PRINTED: 12/30/2016 DEPARTMENT OF HEALTH AND …Team Leader will rearrange the furniture in the current day 09/12/2016 12:00:00AM FORM CMS-2567(02-99) Previous Versions Obsolete

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

12/30/2016PRINTED:

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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TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

PREFIX

TAG

IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

CULVER, IN 46511

15G534 08/12/2016

PATHFINDER SERVICES INC

605 ACADEMY RD

00

W 0000

Bldg. 00

This visit was for the investigation of

complaint number #IN00204044.

Complaint #IN00204044: Substantiated,

federal/state deficiencies related to the

allegation are cited at W104, W149,

W154, W186, W249, and W436.

Dates of Survey: 8/8, 8/9, 8/10, 8/11, and

8/12/16.

Provider Number: 15G534

AIM Number: 100245410

Facility Number: 001048

The following federal deficiencies also

reflect state findings in accordance with

460 IAC 9.

Quality review of this report completed

8/23/16 by #09182.

W 0000 Corrective Actions are stated

under each regulation tag entry

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, record review, and

interview, for 3 of 3 sample clients

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

clients (clients D, E, F, and G), the

governing body failed to exercise

W 0104 What corrective action (S) will be

accomplished for these residents

found to have been affected by

the deficient practice?

1. On 9/1/16, the Day Services

Team Leader will rearrange the

furniture in the current day

09/12/2016 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: CVCY11 Facility ID: 001048

TITLE

If continuation sheet Page 1 of 28

(X6) DATE




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operating direction over the facility to

ensure clients at the facility owned day

services had sufficient space to provide

day services and to ensure maintenance

and repairs were completed at the group

home for client G's broken bed frame and

the worn and stained carpet for clients A,

B, C, D, E, F, and G.

Findings include:

1. On 8/9/16 from 9:00am until 1:20pm,

observation and interviews were

conducted at the facility owned day

program at the agency. During the

observation period, clients C and F were

2 of 15 clients sitting in one room at the

day services along with five long style

conference length tables. From 9:00am

until 1:20pm, clients C and F sat at tables

in one room and Workshop Staff (WKS)

#1 stated the room was "small" for fifteen

clients and four staff in the same room.

WKS #1 indicated the room had five

conference length tables and each table

was "over nine feet long and three feet

wide." WKS #1 stated clients A, B, C,

D, E, F, and G "all" attended the same

room at the facility owned day services.

WKS #1 stated clients who were

dependent on staff for transfers to/from

their wheelchairs and for client G who

needed to use a urinal, those clients were

"to use" the back storage room for

services’ room, so that there is

ample room for clients and staff

to move about the room. The new

room design has removed the

conference room tables and now

includes a variety of different

sized tables, for individual and

small group facility use. Clients

can easily walk around the room

or use their wheelchair and

walkers with ease throughout the

room.

2. On 9/1/16, the Day Services

Team leader will post a room

schedule, so that clients may be

divided into small groups and

may utilize the two other day

services rooms during the day.

On September 12, 2016 day

services will move to a new larger

facility.

3. On 8/30/16 Pathfinder’s

Property Manager inspected the

carpets and came to the

conclusion that the carpet in the

living room and hallways was only

a few years old and rather than

needing replaced, needed a

professional cleaning.

Professional carpet cleaning

throughout the entire house will

take place on 9/9/16. Quarterly

carpet cleanings will take place

starting 9/9/16 and monitored by

the Assistant Director.

4. On 9/1/16 the storage room

usage for the toilet chair and use

of the toilet chair was

discontinued. The client utilizing

the chair is currently attending a

different day services. New

handicapped accessible

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 2 of 28




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00

toileting. At 9:30am, WKS Supervisor

showed the surveyor the back storage

room at the day services. When WKS #1

unlocked the storage room with a key,

stacks of bags, boxes, a mop bucket with

brown water, a portable toilet, and loose

items were visible inside the room. WKS

#1 indicated the portable toilet had urine

located in the bowl of the portable toilet

from the previous day and should have

been cleaned out after every use. WKS

#1 indicated the storage closet had no

running water and no handwashing area

for clients to wash their hands. At

10:20am, the WKS Supervisor stated the

agency "knew the room for day services

was too small" for clients and the agency

was waiting for their new building to

finish its remodel. The WKS Supervisor

indicated the agency had been waiting for

completion of the remodel of the other

location since before March, 2016.

