct care staff were

retrained on documentation forall

aspects of their job duties. They

were trained on what makes

gooddocumentation and the

accountability it establishes.

The Program Coordinator and

Program Director were

retrainedon the requirements of

the documentation to ensure that

all documentation iscompleted, is

thorough, and is accurate. This

training also included theIndiana

MENTOR procedures and policy

on documentation requirements.

The Program Coordinator will

create a new calendar

forscheduled client outings.

Ongoing, the Direct Support staff

will complete the

outingsaccording to the schedule.

If there are other options

available, the staff willbring it to

the client and PC’s attention to be

added or changed on

thecalendar.

Ongoing, the Staff will complete

all documentation accordingto the

Indiana MENTOR Policy and

Procedures.

Ongoing, the Program

Director/Coordinator will review

alldocumentation no less than

weekly to ensure all activities are

being completed,and that there is

a record of it.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8W5M11 Facility ID: 000892 If continuation sheet of 23




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15G378 08/12/2016

REM-INDIANA INC

4002 N MOLLER RD

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483.420(a)(7)

PROTECTION OF CLIENTS RIGHTS

The facility must ensure the rights of all

clients. Therefore, the facility must ensure

privacy during treatment and care of

personal needs.

W 0130

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Based on observation and interview, the

facility failed to ensure privacy during the

observed medication pass for 2 of 5

clients (#4, #5), residing in the group

home, when they received their

medication from facility staff.

Findings include:

An observation was done at the group

home on 8/9/16 from 4:32p.m. to

6:18p.m. At 4:55p.m. staff #7 began the

medication pass for clients #4 and #5.

Staff #7 passed the clients' medications

from the dining room. The clients that

were not receiving their medication were

seated in the living room which was part

of an open area connected to the dining

room. The clients that received

medication were visible to those seated in

the living room. All conversations

between staff #7 and the client receiving

medications (#4, #5) could be heard by

all clients.


1:54p.m. Staff #1 indicated the client

medication pass should be done in a

private area. Staff #1 indicated staff are

W 0130 All staff were retrained on client

rights, including their right

toprivacy, specifically during

medication administration.

There is a door that divides the

kitchen from the hallway, and a

screenthat divides up the dining

room and the living room. Staff

did not use theprivacy screen(s)

as they are expected to do.

The Program Nurse, in

conjunctionwith the Program

Coordinator and Program

Director, will complete

medicationadministration

observation 3 times per week for

the first 4 weeks. After theinitial 4

weeks, the Program

Nurse/Coordinator/Director will

complete no lessthan weekly

medication administration

observations to ensure that staff

arecompleting medication

administration privately.

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15G378 08/12/2016

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4002 N MOLLER RD

00

trained to pass the medication from the

kitchen. The kitchen door should be shut

and a privacy screen should be used

between the kitchen and the dining room.

9-3-2(a)

483.420(b)(1)(i)

CLIENT FINANCES

The facility must establish and maintain a

system that assures a full and complete

accounting of clients' personal funds

entrusted to the facility on behalf of clients.

W 0140

Bldg. 00

Based on record review and interview,

the facility failed for 5 of 5 client

finances reviewed (#1, #2, #3, #4, #5), to

maintain their financial system of client

funds entrusted to the facility.

Findings include:

The client financial record book and cash

on hand (at the group home), entrusted to

the facility, was reviewed on 8/9/16 at

6:00p.m. with staff #3. Staff #3 had to

retrieve the clients' funds from her

vehicle. Staff #3 indicated the client

funds were in her car because she had

planned on taking them to the office

tomorrow for the monthly review. The

client funds were in a carrying bag that

could not be locked. Clients #1, #2, #3,

#4 and #5 had no August 2016 cash on

W 0140 The Program Director and

Program Coordinator will

beretrained on Client Finances.

This training will include ensuring

that theclient’s ledgers balance at

all times, documentation

requirements, and

theexpectations for supervisory

reviews. The direct support staff

will all be retrained on

clientfinances, according to the

Indiana MENTOR policy and

procedures. The Program

Director will purchase a new lock

box/safe to bekept at the house,

where all client money’s will be

kept to avoid anycircumstances

of missing information, or the

chance of missing money. All

financial transactions are

monitored by the

ProgramCoordinator, reconciled

on a monthly basis by the

Program Director, and

thenreviewed by the Client

09/11/2016 12:00:00AM





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15G378 08/12/2016

REM-INDIANA INC

4002 N MOLLER RD

00

hand ledgers in place to show the cash on

hand each client should have had. Staff

#3 counted client funds for clients #2, #3,

#4 and #5. Client #5's money envelope

contained $2.36. Staff #3 indicated the

cash on hand ledgers for prior months

were at the office. Staff #3 indicated the

July cash on hand ledgers for July 2016

would have current balances, due to no

client spending activity in August 2016.

