W 0000 - Indiana · Quality Review of this report completed by #15068 on 4/25/19. W 0000...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

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

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

PREFIX

TAG

IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

SOUTH BEND, IN 46615

15G673 04/10/2019

DUNGARVIN INDIANA LLC

3521 OXFORD

00

W 0000

Bldg. 00

This visit was for the pre-determined full

recertification and state licensure survey. This

visit included the investigation of complaint

#IN00275008.

Complaint #IN00275008: Substantiated, Federal

and State deficiencies related to the allegation are

cited at W149 and W154.

Dates of Survey: April 1, 2, 3, 4, 5, 8 and 10, 2019

Facility Number: 009114

Provider Number: 15G673

AIMS Number: 100244780

These deficiencies also reflect state findings in

accordance with 460 IAC 9.

Quality Review of this report completed by #15068

on 4/25/19.

W 0000

483.410(a)(1)

GOVERNING BODY

The governing body must exercise general

policy, budget, and operating direction over

the facility.

W 0104

Bldg. 00

Based on observation and interview for 7 of 7

clients residing at the group home, (clients A, B,

C, D, E, F and G), the governing body failed to

exercise operating direction over the facility to

ensure the living room couch and love seat were

not worn and broken and failed to ensure the main

bathroom had a toilet paper holder.

Findings include:

An evening observation was conducted at the

W 0104 A maintenance request will be

completed by 05/10/19 to make

the necessary repairs to the

bathroom toilet paper holder. New

couches will be ordered

by 05/10/19.

For six weeks and until proficiency

has been demonstrated Lead DSP

or designee will complete three

time weekly environmental sweeps

of the house to ensure that

05/10/2019 12:00:00AM

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

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

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

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

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

continued program participation.

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

_____________________________________________________________________________________________________Event ID: OIGY11 Facility ID: 009114

TITLE

If continuation sheet of 40

(X6) DATE




05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

group home on 4/1/19 from 4:00 P.M. until 7:45

P.M.. Upon entering the group home the brown

leather love seat located in clients A, B, C, D, E, F

and G's living room was observed with the right

and left arm rests ripped and chunks of the

leather, yellow sponge and white filling missing

measuring 4 inches in diameter. The seat

cushions were observed to have tears. The

brown leather couch arm rests had missing

leather, yellow sponge and white filling measuring

3 inches in diameter. As the surveyor walked

behind the couch, a piece of metal snagged the

surveyor's pants leg. The back rest of the couch

wood was broken and pushed outward with metal

staples protruding. At 5:00 PM, client F was

sitting on the living room couch with his back

leaned back.

An interview with client F was conducted on

4/1/19 at 5:05 P.M.. Client F was asked how long

the living room couch and love seat were ripped

and broken, client F stated "Oh for a while, like 2

or 3 months."

An interview with Direct Support Professional

(DSP) #3 was conducted on 4/1/19 at 5:10 P.M..

DSP #3 was asked how long the living room

furniture had been broken, and DSP #3 stated

"For a couple of weeks."

A morning observation was conducted at the

group home on 4/2/19 from 7:00 A.M. until 9:30

A.M.. At 9:00 A.M., client E exited the main

bathroom. The main bathroom of clients A, B, C,

D, E, F and G's home did not have a toilet paper

holder and the toilet paper roll sat on the back of

the toilet tank.

An interview with DSP #5 was conducted on

4/2/19 at 7:30 A.M.. DSP #5 was asked how long

maintenance requests have been

completed as required. These

environmental sweeps will be

documented via email to the

Program Director / QIDP and Area

Director for review and follow up. If

the Lead fails to complete

maintenance requests as required,

he will receive further retraining

and could face disciplinary action

in accordance with Dungarvin's

policies and procedures. Once

proficiency is demonstrated, the

observations will taper to at least

once weekly in an effort to ensure

that compliance is maintained.

The Program Director will

complete an environmental sweep

of the house at least one time

weekly for oversight purposes.

System wide, all Area Directors &

Area Managers will review this

standard and ensure that this

concern is being addressed at all

Dungarvin ICF/IIDs.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OIGY11 Facility ID: 009114 If continuation sheet of 40




05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

the living room couch and love seat were ripped,

torn and broken; DSP #5 stated "They have been

broken for about 3 months." DSP #5 was asked

how long the toilet paper holder had been

missing; DSP #5 stated "About 2 weeks."

An interview with the Program Director (PD) and

Area Director (AD) was conducted on 4/10/19 at

2:30 P.M.. The PD was asked if there were any

requests for maintenance at the group home in

regard to the broken and torn couch and love seat

and the missing toilet paper holder, and he stated

"No, there is not." The AD stated "The furniture

will be replaced. I was not aware the furniture was

in need of replacing."

9-3-1(a)

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

Bldg. 00


clients, (clients A, B, C, D, E,F and G), residing at

the group home, the facility failed to ensure

clients had access to their personal finances.

Findings include:

An evening observation was conducted at clients

A, B, C, D, E, F and G's home on 4/1/19 from 4:00

P.M. until 7:45 P.M.. At 4:55 P.M., client F sat on

the couch and stated "I get bored here." Client F

was asked if staff took him out into the

community, and he stated "Sometimes we go to

the [name of recreational center]. We went

bowling once. We never do anything anymore."

W 0126 The debit cards for persons served

in the home are kept locked. Petty

cash for persons served is kept in

a separate folder which can be

accessed by staff and persons

served at any time. All staff in the

home will be retrained on this

system by 5/10/19.

For oversight purposes, the

Program Director will monitor the

petty cash ledgers and cash

balances during at least weekly

site visits to ensure that staff

accessing funds as needed. Staff

who fail to follow the system will

05/10/2019 12:00:00AM





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

Client F was asked if he had money to go

anywhere and he stated "No, my money is locked

up." Client F was asked if he was able to get some

of his money if he wanted to go somewhere and

he stated "No, [Program Director name] has to

come unlock it and give it to me."



DSP #3 was asked if they could retrieve the

clients' personal funds kept at the group home;

DSP #3 stated "We do not have access to the

clients' debit cards, only the PD and Group Home

Lead (GHL) have the key." DSP #3 was asked if

the clients wanted to go out into the community

to buy something with their personal funds how

would they do so; DSP #3 stated "We would call

the PD."


4/2/19 at 8:45 A.M.. DSP #5 was asked if clients

could retrieve their personal funds, and DSP #5

stated "We don't have the key to get their debit

cards." When asked if the clients want to go

purchase something in the community with their

personal funds how do they get access to their

funds, DSP #5 stated "We call the PD."

An interview with the PD was conducted at the

facility administrative office on 4/2/19 at 11:15

A.M.. The PD was asked where the clients'

personal funds are kept, the PD stated "Each

client has a debit card and they are kept locked up

at the home." When asked if the clients have

access to their personal debit cards, he stated

"The staff calls me and I give them the debit

cards." When asked how are the clients taught to

manage their personal finances, the PD stated

"Staff take them to the places they want to go and

they buy the things they want."

be retrained and could face

disciplinary action up to an

including termination.





Dungarvin ICF/IIDs.





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

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 observation, record review and

interview, the facility failed for 7 of 7 clients,

residing at the group home, (clients A, B, C, D, E,

F and G), to maintain an accurate accounting

record of clients' personal funds.

Findings include:



P.M.. At 4:55 P.M., client F sat on the couch and

stated "I get bored here." Client F was asked if

staff took him out into the community and he

stated "Sometimes we go to the [name of

recreational center]. We went bowling once. We

never do anything anymore." Client F was asked

if he had money to go anywhere and he stated

"No, my money is locked up." Client F was asked

if he was able to get some of his money if he

wanted to go somewhere and he stated "No,

[Program Director name] has to come unlock it and

give it to me."