On 8/11/16 at 9:57am, an interview with

the Community Supports Assistant

Director (CSAD) was conducted. The

CSAD indicated clients A, B, C, D, E, F,

and G attended the facility owned day

services during the weekdays. The

CSAD stated clients A, B, C, D, E, F, and

G attended the facility owned "day

services a few days a week" and attended

a second agency "contracted" day

services "a few days a week." The CSAD

bathrooms will be available for all

clients at the new facility starting

9/12/16.

How will other residents having

the potential to be affected by the

same deficient practice be

identified and what corrective

action will take place?

1 The Day Services is moving to

a new facility on September 12,

2016. This facility’s day services

rooms are much larger, allowing

for more room per person. If the

day services adds more clients to

its programs, room use will be

evaluated by the Day Services

Team Leader and the Assistant

Director and room use schedules

will be adjusted according to the

number of participants.

2. A cleaning contract will be

made with the professional carpet

cleaners to clean the carpets

every quarter year. This will

assure that clients’ carpets will be

cleaned and maintained

throughout the year.

3. The Day Services is moving to

a new facility on September 12,

2016. This facility’s day services

will have regular and

handicapped accessible toilets.

The use of a storage room and

toilet chair will no longer be an

issue. If a toilet chair is preferred

by a client, then the Day Services

Team Leader will train staff on

the proper use and cleaning of

the toilet chair.

What measures will be put into

place or what systemic changes

you will make to ensure that the





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605 ACADEMY RD

00

indicated the agency had the potential to

have eighteen (18) or more clients from

the agency operated group homes and

additional clients from the community in

the same room at the agency for day

services at any one time. The CSAD

stated the single room for the facility

owned day services "was small" and a

"temporary" location because the agency

had secured a building at a different

location which was being remodeled.

The CSAD indicated five conference

long tables were in the same room with

clients attending the day services at the

agency location. The CSAD stated the

new location "was not ready" for use and

no completion date was available.

On 8/12/16 at 3:28am, the CSAD stated

the room for day services at the agency

was "twenty-three feet wide by

twenty-three feet, ten inches long."

2. Observations and interviews were

conducted at the group home on 8/8/16

from 4:15pm until 5:55pm. Clients A, B,

C, D, E, F, and G were observed at the

group home. During the observation

period the following needed repairs were

observed with the Residential Manager

(RM):

-On 8/8/16 at 4:30pm, the RM stated 2 of

2 hallways and clients A, B, and C's

deficient practices does not

recur?1- The Day Services Team

Leader will post a room use

schedule daily for staff to utilize

and will monitor room use daily to

assure that the clients coming to

day services are not crowded into

one room.

2. The Assistant Director will do

quarterly building inspections,

checking the condition and

cleanliness of the carpets. If the

building inspection reports show a

need for replacement, repair or

cleaning of carpets, the Assistant

Director will make arrangements

for replacement, repairs or

cleaning to take place.

3. The Day Services Staff were

trained on 8/15/16 on the proper

cleaning of the toilet chair. The

storage room is no longer being

used for toilet use.

How will the corrective actions will

be monitored to ensure the

deficient practice will not recur,

what quality assurance program

will be put into place?1- The Day

Services Team Leader will review

the room use schedule each

morning with the day services

staff. Each staff will be assigned

to lead a small group activity and

each group assigned a room.

2. A Quarterly Carpet Cleaning

Schedule for will be utilized by the

group home managers and

monitored by the Assistant

Director. A carpet cleaning is

scheduled for 9/9/16.

3. If a toilet chair is preferred by a

client, then the Day Services





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605 ACADEMY RD

00

bedroom had "worn and stained" floor

carpet. The RM indicated the group

home was in the process of obtaining

bids for the carpet throughout the group

home to be replaced. The RM stated the

carpet was "discolored, stained," and was

worn.