Staff #3 indicated client #1's cash was not

in the house. Staff #3 indicated client #1

had transferred from another group home

to this group home during the end of June

2016. Staff #3 indicated she did not have

client #1's money envelope from the

other group home. Staff #3 indicated the

other group home manager had been

contacted but had not brought the money

envelope to client #1's new residence.



#3. "Individual Cash On Hand" ledgers

for 5/16 through 8/9/16 were reviewed.

There were no August 2016 "Individual

Cash on Hand" ledgers for clients #1, #2,

#3, #4 and #5. The ledgers indicated

clients #3 and #4 had one cash


7/16 ledger indicated client #5 had a

balance of $124.73 (she had $2.36 in her

envelope on 8/9/16 review). Staff #3

presented another envelope that

Finance Specialist at the

completion of each month. For

the first 4 weeks, the Program

Coordinator will revieweach

client’s finances twice per week.

After the initial four weeks, the

ProgramCoordinator will review

each client’s finances no less

than once per week,ongoing.

Reviewing the client finances

includes, but is not limited

to,counting all petty cash,

ensuring all transactions are

recorded and have areceipt for

proof of purchase. For the first 4

weeks, the Program Director will

review eachclient’s finances once

per week. After the initial four

weeks, the ProgramDirector will

review each client’s finances

twice per month. After the next

four weeks, the ProgramDirector

will continue with reviewing each

client’s finances no less than

onceper month. Reviewing the

client finances includes, but is not

limited to,counting all petty cash,



proof of purchase. The Program


Director were retrainedon client

finances and Indiana MENTOR’s

policy and procedure during

admissionsand discharges.

Client #1’s money has been

transferred from her old group

hometo the new one.Ongoing,the

direct support staff, Program

Coordinator, and Program

Director willcomplete all financial

safeguards for all clients at all





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15G378 08/12/2016

REM-INDIANA INC

4002 N MOLLER RD

00

contained $122.00 for client #5. At

12:52p.m., staff #3 indicated client #5

had gone clothing shopping on 7/30/16

and her change had been put in a separate

envelope. Staff #3 indicated the change

money ($122) was in the money bag

during the 8/9/16 review but had

probably fallen out of client #5's money

folder and was loose in the money bag.


12:52p.m. Staff #1 indicated by the first

of each month a current "Cash on Hand

Ledger" should be in place for each

client. Staff #1 indicated the client funds

should be kept locked when not in use.

Staff #1 indicated he was not aware client

#1's funds had not been transferred to her

current group home and he would ensure

this was done. Staff #1 indicated the

monthly ledgers are to be turned into him

for review by the 10th of each month.

9-3-2(a)

times. This includes,holding

money, managing money, and

protecting/monitoring money for

theindividuals that are unable to

do so on a daily basis

483.430(a)

QUALIFIED MENTAL RETARDATION

PROFESSIONAL

Each client's active treatment program must

be integrated, coordinated and monitored by

a qualified mental retardation professional.

W 0159

Bldg. 00


the facility failed for 3 of 3 sampled

W 0159 The Program Director and

Program Coordinator will 09/11/2016 12:00:00AM





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REM-INDIANA INC

4002 N MOLLER RD

00

clients (#1, #2, #3) and 2 non-sample

clients (#4, #5) to ensure each client's

active treatment program was

coordinated and monitored by the

facility's qualified intellectual disabilities

professional (QIDP), by the QIDP not

ensuring client training programs were

reviewed, clients were given

opportunities to make cash transactions

and client #1's personal funds envelope

had been transferred to her new

placement.

Findings include:

The client financial record book and cash

on hand (at the group home), entrusted to

the facility, was reviewed on 8/9/16 at

6:00p.m. with staff #3. Staff #3 had to

retrieve the clients' funds from her





client funds were in a carrying bag that





#3 indicated the July cash on hand

ledgers for July 2016 would have current

balances due to no client spending

activity in August 2016. The cash on

hand ledgers for 5/1/16 through 8/9/16

beretrained on Client Finances.