DSP #3 was asked if they could retrieve the

clients' personal funds kept at the group home,

DSP #3 stated "We do not have access to the

clients' debit cards, only the PD and Group Home

Lead (GHL) have the key." DSP #3 was asked if

the clients wanted to go out into the community

W 0140 The Program Director at the time

of the survey has since left

employment. The interim Program

Director will retrain all staff that

work in the home that debit and

cash transactions are to be

documented on the petty cash or

monthly expenditure ledger by

5/10/19.

For oversight purposes, the

Program Director will monitor the

ledgers during at least weekly site

visits to ensure that staff are

updating them as purchases are

made. Staff who fail to update the

petty cash ledger or monthly

expenditure ledger will be retrained

and could face disciplinary action

up to an including termination.





Dungarvin ICF/IIDs.

05/10/2019 12:00:00AM





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

to buy something with their personal funds how

would they do so; DSP #3 stated "We would call

the PD."


4/2/19 at 8:45 A.M.. DSP #5 was asked if clients

could retrieve their personal funds, and DSP #5

stated "We don't have the key to get their debit

cards." When asked if the clients want to go

purchase something in the community with their

personal funds how do they get access to their

funds, DSP #5 stated "We call the PD."

On 4/2/19 at 8:55 A.M., DSP #5 was asked to

contact the PD and ask that each client's personal

financial records for 6 months be available for

review at the facility's administrative office at

11:00 A.M..

A review of the facility's records submitted for

review, was conducted at the facility's

administrative office on 4/2/19 at 11:00 A.M.

Review of the submitted documentation indicated:

Page #1 with 3 hand written "Petty Cash

Slip...Amount: $2:14 (sic)...Date 6/6/18...To Pay

For: Money goal...[Pop name]...Cash Given To:

[Client F]...Receipt & Cash Returned By: [Client

F]...Petty Cash Slip...Amount: $2:07 (sic)...Date

6/6/18...To Pay For: Money goal...Cola, pot skin

(sic)...Cash Given To: [Client A]...Receipt & Cash

Returned By: [Client A]...Petty Cash


For: Money goal...[candy name] and [tea

name]...Cash Given To: [Client G]...Receipt &

Cash Returned By: [Client G]."

Page #2 with 1 handwritten "Petty Cash


For: Money goal Conditioner, twist comb





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

set...Cash Given To: [Discharged client]...Receipt

& Cash Returned By: [Discharged client]."


Slip...Amount: $3.75...Date 10/31/18...To Pay For:

[Pop name] (2)...Cash Given To: [Client B]...Petty

Cash Slip...Amount: $5.25...Date 8/13/18...To Pay

For: [Pop name] 12 oz (ounce) can 18 pk...Cash

Given To: [Client B]...Petty Cash Slip...Amount:

$2.14...Date 7/9/18...To Pay For: Money goal...

[Pop name]...Cash Given To: [Client B]."



For: 2 [Pop name] Money goal...Cash Given To:

[Client B]...Petty Cash Slip...Amount: $3.75...Date

10/31/18...To Pay For: [Diet Pop name] 6 pk...Cash

Given To: [Client B]."



[Pop name] (2)...Cash Given To: [Client F]...Petty

Cash Slip...Amount: $2.14...Date 6/6/18...To Pay

For: [Tea name] and [Candy name] Money

goal...Cash Given To: [Client G]...Petty Cash


[Diet pop name] and chips Money goal...Cash

Given To: [Client A]."

An interview with the PD was conducted at the

facility administrative office on 4/2/19 at 11:30

A.M.. The PD was asked for 6 months of

documentation indicating an accurate accounting

system of each client's personal funds. The PD

looked through the paperwork and handed this

surveyor the 7 reviewed pages and said "Here it is

right here." When asked if there was any other

documentation available for review, the PD stated

"no that is all." The PD was asked who is

responsible for maintaining each client's finances,





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

the PD stated "The GHL gathers the receipts and

turns them into me." No further documentation

was available for review to indicate the facility

maintained an accurate account of clients A, B, C,

D, E, F and G's personal finances.

An interview with the Area Director (AD) was

conducted on 4/10/19 at 2:30 P.M.. The AD stated

"There should be documentation in a binder with

each client's receipts and monthly ledgers to show

an accurate account of each client's personal

finances."

9-3-2(a)

483.420(d)(1)

STAFF TREATMENT OF CLIENTS

The facility must develop and implement

written policies and procedures that prohibit

mistreatment, neglect or abuse of the client.

W 0149

Bldg. 00

Based on record review and interview, the facility

failed for 5 of 7 clients, residing at the group

home, (clients A, B, D, E, and G) and 1 additional

discharged client (client H), to implement their

Abuse and Neglect policy to thoroughly

investigate incidents of alleged abuse, neglect

and elopement and to the report the results of the

investigations within 5 working days to the

administrator.

Findings include:

A review of the facility's records was conducted

on 4/1/19 at 11:00 A.M.. Review of the facility's

investigation records indicated:

1. "Investigation Report" date of incident March

11, 2019, involving Direct Support Professional

(DSP) #3 and [Discharged Client H] involving an

allegation of verbal abuse indicated the



employment.

All staff are trained upon hire,

annually, and on an as-needed

basis on Dungarvin Indiana’s

policy and procedure concerning

abuse, neglect, and exploitation.

The interim Program Director will

retrain all DSPs that work in the

home on Dungarvin Policy A-7

concerning reportable incidents

and Dungarvin Policy B-2

concerning Abuse, Neglect &

Exploitation by 05/10/19. All

DSPs working in the home will

also be retrained on expectations

for completing documentation,

including T-Log narratives and

GERs (internal incident reports)

05/10/2019 12:00:00AM





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

investigation was conducted on March 13 and 15

and completed on March 20, 2019. This

investigation was not concluded in 5 business

days.

2. "Investigation Report" for an incident of client

to client aggression, date of incident 9/3/18,

involving clients A and E, was investigated on

10/16/18 and completed on 10/16/18. This

investigation was not completed within 5

business days.

3. "Investigation Report" for an allegation of

neglect dated December 21, 2018, involving DSP

#8 and client B was investigated on 12/28/18 and

completed on 1/22/19. This investigation was not

completed within 5 business days.

4. BDDS report dated 7/18/18 involving client E

indicated: "[Client E] was in his room and he

eloped away from the house....Staff looked for him

and found him on [Road name] towards [Store

name]. [Client E] was gone for between 15 and 20

minutes...." Further review of this incident failed

to indicate this incident was investigated.

5. BDDS report dated 6/5/18 indicated: "On

Tuesday, June 5, 2018 at about 2:15 P.M., staff

reported that [Client B] had a small bruise below

his right eye lid. When staff asked him what

happened [Client B] said that his peer, [Client E]

hit him on the eye. When staff asked [Client E]

what happened, [Client E] said that [Client B]

punched him and he hit him back. Staff followed

protocol and informed the Program Director. The

incident happened before [Client B] went to

school in the morning...." Further review of the

report failed to indicate an investigation had been

conducted in regard to this incident of client to

client aggression.

and expectations for using

Dungarvin’s Call Tree if the On Call

supervisor cannot be reached and

will be provided copies of the Call

Tree phone list.

All Program Directors working for

Dungarvin’s South Bend office will

be retrained on Dungarvin Policy

B-2 concerning abuse, neglect &

exploitation and the DDRS/BQIS

Incident Reporting Policy and

expectations for completing a

thorough and timely investigation

by 05/10/19. The Program

Directors will also be retrained on

maintaining these investigations in

a file together with the related

BQIS incident reports filed with all

related investigation statements

so that they are available for

review by authorized agents from

regulatory agencies.