-The RM indicated client G's bed frame

to support his mattress was broken and

needed to be replaced.





and G lived in the group home and the

carpets were stained, worn, and needed to

be replaced. The CSAD indicated she

was not aware of client G's bed frame

being broken.

This federal tag relates to complaint

#IN00204044.

9-3-1(a)

Team Leader will train staff on

the proper use for that client and

will monitor the cleaning of the

toilet chair, which will occur after

each use. The Day Services is

moving to a new facility on

September 12, 2016. This

facility’s day services will have

regular and handicapped

accessible toilets. The use of a

storage room and toilet chair at

the current day services location

is no longer be an issue, as the

client currently is not attending

Pathfinder’s day services.

What is the date by which the

systemic changes will be

completed?9/12/16

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 observation, interview, and

record review, for 1 of 3 sample clients

W 0149 What corrective action(s) will be



09/02/2016 12:00:00AM





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CULVER, IN 46511

15G534 08/12/2016


605 ACADEMY RD

00

(client A) who had staff supervision

needs related to her choking risk and

removing items from the trash, the

facility neglected to implement its

Abuse/Neglect/Mistreatment policy to

thoroughly investigate and to ensure

sufficient numbers of facility staff

supervised client A according to her

identified need.

Findings include:

On 8/8/16 at 2:25pm, the facility's BDDS

(Bureau of Developmental Disabilities

Services) reports were reviewed for the

period from 5/1/16 through 8/8/16 and

indicated the following for client A:

-An 8/5/16 BDDS report for an incident

on 8/4/16 at 11:15pm, indicated client A

"was sweeping in the kitchen, while staff

went into the bathroom to assist another

client. [Client A] went into the garbage

can and ate Watermelon that was thrown

away and ended up choking on it. No

hands on intervention was used or needed

by staff. [Client A] was taken to the ER

(Emergency Room) by ambulance for

choking incident, due to possibility of

aspiration." Client A was discharged

around 1:15am on 8/5/16. The report

indicated client A "will not be left in the

kitchen and living room area with any

food on the countertop or in the garbage

can without staff in sight."


1.The residential Manager will

complete a weekly staffing

schedule that will have no less

than two staff scheduled to work

during waking hours.

2.The Assistant Director will

review staffing schedules weekly.

3.On 9/2/16 the nurse trained

staff on Client A’s choking

protocol which now has two staff

on duty during waking hours at all

times and someone observing

Client A at all times.






1.QDDP will identify how many

staff are needed for each client.

2.The Residential Manager will







4.The nurse or QDDP will

review choking protocols with the

dietitian at each dietitian review

visit or before if needed.



will you make to ensure that

deficient practices do not recur?

1.The Assistance Director will

review staffing schedules weekly

(Residential Managers must turn

in staffing schedules a week

ahead) to assure that two staff

are scheduled during waking





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605 ACADEMY RD

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On 8/8/16 from 4:15pm until 5:55pm,

client A was observed at the group home.

From 4:15pm until 5:55pm, client A and

six (6) additional clients were observed at

the group home with two facility staff.

Client A's record was reviewed on 8/9/16

at 10:30am. Client A's 1/12/16 ISP

(Individual Support Plan) and 2/1/16 BSP

(Behavior Support Plan) indicated client

A "There are dining plan change. Seen

Speech therapist for eating concerns (sic).

Risk plan updated with prompts

increased (sic). [Client A] is to put

silverware down between bites. She

needs to slow down with eating. She

needs to chew more thoroughly and take

drinks in between bites. [Client A] needs

to be watched when she is taking out the

trash to make sure she is not getting into

it..." Client A's 2/2/2015

"Choking/Dining Protocol" indicated

client A was at risk to choke, required

staff supervision when around food

and/or the kitchen, and "...Preventative

supports and strategies to manage risk:

Staff will sit with [client A] at the dinner

table during meals...When [client A] is in

the main living areas of the home, she

should be carefully monitored by staff as

she will go into the kitchen and pantry

area and forage for snacks. This presents

the opportunity for choking...When

hours.

2.The nurse will update choking

protocols as needed and train

staff whenever changes are

made.

How will corrective actions be

monitored to ensure the deficient

practice will not recur, i.e. what

quality assurance program will be

put into place?


monitor staffing schedules for

each week to assure that two

staff are scheduled during all

waking hours.