This training will include ensuring

that theclient’s ledgers balance at

all times, documentation

requirements, and

theexpectations for supervisory

reviews. The direct support staff

will all be retrained on

clientfinances, according to the

Indiana MENTOR policy and

procedures. The Program

Director will purchase a new lock

box/safe to bekept at the house,

where all client money’s will be

kept to avoid anycircumstances

of missing information, or the

chance of missing money. All

financial transactions are

monitored by the

ProgramCoordinator, reconciled

on a monthly basis by the

Program Director, and

thenreviewed by the Client


completion of each month. For

the first 4 weeks, the Program

Coordinator will revieweach

client’s finances twice per week.

After the initial four weeks, the

ProgramCoordinator will review

each client’s finances no less

than once per week,ongoing.

Reviewing the client finances

includes, but is not limited

to,counting all petty cash,



proof of purchase. For the first 4

weeks, the Program Director will

review eachclient’s finances once

per week. After the initial four

weeks, the ProgramDirector will





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indicated clients #3 and #4 had one cash


ledgers indicated she had 2 cash

transactions since 5/1/16. Staff #3

indicated client #1's cash was not in the

house. Staff #3 indicated client #1 had

transferred from another group home to

this group home during the end of June







Record review for client #2 was done on

8/11/16 at 11:47a.m. Client #2 had an

individual support plan (ISP) dated

11/18/15. The most recent ISP review by

the QIDP was completed during 3/16.

Record review for client #3 was done on

8/10/16 at 11:30a.m. Client #3 had an

ISP dated 8/31/15. The most recent ISP

review by the QIDP was completed

during 3/16.

Staff #1 (QIDP) was interviewed on

8/11/16 at 1:54p.m.. Staff #1 indicated

clients #2 and #3's most recent

documented ISP review was during 3/16.

Staff #1 indicated the reviews were to be

done at least quarterly. Staff #1 indicated

he was not aware of client #1's funds not

review each client’s finances

twice per month. After the next

four weeks, the ProgramDirector

will continue with reviewing each

client’s finances no less than

onceper month. Reviewing the

client finances includes, but is not

limited to,counting all petty cash,



proof of purchase. The Program


Director were retrainedon client

finances and Indiana MENTOR’s

policy and procedure during

admissionsand discharges.

Client #1’s money has been

transferred from her old group

hometo the new one.Ongoing,the

direct support staff, Program

Coordinator, and Program

Director willcomplete all financial

safeguards for all clients at all

times. This includes,holding

money, managing money, and

protecting/monitoring money for

theindividuals that are unable to

do so on a daily basis.

The Program Director will be

retrained on completing

clientprograms as follows the

annual plan. This includes

completing the

monthlies,quarterlies, and

annuals as expected.

The Program Coordinator was

retrained on ensuring that staffare

completing all documentation

according to Indiana MENTOR

policy andprocedures. Failing to

do so has resulted in the lack of

documentation for themonthly





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being transferred to her current home.

Staff #1 indicated he reviews clients'

finances on a monthly basis. Staff #1

indicated all clients should be getting out

more and given the opportunity to make

cash transactions.

9-3-3(a)

reports that are to be generated

by the Program Director, and sent

tothe team for updates on each

client’s progress.

The Direct Support Staff was

retrained on responsibilitiesfor

appropriate, accurate, and

complete documentation.

Ongoing, the direct support staff

will complete all

clientdocumentation as expected

in their job responsibilities.


Coordinator will review

alldocumentation to ensure that

the direct support staff are

completing thedocumentation as

expected and needed. Any

missing documentation will

bereported to the Program

Director for further follow up.


Coordinator will supply the

ProgramDirector with copies of

the completed documentation so

that the ProgramDirector can

complete a monthly, quarterly,

and/or annual report as needed

foreach client.

The Area Director will complete

documentation reviews onthis

Program Director on a bi monthly

basis, to include all

monthlies,quarterlies, and

annuals per their completion and

due date.

483.430(e)(1)

STAFF TRAINING PROGRAM

The facility must provide each employee

with initial and continuing training that

enables the employee to perform his or her

W 0189

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duties effectively, efficiently, and

competently.

Based on observation, record review and

interview, the facility failed for 3 of 3

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

non-sampled clients (#4, #5) to ensure

facility staff had been retrained on clients'

finances and meal preparation.