For oversight purposes, the interim

Program Director will complete

three time weekly site visits to the

home to quiz staff about reportable

incidents and reporting and

documentation requirements to

ensure staff proficiency. During the

visits the PD will speak to and/or

assess persons served to ensure

that their health and safety is

maintained. These three time

weekly visits and assessments

will continue for six weeks or until

proficiency has been

demonstrated and will be

documented on an Active

Treatment Observation Form. If at

any time proficiency is not





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

6. BDDS report dated 5/25/18 of client to client

aggression involving clients A and G was not

investigated.


aggression involving clients D and E was not

investigated.

8. An incident dated 10/27/18 of client to client


investigated.


aggression involving clients D and G was not

investigated.

10. BDDS report submitted by outside day

service provider indicated an incident involving

clients D and G at their outside day service

provider, dated 9/21/18 indicated: "[Client G]

approached QDDP (Qualified Developmental

Disabilities Professional) at [Day Program name]

and stated that he and his housemate [Client D]

did not have lunches today. [Client G] stated they

were supposed to go grocery shopping, but the

staff hasn't taken them yet. [Client D] was asked

to verify whether this was the case. [Client D]

stated that they did not have food to pack for

lunch today. QDDP asked if they had food but

just not what they desired for lunch. [Client D]

stated that there was some lunch meat, but no

bread. Both men stated that [Client G] had asked

staff in the home what they should do about

packing lunches, but that staff did not respond to

their requests. Both men stated that they asked

staff last night whether they were going grocery

shopping and they were told by staff that they

didn't know." Further review of the facility's

records failed to indicate a thorough investigation

demonstrated staff will be

immediately retrained.

During this time period, the Area

Director will review all incident

reports, T-Logs, and GERs five

times weekly to ensure all

incidents are documented,

reported, and investigated as

required.





Dungarvin ICF/IIDs.





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

was conducted in regard to this allegation of

neglect.

11. BDDS report dated 1/5/19 involving client A

indicated: "Yesterday staff called on call

supervisor to report that when he was picking up

[Client A] from work, [Client A] became upset

when he reminded him that his time of getting off

work was 9:00 P.M. instead of 11:00 P.M.. [Client

A] refused to get into the staff's car and decided

to walk away. Staff tried to follow him driving but

there was a lot of traffic and staff lost sight of him.

Staff followed the protocol and called the on call

and then the police. Staff and police were able to

find [Client A] and claimed he was walking home

because he was upset. Police spoke with him and

he rode with staff home. It is estimated that

[Client A] was without supervision for about

twenty minutes...." Further review of the report

failed to indicate an investigation had been

completed in regard to this incident.

The facility's policy and procedures were

reviewed on 4/1/19 at 2:45 P.M.. Review of the

facility's June 2015 Policy and Procedure

Concerning Abuse, Neglect and Exploitation

indicated the following (not all inclusive):

-"Dungarvin believes that each individual has the

right to be free from mental, emotional and

physical abuse in his/her daily life. This policy

establishes Dungarvin's procedures to prevent

abuse, neglect, or exploitation and identifies

specific actions to be taken if abuse, neglect, or

exploitation occurs or is suspected. Abuse,

neglect or exploitation of the individuals' served is

strictly prohibited in any Dungarvin service

delivery system...

-C. Neglect is defined as failure to provide





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

appropriate care, supervision or training, failure to

provide food and medical services as needed,

failure to provide a safe, clean and sanitary

environment...."

A second request of any reportables and

investigations was made on 4/8/19 at 2:00 P.M..

The PD submitted the following:

-BDDS report dated 4/1/19 indicated: "On Friday,

March 29, 2019 [Discharged client H] reported to

his advocate that his peer [Client A] has been

using his debit cards to buy cigarettes for himself.

[Discharged client H] reported that [Client A]

insists on using his debit card until [Discharged

client H] agrees. [Discharged client H] told his

Advocate and the advocate informed our Agency.

The Program Director will investigate the

allegation....The program Director (sic) will

investigate the issues and if it is determined that

[Client A] used [Discharged client H]'s money, the

funds will be reimbursed back to [Discharged

client H]. The team will continue to monitor

individuals closely and ensure their safety at all

times." Further review of the report failed to

indicate written documentation an investigation

had been conducted in regard to this incident.

An interview with the Program Director (PD) was

conducted on 4/8/19 at 2:30 P.M.. The PD was

asked what is the time frame for completing

investigations, the PD stated "Five days." When

asked if the investigations were completed within

5 days, he stated "No they were not." When

asked if an investigation was conducted in regard

to clients' lunches, client to client aggression and

elopements, he stated "No." When asked if an

investigation was conducted in regard to client A

and the discharged client's debit card, the PD

stated "We reimbursed the client $26.00." A





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

request to review the investigation record was

made in regard to the incident, the PD stated

"There is no investigation record, I looked into it

and the money was given back."

This federal tag relates to complaint #IN00275008.

9-3-2(a)

483.420(d)(3)


The facility must have evidence that all

alleged violations are thoroughly investigated.

W 0154

Bldg. 00

Based on record review and interview for 5 of 7


D, E and G), plus 1 discharged client (H), the

facility failed to conduct thorough investigations

of alleged abuse and neglect.

Findings include:






investigated.



investigated.

3. BDDS (Bureau of Developmental Disabilities

Services) report dated 7/18/18 involving client E

indicated: "[Client E] was in his room and he

eloped away from the house....Staff looked for him

and found him on [Road name] towards [Store

name]. [Client E] was gone for between 15 and 20

minutes...." Further review of this incident failed



employment. All Program

Directors working for Dungarvin’s

South Bend office will be retrained

on expectations for completing a

thorough and timely investigation

by 05/10/19. The Program









For oversight purposes, the Area

Director will review all

investigations to ensure they are

thorough and are completed within

5 business days and/or an update

on the progress of the

investigation is submitted to the

administrator.




05/10/2019 12:00:00AM





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

to indicate this incident was investigated.

4. BDDS report dated 6/5/18 indicated: "On

Tuesday, June 5, 2018 at about 2:15 P.M., staff

reported that [Client B] had a small bruise below

his right eye lid. When staff asked him what

happened [Client B] said that his peer, [Client E]

hit him on the eye. When staff asked [Client E]

what happened, [Client E] said that [Client B]

punched him and he hit him back. Staff followed

protocol and informed the Program Director. The

incident happened before [Client B] went to

school in the morning...." Further review of the

report failed to indicate an investigation had been

conducted in regard to this incident of client to

client aggression.


aggression involving clients D and E was not

investigated.



investigated.



investigated.



investigated.

9. BDDS report submitted by outside day service

provider indicated an incident involving clients D

and G at their outside day service provider, dated

9/21/18 indicated: "[Client G] approached QDDP

(Qualified Developmental Disabilities

Professional) at [Day Program name] and stated

that he and his housemate [Client D] did not have


Dungarvin ICF/IIDs.





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

lunches today. [Client G] stated they were

supposed to go grocery shopping, but the staff

hasn't taken them yet. [Client D] was asked to

verify whether this was the case. [Client D] stated

that they did not have food to pack for lunch

today. QDDP asked if they had food but just not

what they desired for lunch. [Client D] stated that

there was some lunch meat, but no bread. Both

men stated that [Client G] had asked staff in the

home what they should do about packing

lunches, but that staff did not respond to their

requests. Both men stated that they asked staff

last night whether they were going grocery

shopping and they were told by staff that they

didn't know." Further review of the facility's

records failed to indicate a thorough investigation

was conducted in regard to this allegation of

neglect.