2.The nurse will review any

incidents of choking to check if

choking protocols were followed.

If needed she will retrain staff on

dining plans. She will consult with

the dietitian if dining plans need

changes made to them.



completed?

9/2/16





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[client A] is taking out any trash, staff

will monitor her by walking with her to

the dumpster and watching her place the

tied trash bag inside the dumpster. This

should help deter [client A] from

foraging for food in the trash and

possible choking on that food."


the QIDP (Qualified Intellectual

Disabilities Professional) was conducted.

The QIDP stated the facility was to have

"at least" two staff "always" on duty. The

QIDP indicated on 8/4/16 there were two

staff on duty at the group home, the

second staff had left the facility, and the

remaining one staff person did not know

she was alone in the group home at the

time. The QIDP stated the lone staff

person was in the bathroom assisting

another client when client A had been

sweeping the kitchen, got into the trash,

and choked on the watermelon when

client A was left unsupervised by the

staff. The QIDP stated the incident took

place at "8:15pm not 11:15pm" and

indicated she put in the wrong numbers

by error when submitting the report. The

QIDP indicated staff neglected to

supervise client A according to her

identified needs on 8/4/16. The QIDP

indicated the facility neglected to ensure

there were sufficient staff on duty to

supervise client A on 8/4/16. The QIDP





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indicated the facility followed the BDDS

reporting and investigating guidelines for

abuse, neglect, and/or mistreatment. The

QIDP indicated she interviewed the staff

on duty at the group home, stated she

"discovered" one staff was left alone to

supervise seven clients, and did not

document a written investigation into the

8/4/16 incident.

On 8/9/16 at 11:30am, the QIDP

provided an 8/4/16 at 11:00pm "e-mail

Re: [client A]...had a choking incident on

Thursday that sent her to the hospital.

She got watermelon out of the trash can

when the house was down to one staff

and that staff was assisting another client

in the bathroom...Never leave [client A]

out of sight with access to food in the

garbage or on the counter top. She has a

history of getting food out of the

garbage...I also would not like to see staff

go down to one until the clients have all

went to bed."


the CSC (Community Supports

Coordinator) was conducted. The CSC


reporting guidelines and the agency's

policy and procedures for abuse, neglect,

and/or mistreatment to protect clients

from abuse, neglect, and/or mistreatment.

The CSC stated client A "should not be





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left alone" around food. The CSC

indicated it was staff neglect for the

failure to provide staff supervision while

client A did not have facility staff to

supervise her one on one in the kitchen.

On 8/8/16 at 2:15pm, a review of the

facility's records indicated the facility's

undated "Handling client Abuse, Neglect,

and Injuries of Unknown Origin & (and)

BDDS Incident Reporting" policy which

indicated "It is Pathfinder Services, Inc.

policy to provide a service where clients

are free from abuse, neglect, or

exploitation. In the event that any of

these conditions are suspected, an

investigation will immediately be

conducted...Any alleged, suspected, or

actual abuse-physical, sexual, emotional,

or domestic improper treatment,

neglect-failure to provide appropriate

care, environment, food, medical care, or

supervision, exploitation or any other

mistreatment must be immediately

reported...."


#IN00204044.

9-3-2(a)

483.420(d)(3)

STAFF TREATMENT OF CLIENTS

W 0154





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The facility must have evidence that all

alleged violations are thoroughly

investigated.

Bldg. 00


record review, for 1 of 1 BDDS (Bureau

of Developmental Disabilities Services)

reports reviewed for 1 of 3 sample clients

(client A), the facility failed to implement

its Abuse/Neglect/Mistreatment policy to

thoroughly investigate client A's choking

incident at the group home.

Findings include:











can and ate Watermelon (sic) that was

thrown away and ended up choking on it.

No hands on intervention was used or

needed by staff. [Client A] was taken to

the ER (Emergency Room) by ambulance

for choking incident, due to possibility of











































deficient practices o not recur?

09/02/2016 12:00:00AM





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QIDP indicated the facility failed to

ensure there were sufficient staff on duty

to supervise client A on 8/4/16. The

QIDP indicated the facility followed the

BDDS reporting and investigating







hours.




made.





put into place?





waking hours.










completed?