Findings include:

1. An observation was done at the group


6:18p.m. At 4:55p.m., staff #6 was

observed in the kitchen preparing supper.

Staff #6 was observed to: put aluminum

foil on a cookie sheet and get out

breadsticks and put the breadsticks on the

cookie sheet, get out a drink mix packet

and a pitcher and added water and stirred

the drink mix, put clean dishes away

from the dishwasher, poured store bought

macaroni salad and watermelon pieces

into serving bowls, cleaned the dishes

used in the meal preparation and took the

food (serving bowls) to the dining room

table. At 5:10p.m. client #1 went to the

kitchen and asked to make the drink for

supper. Staff #6 told client #1 the drink

was already made and client #1 went

back to the living room. Client #1 was

not prompted to assist with other meal

preparation tasks. Clients #1, #2, #3, #4,

#5 and #6 were seated in the living room

W 0189 The Direct Support Professionals

will be retrained oncompleting

formal and informal active

treatment opportunities for each

clientat any given teaching

moment. This training included

what Active Treatment is,and

what different opportunities that

they might encounter each day.

The Program Director will

complete 2 weekly active

treatmentobservations for 4

weeks, and then 1 per week

afterwards to ensure that

theactive treatment policy is being

instructed and utilized as

expected. Ongoing, the Area

Director will complete quarterly

pop invisits to ensure that all

policies and procedures are being

followed. All staff will be retrained

on completing and

properlydocumenting all goals.

This retraining included what

appropriate and

completedocumentation is in all

situations, according to Indiana

MENTOR’s policy

andprocedures. The Program

Coordinator will complete two

weeklyobservations to ensure

that all staff are completing the

objectives correctlywith the

clients. The Program Coordinator

will be retrained on

completingdocumentation reviews

weekly. Along with the

observations, the Program

Coordinator willalso complete

weekly random documentation

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during the supper preparation.

2. The client financial record book and

cash on hand (at the group home),

entrusted to the facility, was reviewed on

8/9/16 at 6:00p.m. with staff #3. Staff #3

had to retrieve the clients' funds from her





clients' funds were in a carrying bag that





#3 counted client funds for clients #2, #3,

#4 and #5. Client #5's money envelope

contained $2.36. Staff #3 indicated the

cash on hand ledgers for prior months

were at the office. Staff #3 indicated the

July cash on hand ledgers for July 2016

would have current balances due to no

client spending activity in August 2016.

Staff #3 indicated client #1's cash was not

in the house. Staff #3 indicated client #1

had transferred from another group home

to this group home during the end of June







reviews to ensure that all staff

arecompleting the documentation

to record the completion of the

objectives. The Program Director

will review all documentation

reviewsand completed

observations to ensure that they

are being completed correctly

byboth the staff and the Program

Coordinator. Ongoing, the Area

Director will complete random

quarterlyaudits to ensure that all

documentation is being

completed and correctly.The

Program Director and


be retrained on Client

Finances. This training

will include ensuring that

the client’s ledgers

balance at all times,

documentation

requirements, and the

expectations for

supervisory reviews.The

direct support staff will all

be retrained on client

finances, according to

the Indiana MENTOR

policy and

procedures.The Program

Director will purchase a

new lock box/safe to be

kept at the house, where

all client money’s will be





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#3. "Individual Cash On Hand" ledgers

for 5/16 through 8/9/16 were reviewed.

There were no August 2016 "Individual

Cash on Hand" ledgers for clients #1, #2,

#3, #4 and #5. The ledgers indicated

clients #3 and #4 had one cash


7/16 ledger indicated client #5 had a

balance of $124.73 (she had $2.36 in her

envelope on 8/9/16 review). Staff #3

presented another envelope that

contained $122.00 for client #5. At

12:52p.m., staff #3 indicated client #5

had gone clothing shopping on 7/30/16

and her change had been put in a separate

envelope. Staff #3 indicated the change

money ($122) was in the money bag

during the 8/9/16 review but had

probably fallen out of client #5's money

folder and was loose in the money bag.

Staff #2 (area director) was interviewed

on 8/11/16 at 1:54p.m. Staff #2 indicated

all staff, including professional staff,

were in need of retraining in regards to

implementing client programs and the

monitoring of client programs and client

finances.