10. BDDS report dated 1/5/19 involving client A

indicated: "Yesterday staff called on call

supervisor to report that when he was picking up

[Client A] from work, [Client A] became upset

when he reminded him that his time of getting off

work was 9:00 P.M. instead of 11:00 P.M.. [Client

A] refused to get into the staff's car and decided

to walk away. Staff tried to follow him driving but

there was a lot of traffic and staff lost sight of him.

Staff followed the protocol and called the on call

and then the police. Staff and police were able to

find [Client A] and claimed he was walking home

because he was upset. Police spoke with him and

he rode with staff home. It is estimated that

[Client A] was without supervision for about

twenty minutes...." Further review of the report

failed to indicate an investigation had been

completed in regard to this incident.

A second request of any reportables and

investigations was made on 4/8/19 at 2:00 P.M..





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

The PD submitted the following:

-BDDS report dated 4/1/19 indicated: "On Friday,

March 29, 2019 [Discharged client H] reported to

his advocate that his peer [Client A] has been

using his debit cards to buy cigarettes for himself.

[Discharged client H] reported that [Client A]

insists on using his debit card until [Discharged

client H] agrees. [Discharged client H] told his

Advocate and the advocate informed our Agency.

The Program Director will investigate the

allegation....The program Director (sic) will

investigate the issues and if it is determined that

[Client A] used [Discharged client H]'s money, the

funds will be reimbursed back to [Discharged

client H]. The team will continue to monitor

individuals closely and ensure their safety at all

times." Further review of the report failed to

indicate written documentation an investigation

had been conducted in regard to this incident.


conducted on 4/8/19 at 2:30 P.M.. When asked if

an investigation was conducted in regard to

clients' lunches, client to client aggression and

elopements, he stated "No."

This federal tag relates to complaint #IN00275008.

9-3-2(a)

483.420(d)(4)


The results of all investigations must be

reported to the administrator or designated

representative or to other officials in

accordance with State law within five working

days of the incident.

W 0156

Bldg. 00

Based on record review and interview, the facility

failed for 3 of 7 clients, residing at the group home W 0156 The Program Director at the time

of the survey has since left 05/10/2019 12:00:00AM





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

and 1 additional discharged client, (clients A, B, E

and H), to report the results of investigations

within 5 working days.

Findings include:




1. "Investigation Report" date of incident March

11, 2019, involving Direct Support Professional

(DSP) #3 and [Discharged Client H] involving an

allegation of verbal abuse indicated the

investigation was conducted on March 13 and 15

and completed on March 20, 2019. This

investigation was not concluded in 5 business

days.

2. "Investigation Report" for an incident of client

to client aggression, date of incident 9/3/18,

involving clients A and E, was investigated on

10/16/18 and completed on 10/16/18. This

investigation was not concluded with 5 business

days.

3. "Investigation Report" an allegation of neglect

dated December 21, 2018, involving DSP #8 and

client B was investigated on 12/28/18 and

completed on 1/22/19. This investigation was not

concluded with in 5 business days.



asked what the time frame for completing

investigations is, the PD stated "Five days."

When asked if the investigations were completed

within 5 business days, he stated "No they were

not."

employment. All Program

Directors working for Dungarvin’s

South Bend office will be retrained

on expectations for completing a n

investigation within 5 business

days by 05/10/19. The Program









For oversight purposes, the Area

Director will review all

investigations to ensure they are

thorough and are completed within

5 business days and/or an update

on the progress of the

investigation is submitted to the

administrator.





Dungarvin ICF/IIDs.





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

9-3-2(a)

483.440(c)(3)

INDIVIDUAL PROGRAM PLAN

Within 30 days after admission, the

interdisciplinary team must perform accurate

assessments or reassessments as needed

to supplement the preliminary evaluation

conducted prior to admission.

W 0210

Bldg. 00

Based on record review and interview for 7 of 7


C, D, E, F and G), the facility failed to have

completed Comprehensive Functional

Assessments (CFA) for each client.

Findings include:

A review of client A's record was conducted on

4/2/19 at 10:30 A.M.. Review of client A's records

failed to indicate a CFA.

A review of client B's record was conducted on

4/2/19 at 11:00 A.M.. Review of client B's records


A review of client C's record was conducted on

4/2/19 at 11:30 A.M.. Review of client C's records


A review of client D's record was conducted on

4/2/19 at 12:00 P.M.. Review of client D's records


A review of client E's record was conducted on

4/2/19 at 12:30 P.M.. Review of client E's records


A review of client F's record was conducted on

4/2/19 at 1:00 P.M.. Review of client F's records




Director will ensure that

a Comprehensive Functional

Assessment has been completed

for all persons served in the home

by 5/10/19. All Program Director /

QIDPs are trained at the time of

hire that a Comprehensive

Functional Assessment must be

completed for all newly admitted

individuals within 30 days of

admission and updated at least

annually thereafter. The interim

Program Director for the home will

be retrained on this expectation by

05/10/19.

Quarterly, the Program Director /

QIDP will conduct audits of the

client files. This audit will include

assuring that current

Comprehensive Functional

Assessments are in place for all

persons served within 30 days of

being admitted. These audits will

be reviewed by the Area Director

for follow up assurance.

System wide, all Program Director

/ QIDPs will review this standard

and will ensure that this concern

05/10/2019 12:00:00AM





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00


A review of client G's record was conducted on

4/2/19 at 1:30 P.M.. Review of client G's records



conducted on 4/2/19 at 11:30 A.M.. The PD was

asked if there was a CFA in each client's record

available for review. The PD assisted this

surveyor with looking through each client's record

and could not find CFAs in each client's record.

No CFAs were available for review.



asked if each client should had a completed CFA,

the PD stated "Yes, they should."

9-3-4(a)

is being addressed at all

Dungarvin ICF-IID’s.

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


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

C and D), the facility failed to implement clients'

programs.

Findings include:



W 0249 Staff that work in the home will be

retrained on ISP goals for clients

A, B, C & D as well as the active

treatment schedule by 05/10/19.


has been demonstrated, the

interim Program Director will

complete three time weekly site

visits at various, unannounced

05/10/2019 12:00:00AM





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

P.M.. From 4:00 P.M. until 6:00 P.M., client B

remained in his bedroom sleeping and clients A,

C, D, E, F and G sat on the living room couch and

would walk back and forth to and from their

bedrooms as Direct Support Professional (DSP) #3

cooked the clients' evening meal and DSP #2

walked back and forth from the staff office to the

living room. At 6:00 P.M., clients B, C, E, F and G

sat at the kitchen table and client F began serving

clients B and F's food onto their plates. Clients A

and D remained in their bedrooms with no

interaction or activity. The clients did not

participate in any teaching and/or training during

the observation period.

A morning observation was conducted on 4/2/19

from 7:00 A.M. until 8:30 A.M.. During the

observation period, DSP #4 sat in the living room

as client A laid on the living room couch and

client E sat on the white love seat with the lights

out. Clients C and F sat at the dining table.

Clients D and G left for Day Program and client B

remained in his bedroom sleeping. DSP #5

cleaned the kitchen and DSP #6 dusted and swept

the living room. The clients did not participate in

any teaching and/or training during the

observation period. DSP #5 cleaned the living

room and DSP #6 cleaned the kitchen with no

client involvement.



indicated an Individual Support Plan (ISP) dated

2/22/18 which indicated: "[Client A] will comply

with all medication administration as prescribed

by the doctor and will comply with all diabetes

care...Will learn how to budget his money

appropriately."


times to ensure that active

treatment expectations are being

met for clients A, B, C & D and all

persons served in the home.

These observations will be

documented and the records will

be submitted to the Area Director

weekly for review and follow up.