9/2/16





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guidelines for abuse, neglect, and/or

mistreatment. The QIDP indicated she

interviewed the staff on duty at the group

home, stated she "discovered" one staff

was left alone to supervise seven clients,

and did not document a written

investigation into client A's 8/4/16

incident.


provided a 8/4/16 at 11:00pm "e-mail Re:

[client A]...had a choking incident on


She got Watermelon (sic) out of the trash

can when the house was down to one

staff and that staff was assisting another

client in the bathroom...Never leave

[client A] out of sight with access to food

in the garbage or on the counter top. She

has a history of getting food out of the



went to bed."





reporting guidelines and the agency's

policy and procedures for abuse, neglect,

and/or mistreatment to protect clients

from abuse, neglect, and/or mistreatment.

The CSC stated client A "should not be

left alone" around food and no formal





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investigation was available for review.

The CSC indicated it was staff neglect

for the failure to provide staff supervision

while client A did not have facility staff

to supervise her one on one in the

kitchen.


#IN00204044.

9-3-2(a)

483.430(d)(1-2)

DIRECT CARE STAFF

The facility must provide sufficient direct

care staff to manage and supervise clients in

accordance with their individual program

plans.

Direct care staff are defined as the present

on-duty staff calculated over all shifts in a

24-hour period for each defined residential

living unit.

W 0186

Bldg. 00


record review, for 1 of 3 sampled clients




facility failed to ensure sufficient

numbers of facility staff supervised client

A according to her identified need.

Findings include:

















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(Behavior Support Plan) indicated for

client A "There are dining plan change.

Seen Speech therapist for eating concerns































hours.




made.





put into place?







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(sic). Risk plan updated with prompts

increased (sic). [Client A] is to put

silverware down between bites. She






it..." Client A's 2/2/2015



























waking hours.










completed?

9/2/16





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QIDP indicated staff neglected to

supervise client A according to her

identified needs on 8/4/16. The QIDP

indicated the facility failed to ensure

there were sufficient staff on duty to

supervise client A on 8/4/16.


provided a 8/4/16 at 11:00pm "e-mail Re:

[client A]...had a choking incident on














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went to bed."




stated client A "should not be left alone"

around food. The CSC indicated it was

staff neglect for the failure to provide

staff supervision while client A did not

have facility staff available to supervise

her one on one in the kitchen. The CSC

indicated two facility staff should have

been on duty at the group home when

clients were awake.


#IN00204044.

9-3-3(a)

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


record review, for 1 of 3 sample clients







09/02/2016 12:00:00AM





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facility failed to implement client A's ISP

(Individual Support Plan) and BSP

(Behavior Support Plan) to ensure facility

staff supervised client A according to her

identified need.

Findings include:

























1.The QDDP will train staff on

Client's A ISP & BSP,

emphasizing implementation of

goals and methods during formal

and informal opportunities.



















1.The QDDP will monitor all

clients ISP & BMP goals and

staff's implementation of those

goals through monthly reviews of

goal progress and required in

house observations of staff

working with clients. Immediate

training of staff will take place if

deficient practices are observed.














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client A "There are dining plan change

(sic). Seen Speech therapist for eating

concerns (sic). Risk plan updated with

prompts increased (sic). [Client A] is to

put silverware down between bites. She






it..." Client A's 2/2/2015
























1.The QDDP will monitor all

clients' ISP & BMP goals and

staff's implementation of those

goals through monthly reviews of

goal progress and required in

house observations of staff

working with clients. Observations

will always include observing

clients during meals.







hours.




made.





put into place?

1.The QDDP will review ISP

and BMP goals and progress

monthly and during required in

house observations. The QDDP

will immediately address through

training of staff, any deficient

practices observed at reviews or





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QIDP indicated staff failed to supervise

client A according to her identified needs

on 8/4/16. The QIDP indicated the

facility failed to ensure there were

sufficient staff on duty to supervise client

A on 8/4/16.


provided an 8/4/16 at 11:00pm "e-mail

during observations.





waking hours.










completed?