9-3-3(a)

kept to avoid any

circumstances of missing

information, or the

chance of missing

money.All financial

transactions are

monitored by the

Program Coordinator,

reconciled on a monthly

basis by the Program

Director, and then

reviewed by the Client


completion of each

month. For the first 4

weeks, the Program

Coordinator will review

each client’s finances

twice per week. After the

initial four weeks, the

ProgramCoordinator will

review each client’s

finances no less than

once per week,ongoing.

Reviewing the client

finances includes, but is

not limited to,counting all

petty cash, ensuring all

transactions are

recorded and have

areceipt for proof of





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purchase. For the first 4

weeks, the Program

Director will review

eachclient’s finances

once per week. After the

initial four weeks, the

ProgramDirector will

review each client’s

finances twice per

month. After the next

four weeks, the

ProgramDirector will

continue with reviewing

each client’s finances no

less than onceper

month. Reviewing the

client finances includes,

but is not limited

to,counting all petty

cash, ensuring all

transactions are

recorded and have

areceipt for proof of

purchase.The Program

Coordinator and

Program Director were

retrainedon client

finances and Indiana

MENTOR’s policy and

procedure during

admissionsand





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discharges. Client #1’s

money has been

transferred from her old

group home to the new

one.Ongoing,the direct

support staff, Program

Coordinator, and

Program Director

willcomplete all financial

safeguards for all clients

at all times. This

includes,holding money,

managing money, and

protecting/monitoring

money for the individuals

that are unable to do so

on a daily basis

483.440(d)(1)

PROGRAM IMPLEMENTATION

As soon as the interdisciplinary team has

formulated a client's individual program plan,

each client must receive a continuous active

treatment program consisting of needed

interventions and services in sufficient

number and frequency to support the

achievement of the objectives identified in

the individual program plan.

W 0249

Bldg. 00

Based on observation, record review, and

interview, the facility failed for 2 of 3

sampled clients (#1, #2) to ensure the

clients' training programs were

implemented when opportunities were

present.

W 0249 The Direct Support Professionals

will be retrained on medication

administration; specifically on

including the medication goals

each time that medication

administration is completed with

each client.

After the retraining occurs, the

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Findings include:






















preparation tasks. Clients #1 and #2 were

seated in the living room during the

supper preparation.

Client #1's record was reviewed on

8/10/16 at 12:15p.m. Client #1's 4/19/16

Individual Support Plan (ISP) and

6/23/16 "Dining Plan" indicated she was

to be encouraged to assist with meal

preparation and the after meal clean up.

Program Coordinator and/or

Program Nurse will complete two

(2) weekly medication

administration observations to

ensure that the medication goals

are being completed with each

client as specified for four (4)

weeks. These will then be

reviewed by the QIDP/Program

Director ensuring that there are

no further training needs.

After the initial four (4) weeks, the

Program Coordinator and/or

Program Nurse will complete

weekly medication administration

observations ongoing, and will

ensure that all needed retrainings

will be completed.

Ongoing each DSP will work with

each client during medication

administration on their specific

Individualized Support Plan that

states each medication goal.

The QIDP/Program Director will

retrain the Direct Care Staff on

each client’s dining plan to ensure

that they are appropriately being

followed. This includes all staff to

be retrained on Client #1’s plan to

wipe her face after meals

independently, and to remain

sitting upright for 30 minutes after

any meal.

The Direct Care Staff will be

retrained on Client #1’s plan to

ensure that they redirect her

when she attempts to scratch her

vaginal area. The DSPs will also

be retrained on client dignity, and

completing formal training goals

according to Indiana MENTOR

policy and procedures.





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4002 N MOLLER RD

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Client #2's record was reviewed on

8/11/16 at 11:47a.m. Client #2's 11/18/15

ISP indicated she was to be encouraged

to increase her independence with meal

time activities.


1:54p.m. Staff #1 indicated clients #1 and

#2 had dining training program needs to

increase their independence with meal

preparation. Staff #1 indicated clients #1

and #2 should have been more involved

with the meal preparation and clean up.

9-3-4(a)

The client was taken to her PCP

on 8/17/16 to rule out any medical

concerns or reasons for the

continued scratching. No

concerns were noted, and no

changes were made at this time.

The QIDP/Program Director will

complete 2 weekly active

treatment observations for 4

weeks, and then 1 per week

afterwards to ensure that the

dignity policy and plans for client

# 1 are being instructed and

utilized as expected.