Any staff who fail to implement

active treatment goals and

objectives for clients A, B, C, &

D or others served in the home

during these visits will receive

further retraining and could face

disciplinary action in accordance

with Dungarvin's policies and

procedures. Once proficiency is

demonstrated, the observations

will taper to at least once weekly

in an effort to ensure that

compliance is maintained.





Dungarvin ICF/IIDs.





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00


indicated an ISP dated 2/5/18 which indicated:

"[Client B] will transition between activities

without displaying aggression or anger...Will

complete activities of daily living independently

with prompting from staff such as brushing his

teeth, combing his hair and showering."




"Will ensure that he is completing all activities of

daily living and care independently of his hygiene

with one prompt...Will manage and save his

money so that he is able to get into supported

living where he has his own apartment...Will learn

and practice life skills and vocational skills so that

he is able to transition to semi independent

living."




"Will learn good personal boundaries...Will

ensure that his room is clean...Will learn to

manage his own finances...Will learn to take care

of his personal hygiene."



asked if clients should be involved in activity and

he stated "Yes, they should be involved in

activity at all times."

9-3-4(a)

483.440(d)(2)

PROGRAM IMPLEMENTATION

The facility must develop an active treatment

schedule that outlines the current active

W 0250

Bldg. 00





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

treatment program and that is readily

available for review by relevant staff.


interview for 7 of 7 clients residing at the group

home, (clients A, B, C, D, E, F and G), the facility

failed to have a personalized active treatment

schedule for each client.

Findings include:








cooked the clients' evening meal and DSP #2

walked back and forth from the staff office to the

living room. At 6:00 P.M., clients B, C, E, F and G

sat at the kitchen table and client F began serving

clients B and F's food onto their plates. Clients A

and D remained in their bedrooms with no

interaction or activity. The clients did not


the observation period.


from 7:00 A.M. until 8:30 A.M.. During the

observation period, DSP #4 sat in the living room

as client A lay on the living room couch and client

E sat on the white love seat with the lights out.

Clients C and F sat at the dining table. Clients D

and G left for Day Program and client B remained

in his bedroom sleeping. The clients did not


the observation period. DSP #5 cleaned the living

room and DSP #6 cleaned the kitchen with no

client involvement.


of survey has since left


Director will be retrained on the

standard that an

individualized active treatment

schedule be in place for all

persons served in the home by

05/10/19. The Lead DSP and

Program Director will work

together to develop an active

treatment schedule for all

individuals in the home and staff

will be trained on the plan by

05/10/19.




three time weekly site visits at

various, unannounced times to

ensure that active treatment

expectations are being met and

staff are implementing the active

treatment schedule. These

observations will be documented

and the records will be submitted

to the Area Director weekly for

review and follow up. Any staff who

fail to follow the active treatment

requirements outlined for any

person served during these visits

will receive further retraining and

could face disciplinary action in

accordance with Dungarvin's

policies and procedures. Once

proficiency is demonstrated, the

observations will taper to at least

once weekly in an effort to ensure

05/10/2019 12:00:00AM





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

An interview with DSPs #4, #5 and #6 was

conducted on 4/2/19 at 8:45 A.M.. DSPs #4, #5

and #6 were asked if the clients had Active

Treatment schedules (ATS). DSP #4 stated "I

don't know what that is, but I'll go look in the

office." DSP #6 returned with a group home

activity calendar for the month of December (no

year noted) and a Day Program activity schedule

for the month of April (no year noted).

An interview with the Group Home Lead (GHL)

was conducted on 4/2/19 at 9:00 A.M.. The GHL

was asked if there were individualized ATS for

each client and he stated "We have schedules for

the clients on different things we do." The GHL

was asked to provide the client program books for

review at the administrative office. The GHL

stated "I will have them at the office by 11:00

A.M.."



failed to indicate an individualized ATS.













that compliance is maintained.





Dungarvin ICF/IIDs.





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

A review of client F's record was conducted on

4/2/19 at 1:00 P.M.. Review of client F's records


A review of client G's record was conducted on

4/2/19 at 1:30 P.M.. Review of client G's records




asked if each client had an individualized ATS and

he stated "Staff follow an ATS but it is not

individualized, its a general schedule." No

documentation was available for review to

indicate clients A, B, C, D, E, F and G had

individualized ATS in place.

9-3-4(a)

483.460(c)

NURSING SERVICES

The facility must provide clients with nursing

services in accordance with their needs.

W 0331

Bldg. 00


interview, for 2 of 2 sampled clients and 2

additional clients requiring nursing services,

(clients A, B, E and F), the facility's nursing

services failed to ensure a client's medication was

available for the client, failed to follow physicians

orders of increase of insulin, failed to ensure

clients had their prescribed adaptive equipment,

failed to ensure documentation of monitoring a

diabetic client's health risk plans was followed and

failed to ensure clients had procedures completed

as recommended by the physician.

Findings include:

1. At 7:32 P.M., DSP #3 prompted client B into the

medication administration room and began

W 0331 The nurse will be retrained on

expectations that she ensure

physicians' orders are followed,

documentation of monitoring a

diabetic client's health risk plans

is occurring as ordered, client's

medications and adaptive

equipment are available in the

home as ordered, and that clients

have procedures completed as

recommended by the physician by

05/10/19.

The order for insulin for Client A

and frequency of blood glucose

testing has been clarified and the

risk plan has been updated. All

staff that work in the home will be

05/10/2019 12:00:00AM





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

popping medications into a white souffle cup

standing in the medication closet located across

the room from the staff computer. DSP #3 handed

the medications to client B and he took his

prescribed oral medications with pop. Review of

the medication labels indicated: "[Client

B]...Divalproex 500 mg (milligram) tablet

(seizures)...1 tablet at bedtime...Depakote ER

(Extended Release) 250 mg tablet (seizures)...1

tablet at bedtime...Risperidone 2 mg tablet

(psychosis)...1 tablet at bedtime...Guanfacine 2 mg

tablet (attention deficit disorder)...1/2 tablet at

bedtime." DSP #3 did not reconcile the

medication label with the Medication

Administration Record (MAR) prior to

administration, during the administration and after

the administration. There was no teaching and

training during the medication administration.

At 7:35 P.M., DSP #3 popped out medications

from medication packets into a white souffle cup

and prompted client A to the medication room.

Client A entered the medication administration

room carrying a plastic locked box. Client A

unlocked the box at the desk where the staff

computer was located, as DSP #3 stood across the

room. Client A retrieved a Lantus (insulin) pen,

pulled the cap off, saw it was empty, put the cap

back on and put the empty pen on the desk in

front of the staff computer. Client A repeated this

eight times. Client A then took a ninth insulin pen

out of the box, turned to dial, did not and was not

prompted to wash his hands, lifted his shirt, did

not and was not prompted by staff to show the

dosage dialed and injected the insulin into his

stomach. Client A did not and was not prompted

to wipe the injection site. Client A was asked by

this surveyor how many units he just injected and

he stated "There was only ten units." He then put

the lid on the pen and put the now empty pen with

retrained on this updated risk plan

by 5/10/19. Staff will also be

retrained on expectations for

documenting blood glucose

readings as outlined in the risk

plan by 5/10/19.

All staff that work in the home will

also be retrained on Dungarvin

Policy C-3 concerning medication

administration, which includes

expectations for reporting and

documenting new medication

orders and as well reordering

medications when 5 days worth of

doses remain.