Ongoing, the Area Director will

complete quarterly pop in visits to

ensure that all policies and

procedures are being followed.

483.460(c)

NURSING SERVICES

The facility must provide clients with nursing

services in accordance with their needs.

W 0331

Bldg. 00


the facility nurse failed to ensure for 1 of

3 sampled clients (#1), that client #1's

Medication Administration Record

(MAR) and medications in the group

home were reviewed at the beginning of

each month.

Findings include:

The record of client #1 was reviewed on

8/10/16 at 12:15p.m. Client #1 had

W 0331 The Program Nurse was

retrained at the time of the

incident,on reviewing all client

Physician orders and Medication

Administration Recordsfor

accuracy, each and every month.

All staff were retrained at the time

of the incident onmedication

administration, and reporting

missing, inaccurate, and

incorrectmedications as they

become aware.


retained on ordering

medicationsappropriately from the

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physician's orders on 6/22/16 to

discontinue Seroquel 200 milligrams

(mg.). The orders were changed on the

6/16 Medication Administration Record

(MAR). The 7/16 MAR, that started on

7/1/16, had the discontinued Seroquel

back on it and the medication had been

delivered to the group home. On 7/17/16

client #1 had an incident

report/investigation that indicated client

#1's discontinued medication (Seroquel)

had been administered to client #1 from

7/1/16 through 7/16/16. The investigation

indicated the July MAR and medications

for client #1 had not been updated to

reflect the physician's order changes of

6/22/16.

Interview of staff #4 (nurse) on 8/11/16 at

2:22p.m. indicated client #1 did not

receive her Seroquel per physician orders

from 7/1/16 through 7/16/16. Staff #4

indicated on 7/1/16 the pharmacy

delivered the MARs and medications for

the group home. Staff #4 indicated client

#1's MAR and medications included

Seroquel 200mg. which had been

discontinued on 6/22/16. Staff #4

indicated she was responsible to review

the MAR and medications to ensure they

were correct at the beginning of each

month.

9-3-6(a)

pharmacy as needed to ensure

timely delivery. Thisretraining

included what the Program

Coordinator’s role is, for checking

in themedication upon delivery

each and every month. This is to

be completed beforethe start of

the month to ensure no wrong

meds, missing meds, or

additionalmeds.

Ongoing, the Williams’ Brother’s

Pharmacy conducts

quarterlyaudits to ensure that all

errors are addressed and

corrected.

Ongoing, the Program Nurse will

complete random audits ofthe

med cabinets to ensure that all

appropriate medications are in

the house asneeded and

prescribed.





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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

Bldg. 00


the facility failed for 1 of 3 sampled

clients (#1) who received medications, to

ensure each client received their

medication per the current physician's

orders.

Findings include:

The record of client #1 was reviewed on

8/10/16 at 12:15p.m. Client #1 had

physician's orders on 6/22/16 to

discontinue Seroquel 200 milligrams

(mg.). The orders were changed on the

6/16 Medication Administration Record

(MAR). The 7/16 MAR, that started on

7/1/16, had the discontinued Seroquel

back on it and the medication had been

delivered to the group home. On 7/17/16

client #1 had an incident

report/investigation that indicated client

#1's discontinued medication (Seroquel)

had been administered to client #1 from

7/1/16 through 7/16/16. The 7/16/ MAR

indicated client #1 had received Seroquel

200mg. from 7/1/16 through 7/16/16. The

investigation indicated the July MAR and

W 0368 The Program Nurse was

retrained at the time of the

incident, on reviewing all client

Physician orders and Medication

Administration Records for

accuracy, each and every month.

All staff were retrained at the time

of the incident on medication

administration, and reporting

missing, inaccurate, and incorrect

medications as they become

aware.


retained on ordering medications

appropriately from the pharmacy

as needed to ensure timely

delivery. This retraining included

what the Program Coordinator’s

role is, for checking in the

medication upon delivery each

and every month. This is to be

completed before the start of the

month to ensure no wrong meds,

missing meds, or additional

meds.

Ongoing, the Williams’ Brother’s

Pharmacy conducts quarterly

audits to ensure that all errors are

addressed and corrected.

Ongoing, the Program Nurse will

complete random audits of the

med cabinets to ensure that all

appropriate medications are in

the house as needed and

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medications for client #1 had not been

updated to reflect the physician's ordered

changes of 6/22/16.

Interview of staff #4 (nurse) on 8/11/16 at

2:22p.m. indicated client #1 did not

receive her Seroquel per physician orders

from 7/1/16 through 7/16/16. Staff #4

indicated on 7/1/16 the pharmacy

delivered the MARs and medications for

the group home. Staff #4 indicated client

#1's MAR and medications included

Seroquel 200mg. which had been

discontinued on 6/22/16. Staff #4

indicated the administration of Seroquel

was discovered on 7/16/16 and it was

discontinued and removed from the

group home.

9-3-6(a)

prescribed.

483.470(i)(1)

EVACUATION DRILLS

The facility must hold evacuation drills at

least quarterly for each shift of personnel.

W 0440

Bldg. 00


the facility failed for 5 of 5 clients (#1,

#2, #3, #4, #5) to ensure evacuation drills

were completed quarterly, for each of the

facility's personnel shifts, from 8/1/15

through 8/10/16.

W 0440 The direct support staff and the

Program Coordinator were

retrained on Indiana MENTOR's

policy and procedures for fire

drills, and safety procedures. All

Direct Support Professionals will

receive a retrainingevery other

month to ensure that they

understand the importance of

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Findings include:

Record review of the facility's evacuation

drills from 8/1/15 through 8/10/16, for

clients #1, #2, #3, #4 and #5 was

completed on 8/10/16 at 10:52a.m. The

night shift had documented drills 9/8/15,

12/10/15 and 3/22/16.

Interview of professional staff #2 on

8/10/16 at 10:52a.m. indicated she did

not have any other documented

evacuation drills for review. Staff #2

indicated evacuation drills should have

been completed per each shift on a

quarterly basis. Staff #2 indicated a night

evacuation drill should have been

completed during 6/16.

9-3-7(a)

completingthe monthly fire drills.

The retraining will include

reviewing a copy of theFire Drill

Schedule. Ongoing, the Direct

Support Professionals will

complete onefire drill per month

(or more as needed) according to

the schedule to ensurethat the

health and safety of the client’s

needs are met. Ongoing, all

completed fire drill reports will be

turned into and reviewed by

Quality Assurance for accuracy

and thoroughness of eachdrill.

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

Based on observation and interview for 3

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

additional clients (#4, #5), the facility

failed to encourage clients to participate

in meal preparation to the extent they

were capable.

W 0488 The Direct Support

Professionals will be

retrained oncompleting

formal and informal

active treatment

opportunities for each

clientat any given

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4002 N MOLLER RD

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Findings include:






















preparation tasks. Clients #1, #2, #3, #4,

#5 and #6 were seated in the living room

during the supper preparation.

Interview of staff #1 on 8/11/16 at

1:54p.m. indicated all of the clients were

capable of assisting (at varying abilities)

with the preparation of supper. Staff #1

indicated facility staff should have had

the clients involved with the meal

preparation.

teaching moment. This

training included what

Active Treatment is,and

what different

opportunities that they

might encounter each

day.The Program

Director will complete 2

weekly active

treatmentobservations

for 4 weeks, and then 1

per week afterwards to

ensure that theactive

treatment policy is being

instructed and utilized as

expected.Ongoing, the

Area Director will

complete quarterly pop

invisits to ensure that all

policies and procedures

are being followed.All

staff will be retrained on

completing and

properlydocumenting all

goals. This retraining

included what

appropriate and

completedocumentation

is in all situations,

according to Indiana

MENTOR’s policy





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9-3-8(a)andprocedures.The


complete two

weeklyobservations to

ensure that all staff are

completing the

objectives correctlywith

the clients. The Program

Coordinator will be

retrained on

completingdocumentatio

n reviews weekly.Along

with the observations,

the Program Coordinator

willalso complete weekly

random documentation

reviews to ensure that all

staff arecompleting the

documentation to record

the completion of the

objectives.The Program

Director will review all

documentation

reviewsand completed

observations to ensure

that they are being

completed correctly

byboth the staff and the

Program

Coordinator. Ongoing,

the Area Director will





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complete random

quarterlyaudits to ensure

that all documentation is

being completed and

correctly.The Program

Director and Program

Coordinator will be

retrained on Client

Finances. This training

will include ensuring that

the client’s ledgers

balance at all times,

documentation

requirements, and the

expectations for

supervisory reviews.


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