By 05/10/19 the Medical Support

DSP or nurse will schedule an

appointment with Client E's dentist

to ensure that the recommended

procedure is scheduled. By

05/10/19 the Medical Support

DSP or nurse will ensure that

eyeglasses and hearing aids for

clients A, B & E are ordered. All

staff who work in the home and

the interim Program Director and

nurse will be retrained on the

expectation that physician's

recommendations

are implemented by 05/10/19. The

nurse will also review this concern


to ensure that adaptive equipment

is ordered, present in the home,

and in good repair and any follow

up appointments that are needed

will be scheduled by 5/10/19.






05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

the other eight empty pens. Client A then

retrieved a tenth insulin pen, dialed the pen until it

stopped, this surveyor asked client A to show the

units dialed and he showed it to this surveyor and

it displayed ten units. Client A then injected the

insulin into the same injection site. This surveyor

asked DSP #3 and Client A how many units he

was prescribed to take and both DSP #3 and client

A stated "32 units." Client A then stated "I'm

supposed to do 32 units but I don't have

enough." DSP #3 then popped medications from

the medication cards into a white souffle cup and

handed the medications to client A who took his

medications with water. A review of the

medication labels indicated "[Client

A]...Metformin 1000 mg tablet (diabetes)...1 tablet

twice daily with meals...Saphris 10 mg tablet...1

tablet under tongue at bedtime." Client A did not

inject 36 units of Lantus, did not and was not

prompted to put the medication under his tongue

as prescribed. Client A took his medications with

water. Client A did not take his Metformin with

his dinner meal. During the observed medication

administration, DSP #3 did not prompt client A to

wash his hands, clean the injection site, did not

observe the dosage injected prior to injection and

did not review the MAR with the medication

labels prior to, during or after administration.

An interview was conducted with DSP #3 on

4/1/19 at 7:40 P.M.. DSP #3 was asked why client

A did not get his prescribed dosage of Lantus and

she stated "The Medical staff was notified on

Sunday that he was running out and we were told

the pharmacy said his insurance won't cover his

Lantus until April 2. DSP #3 was asked what they

are to do in situations when clients do not have

medications and she stated "Let the Medical staff

know."

has been demonstrated, the nurse

will complete two time weekly site

visits during medication

administration times to ensure

that staff are monitoring and

administering Client A's

medications as ordered and that

medications are available in the

home and/or are reordered from

the pharmacy in an effort to

prevent medication errors. These




review and follow up. Daily, the

nurse, Program Director, or

designee will review blood glucose

tracking documentation to ensure

that it is completed as required.

Weekly, the nurse will review all

medical appointments to ensure

that physicians' recommendations

are followed up on and adaptive

equipment is ordered as needed.

Any staff who fail to reoder

medications or administer

medications as ordered for Client

A during these observations and/or

staff who fail to document blood

glucose readings as required, will

receive further retraining and could

face disciplinary action in

accordance with Dungarvin's

policies and procedures.





Dungarvin ICF/IIDs.





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

An interview with the Medical Direct Support

Professional (MDSP) was conducted on 4/2/19 at

7:28 A.M.. The MDSP was asked if she was

notified that client A did not receive his full

dosage of Lantus on 4/1/19 and she indicated she

had not and stated "I was notified he was running

out on Sunday, I immediately called the pharmacy

and they told me he couldn't get any more until

4/2/19 because his insurance would not cover it

until then." The MDSP was asked if client A

should take his medications as labeled, she stated

"Yes."

2.) An evening observation was conducted at the


P.M.. At 7:00 P.M., client A took a plate and

began serving himself 4 cups of pasta and cheese

sauce and began eating the pasta. Client A then

took a 2 liter bottle of diet pop and started

drinking from the bottle. DSPs #2 and #3 did not

prompt or encourage client A in regard to the

portion of food and the diet pop or drinking water.

Review of client A's record indicated: "MAR

dated April 2019: Lantus Solostar 100 Unit/ml

(milliliter)-insulin pen, subcutaneous, Scheduled

Medication...Indication/Purpose: To maintain a

normal/healthy blood

levels...Instructions/Concerns: Inject 36 units

subcutaneous daily as directed (plus two units for

priming with each dose=38 units

daily...Saphris-Tablet , Sub-lingual, Scheduled

Medication...Indication/Purpose: To treat the

symptoms of psychotic

conditions...Instructions/Comments: Place one

tablet under tongue one time daily at bedtime**do

not give water with this medication." The MAR

was initialed by DSP #3 and failed to indicate

client A did not receive his proper dosage of

Lantus on 4/1/19 at bedtime. Further review of





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

client A's record failed to indicate documentation

of the client A not receiving the proper amount of

his prescribed Lantus.

Review of client A's record indicated:

Consultation Form dated 4/23/18 at 10:00 A.M.:

"The doctor will talk about his (client A) blood

sugar...Start taking Metformin 1000 mg with

breakfast and dinner...80-130 (A.M.)...<180 (2

hours after meals)-Blood sugar goals...Accu check

Fast Clix Lancets...frequency 4 to 6 times daily"


"Follow-Up:...Write down blood sugars on paper

logs...Accu check Fast Clix Lancets...frequency 4

to 6 times daily." Further review of client A's

record failed to indicate staff were writing down

his blood sugars on paper logs as recommended

by his physician.

Consultation Form dated 7/17/18 at 12:30 P.M.:

"Increase Lantus to 36 units at bedtime...Start

nicotine patches to promote cessation of smoking.

No smoking while using patches...New script sent

with instructions."


"Increase Lantus to 36 units before bedtime...If

<70, drink 4 oz (ounces) of juice or regular soda

and recheck blood sugar after 15 minutes."

Review of client A's record did not indicate client

training on his illness and teaching in regard to

his non-compliance of his physician's orders .

Review of client A's Blood Glucose Level (BGL)

electronic log dated 3/1/19 to 4/10/19 indicated:

"3/1/19: 9:13 A.M....137





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

10:44 P.M....143

3/2/19: 7:39 A.M....134

12:00 P.M...125

11:25 P.M...176

3/3/19: 8:26 A.M....181

10:35 P.M...129

3/4/19: 8:00 A.M....144

12:33 P.M...101

3/5/19: 11:45 A.M...145

3/6/19: 8:41 A.M....145

12:22 P.M...171

3/7/19: 7:56 A.M....246

11:30 A.M...246

3/8/19: 11:30 A.M...141

10:52 P.M...176

3/9/19: 7:26 A.M....203

11:07 A.M...119

3/10/19: 8:21 A.M....122

3/12/19: 11:05 A.M...338

3/13/19: 9:43 P.M...228

8:05 A.M...190

3/14/19 7:47 A.M...222

12:46 P.M...444

8:57 P.M...258

3/15/19 2:34 P.M...214

10:35 P.M...282

7:42 A.M...138

3/16/19 7:34 A.M....219

3/17/19 8:52 A.M...265

3/18/19 7:19 A.M...150

3/19/19 12:30 P.M..222

3/19/19 7:57 A.M...201

6:33 P.M...206

3/20/19 7:30 A.M...266

12:39 P.M...180

8:40 P.M....208

3/21/19 8:13 A.M...328

12:57 P.M...343

3/22/19 5:55 P.M...241

3/23/19 7:44 A.M...245





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

11:42 A.M...243

3/24/19 7:43 A.M...235

3/25/19 7:41 A.M...270

3/26/19 8:15 A.M...231

3/27/19 8:35 A.M...138

1:24 P.M...135

3/28/19 8:15 A.M...178

3/29/19 7:30 A.M...189

3/30/19 12:10 P.M...220

9:12 P.M...197

3/31/19 6:46 A.M...141

10:48 A.M...293

4/1/19 8:01 A.M...441

12:43 P.M...347

4/2/19 12:05 P.M...283

4/3/19 7:01 A.M...249

4/4/19 7:00 A.M...392

12:00 P.M...192

4/5/19 8:22 A.M...258

12:06 P.M. 210

12:50 P.M...213

4/6/19 8:17 A.M...286

11:30 A.M...314

11:52 A.M...229

4/7/19 7:23 A.M...438

4/8/19 7:52 A.M...594

11:00 A.M...246

8:30 P.M...518

4/9/19 11:24 A.M...185

5:00 P.M...123

8:45 P.M...215

4/10/19 7:48 A.M...297

12:46 P.M...203

Further review of the record failed to indicate

client A's BGL were tested 4 to 6 times daily.

There was no documentation in his record to

indicate review by the facility's nursing services.

There were no written logs of his BGL as ordered

by the physician. There was no documentation in





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

the record to indicate when the nurse and/or

doctor were notified of client A's high BGL. There

was no documentation in the record to indicate

client A was assessed by a nurse or doctor.

3) An evening observation was conducted at the


P.M.. During the entire observation clients A, B

and F did not wear eyeglasses and client E did not

wear hearing aids in both of his ears.


from 7:00 A.M. until 8:30 A.M.. During the entire

observation clients A, B and F did not wear

eyeglasses and client E did not wear hearing aids

in both of his ears.



indicated a vision assessment dated 3/6/29 which

indicated: "[Client A] has been diagnosed with

Myopia (near sightedness). He need new glasses

for full time wear."



indicated a hearing assessment dated 7/12/17

which indicated "Would benefit with hearing aids

in both ears." Further review of his record

indicated a dental assessment dated 9/17/18 which

indicated "Needs restorative surgery."

An interview with the agency Registered Nurse

(RN) was conducted on 4/2/19 at 3:00 P.M.. The

RN was asked if she knew client had run out of his

Lantus and she stated "I was informed that he

was low on his Lantus but the pharmacy said it

could not be filled until today because of his

insurance not covering it." The RN was asked

how often Nursing Services went to the group





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

home, she stated "At least once a week."The RN

was asked if the clients should have their

prescribed medication at all times, she stated "Yes

they should." The RN was asked in client E had

the ordered restorative surgery and she stated

"No, I don't think he has." The RN was asked if

the clients should have their prescribed adaptive

equipment and she stated "Yes, they should."

9-3-6(a)

483.460(g)(2)

COMPREHENSIVE DENTAL TREATMENT

The facility must ensure comprehensive

dental treatment services that include dental

care needed for relief of pain and infections,

restoration of teeth, and maintenance of

dental health.

W 0356

Bldg. 00

Based on record review and interview, for 1

additional client (client E), the facility failed to

ensure client E had a dental procedure completed

as recommended by the physician.

Findings include:





in both ears." Further review of his record

indicated a dental assessment dated 9/17/18 which

indicated "Needs restorative surgery."



RN was asked in client E had the ordered

restorative surgery and she stated "No, I don't

think he has."

W 0356 The Program Director and nurse

who were responsible for the home

at the time the recommendation

was made have since left

employment with Dungarvin. By


DSP or nurse will schedule an

appointment with Client E's dentist

to ensure that the recommended

procedure is scheduled.

All staff who work in the home and




recommendations




to ensure that medical needs are

being met. Any follow up

05/10/2019 12:00:00AM





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

9-3-6(a) appointments that are needed will

be scheduled by 05/10/19.





Dungarvin ICF/IDDs.

483.460(k)(2)

DRUG ADMINISTRATION

The system for drug administration must

assure that all drugs, including those that are

self-administered, are administered without

error.

W 0369

Bldg. 00


interview for 1 of 3 clients observed during the

evening medication administration, (client A), the

facility failed to ensure his medications were

administered without error.

Findings include:



P.M. At 7: 35 P.M., DSP #3 popped out

medications from medication packets into a white

souffle cup and prompted client A to the

medication room. Client A entered the medication

administration room carrying a plastic locked box.

Client A unlocked the box at the desk where the

staff computer was located, as DSP #3 stood

across the room. Client A retrieved a Lantus

(insulin) pen, pulled the cap off, saw it was empty,

put the cap back on and put the empty pen on the

desk in front of the staff computer. Client A

repeated this eight times. Client A then took a

ninth insulin pen out of the box, turned to dial, did

not and was not prompted to wash his hands,

W 0369 Dungarvin's Policy C-3 on

Medication Administration outlines

expectations that staff notify the

pharmacy and the Program

Director when there are 5 days

worth of doses remaining for any

medication. All staff that work in

the home will be retrained on this

policy and staff. All staff that work

in the home will also be retrained

on medication administration for

Client A and expectations for

monitoring him when he self

administers his medications by

05/10/19. Staff will also be trained

on expectations for documenting

and reporting incidents, including

medication errors, by 05/10/19.


has been demonstrated, the nurse

will complete two time weekly site

visits during medication

administration times to ensure

that staff are monitoring and

05/10/2019 12:00:00AM





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

lifted his shirt, did not and was not prompted by

staff to show the dosage dialed and injected the

insulin into his stomach. Client A did not and was

not prompted to wipe the injection site. Client A

was asked by this surveyor how many units he

just injected and he stated "There was only ten

units." He then put the lid on the pen and put the

now empty pen with the other eight empty pens.

Client A then retrieved a tenth insulin pen, dialed

the pen until it stopped, this surveyor asked client

A to show the units dialed and he showed it to

this surveyor and it displayed ten units. Client A

then injected the insulin into the same injection

site. This surveyor asked DSP #3 and Client A

how many units he was prescribed to take and

both DSP #3 and client A stated "32 units." Client

A then stated "I'm supposed to do 32 units but I

don't have enough." DSP #3 then popped

medications from the medication cards into a

white souffle cup and handed the medications to

client A who took his medications with water. A

review of the medication labels indicated "Client

A...Metformin 1000 mg tablet (diabetes)...1 tablet

twice daily with meals...Saphris 10 mg tablet...1

tablet under tongue at bedtime." Client A did not

inject 36 units of Lantus, did not and was not

prompted to put the medication under his tongue

as prescribed. Client A took his medications with

water. Client A did not take his Metformin with

his dinner meal. During the observed medication

administration, DSP #3 did not prompt client A to

wash his hands, clean the injection site, did not

observe the dosage injected prior to injection and

did not review the MAR with the medication

labels prior to, during or after administration.

An interview was conducted with DSP #3 on

4/1/19 at 7:40 P.M.. DSP #3 was asked why client

A did not get his prescribed dosage of Lantus and

she stated "The Medical staff was notified on

administering Client A's

medications as ordered and that

medications are available in the

home and/or are reordered from

the pharmacy in an effort to

prevent medication errors. These




review and follow up. Any staff who

fail to reoder medications or

administer medications as

ordered for Client A during

these observations will receive




procedures.





Dungarvin ICF/IIDs.





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

Sunday that he was running out and we were told

the pharmacy said his insurance won't cover his

Lantus until April 2." DSP #3 was asked what

they are to do in situations when clients do not

have medications and she stated "Let the Medical

staff know."

An interview with the Medical Direct Support

Professional (MDSP) was conducted on 4/2/19 at

7:28 A.M.. The MDSP was asked if she was

notified that client A did not receive his full

dosage of Lantus on 4/1/19 and she indicated she

had not and stated "I was notified he was running

out on Sunday, I immediately called the pharmacy

and they told me he couldn't get any more until

4/2/19 because his insurance would not cover it

until then." The MDSP was asked if staff should

administer client's medication following the

directives on the label and MAR and she stated

"Yes."



RN was asked if she knew client had run out of is

Lantus and she stated "I was informed that he

was low on his Lantus but the pharmacy said it

could not be filled until today because of his

insurance not covering it." The RN was asked if

staff notified her that client A only received 20

units of Lantus and she stated "No, I was not

notified." When asked how much Lantus client A

should have received on 4/1/19 at bedtime, the RN

stated "Honestly, I'm not sure." When asked

what steps staff should take when a medication

error occurs, the RN stated "Staff should call me

and then document into [Electronic File] and an

incident report should be documented." When

asked if a BDDS report had been filed, the RN

stated "Not that I'm aware of." The RN was asked

to explain how staff are trained to administer





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

medications, the RN stated "Staff and clients

should wash their hands. Staff should verify the

medication label with the MAR three times and

check for the 6 rights, before dispensing the

medication, while they are dispensing the

medication and after the medication has been

administered. Staff should then initial the MAR."

When asked if staff should follow the directions

on the label and the MAR, she stated "Yes."

9-3-6(a)

483.470(g)(2)

SPACE AND EQUIPMENT

The facility must furnish, maintain in good

repair, and teach clients to use and to make

informed choices about the use of dentures,

eyeglasses, hearing and other

communications aids, braces, and other

devices identified by the interdisciplinary

team as needed by the client.

W 0436

Bldg. 00


interview, the facility failed for 2 of 4 sampled

clients and 1 additional client, (clients A, B and E),

to ensure the clients had their ordered adaptive

equipment.

Findings include:



P.M.. During the entire observation clients A and

B did not wear eyeglasses and client E did not

wear hearing aids in both of his ears.


from 7:00 A.M. until 8:30 A.M.. During the entire

observation client A did not wear eyeglasses and

client B did not wear hearing aids in both of his

ears.

W 0436 The Program Director and nurse

who were responsible for the home

at the time the recommendation

was made have since left

employment with Dungarvin. By


DSP or nurse will ensure that

eyeglasses and hearing aids for

clients A, B & E are ordered.

All staff who work in the home and




recommendations




to ensure that adaptive equipment

05/10/2019 12:00:00AM





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00




indicated: "[Client A] has been diagnosed with

Myopia (near sightedness). He needs new

glasses for full time wear."




indicated: "No change in prescription glasses."





in both ears."


(RN) was conducted on 4/2/19 at 3:00 P.M. The

RN was asked if clients A and B had their ordered

eyeglasses and client E had his hearing aids, she

responded "No, they do not." When asked if the

clients should have their ordered adaptive

equipment, the RN stated "Yes they should."

9-3-7(a)

is ordered, present in the home,

and in good repair. Any follow up

appointments that are needed will

be scheduled by 5/10/19 and any

equipment needing replaced will

be ordered by 05/10/19.





Dungarvin ICF/IDDs.

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, the facility failed for 1 of 4 sampled

clients, (client A), to follow the client's prescribed

diet.

Findings include:

W 0460 Client A is not compliant with his

prescribed diet. His prescribed

diet is addressed on the menu and

should be implemented by staff.

All staff that work in the home will

be retrained on the expectation

05/10/2019 12:00:00AM





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00



P.M.. At 7:00 P.M., client A took a plate and

began serving himself 4 cups of pasta and cheese

sauce and began eating the pasta. Client A then

took a 2 liter bottle of diet pop and started

drinking from the bottle. DSPs #2 and #3 did not

prompt or encourage client A in regard to the

portion of food and the diet pop or drinking water.


4/2/19 at 10:30 A.M.. Review of client A's record

indicated:

"Dungarvin Indiana, LLC Health Risk Plan Insulin

Diabetic Mellitus" dated 4/2018 which indicated

"Problems: [Client A] has a history of Insulin

Dependent Diabetes Mellitus...Goals: Promotion

of blood sugar levels within normal range with

diet, exercise and medication regimen. To

decrease the risk of complications from

diabetes....Current Status: [Client A] is a (sic)

insulin dependent controlled by diet, insulin and

oral anti-hyperglycemic....Medications: Lantus 32

units injected every night at bedtime...Metformin

1000 mg twice daily...Victoza once daily

subcutaneous...Treatment: Follow diet as ordered

1500 calorie ADA (American Diabetic

Association), skim milk...Interventions: AM

(morning) blood sugar parameters 80-130....PM

(night) blood sugar parameters below 480....Any

sugar levels out of these parameters will be

reported to the site Nurse and PD (Program

Director) and all instructions given will be

followed up on by site staff....Administer

prescription medication as ordered....Monitor

injection sight for any signs of

complications...Examples: redness, hard to the

touch, bleeding....Monitor blood sugar as

that Client A is prompted to follow

his prescribed diet as per the

menu during meal times by

5/10/19. His refusals will be

documented in T-log narratives.





various, unannounced times,

including meal times, to ensure

that staff are prompting Client A to

follow his prescribed diet and are

documenting any refusals that

occur.These observations will be

documented and the records will

be submitted to the Area Director

weekly for review and follow up.

Any staff who fail to prompt Client

A to follow his prescribed diet

during these visits will receive













Dungarvin ICF/IIDs.





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

ordered...Monitor for sings (sic)/symptoms of

Hypoglycemia...a.) Chills, cold sweat, blurred

vision, shaking, rapid heart rate, Fainting (sic) and

headache...Monitor for signs/symptoms of

Hyperglycemia...a.) Increased thirst for water,

increased urination, confusion, flushing, rapid

breathing, unconsciousness and fruity smelling

breath...Notify PD/Nurse with any concern

regarding diabetes...Routine labs as ordered by

physician, obtain a copy of result for file...Follow

prescribed diet: 1500 calorie ADA, Skim

milk...Read nutritional information on food labels

when shopping...Choose low sugar/carbohydrate

items when shopping...Encourage proper food

choices...Provide more than one healthy

option....Encourage client to eat at the proper time

i.e. (such as) breakfast between 7-9 am...lunch

between 11:30 am-1:30 pm, dinner between

4:30-6:30 pm...."


(RN) was conducted on 4/2/19 at 3:00 P.M.. When

asked if staff should follow the developed risk

plans and prescribed diet, the RN stated "Yes."

When asked if staff should prompt client A about

his prescribed diet, the RN stated "Yes, they

should."

9-3-8(a)

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



C, D, E, F and G), the facility failed to ensure the

clients participated in meal preparation and served

themselves independently.

W 0488 All staff in the home will be

retrained on the meal preparation

goals for all persons served in the

home and the expectation that

individuals assist with meal

05/10/2019 12:00:00AM





05/15/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G673 04/10/2019


3521 OXFORD

00

Findings include:








cooked the clients' evening meal which consisted

of pasta and cheese sauce, baked barbeque

chicken, fruit cocktail, concentrated apple juice

and concentrated orange juice. At 6:00 P.M.,

clients B, C, E, F and G sat at the kitchen table and

client F began serving clients B and F's food onto

their plates. Clients A and D remained in their

bedrooms with no interaction or activity. The

clients did not participate in meal preparation.

Clients B and F did not serve themselves.



asked if each client was capable of participating in

meal preparation. The PD stated "Yes the clients

are capable of assisting in cooking their dinner

and should be doing so at all times." When asked

if clients B and F should be serving themselves,

the PD stated "Yes they should."

9-3-8(a)

preparation, including packing

lunches, to the best of their ability

by 05/10/19.





various, unannounced times to

ensure that all individuals served in

the home are assisting with meal

preparation. These observations

will be documented and the

records will be submitted to the

Area Director weekly for review

and follow up. Any staff who fail to

ensure that a that all individuals

served in the home are assisting

with meal preparation will receive













Dungarvin ICF/IIDs.


W 0000 - Indiana · Quality Review of this report completed by #15068 on 4/25/19. W 0000...

Documents

Transcript of W 0000 - Indiana · Quality Review of this report completed by #15068 on 4/25/19. W 0000...