9/2/16





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Re: [client A]...had a choking incident on











went to bed."




stated client A "should not be left alone"

around food. The CSC indicated it was

staff neglect for the failure to provide

staff supervision while client A did not

have facility staff to supervise her one on

one in the kitchen.


#IN00204044.

9-3-4(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

W 0436

Bldg. 00





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communications aids, braces, and other

devices identified by the interdisciplinary

team as needed by the client.

Based on observation, record review, and

interview, for 2 of 3 sampled clients

(clients A and C) and 2 additional clients

(clients E and G), the facility failed to

have available clients A, C, E, and G's

youth size silverware.

Findings include:

Observations and interviews were

conducted at the group home on 8/8/16

from 4:15pm until 5:55pm. Clients A, C,

E, and G were observed at the group

home. During the observation period

clients A, C, E and G used small youth

size silverware to eat. During the

observation period clients A, C E, and G

served themselves their food portions

with staff assistance and facility staff sat

at the table to supervise clients A, C, E,

and G consume their meal. At 5:50pm,

GHS (Group Home Staff) #2 and the

Residential Manager (RM) both indicated

clients A, C, E, and G required staff

supervision during dining and clients A,

C, E, and G were at risk to choke. At

5:50pm, GHS #2 indicated clients A, C,

E, and G needed youth adaptable utensils

to control their eating rate and bite

portion to prevent choking and aspiration

of food.

W 0436 What corrective action (S) will be




1 On 8/13/16, adaptive

silverware, special sized bowls

and lip plates, per clients dining

plans, was purchased for use in

day services. The Day Services

Team Leader will monitor daily

that proper adaptive silverware is

used as per each clients’ dining

plan.






1. The dietitian will monitor the

need for adaptive silverware

during her quarterly meal

observations. If different or new

adaptive silverware is needed, the

dietitian will communicate this to

the nurse. The nurse will then

rewrite the dining plan and train

staff, both the group home and

day services, on any new

procedures.


place or what systemic

changes will you make to ensure

that the deficient practices does

not recur?

1. The nurse will update adaptive

silverware usage whenever there

is a change in dietitian

recommendations and train both

group home and day services

09/02/2016 12:00:00AM





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On 8/9/16 from 9:00am until 1:20pm,

observation and interviews were

conducted at the facility owned day

program at the agency. During the

observation period WKS (Workshop

Staff) #1, WKS #2, WKS #3, and WKS

#4 unpacked client lunches without

clients present, opened lids and packages

from each client's personal lunch box

without clients present, and prepared then

served each client their lunch at the same

table where clients had been sitting

throughout the observation period.

During the observation period, clients C

and E used plastic spoons to consume

their meal, no staff were present at the

table during dining, and no adaptive

equipment was available for use. At

11:40am, WKS #1, WKS #2, WKS #3,

and WKS #4 indicated no adaptive

equipment and no youth size silverware

was available at the agency owned day

services for client use. The four staff

indicated they did not sit at the tables

with clients during dining because they

were preparing their lunches across the

room.




The QIDP indicated staff should

supervise the clients while dining and

staff. The Day Services Team

Leader will monitor daily, through

observation, that proper adaptive

silverware is used as per each

clients’ dining plan.

How will the corrective actions be


practice will not recur, what


put into place?

1. The Day Services Team

Leader will monitor daily, through

observation, that proper adaptive

silverware is used as per each

clients’ dining plan.



completed? 9/2/16.





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clients A, C, E, and G were at risk to

choke. The QIDP indicated clients A, C,

E, and G used youth size silverware to eat

meals and each client should have had

their youth size silverware available at

the facility owned day services to eat.

On 8/9/16 at 1:20pm, an interview with

the agency RN (Registered Nurse) was

conducted. The RN stated clients A, C,

E, and G were at risk to choke and

"required" staff supervision "as well as

their adaptive equipment" (youth size

silverware) to eat food. The RN

indicated each house ordered their own

adaptive equipment and she was unsure

about who would monitor the day

services to ensure clients used their

adaptive equipment.





and G attended the facility owned day

services during the weekdays. The

CSAD stated clients A, B, C, D, E, F, and

G attended the facility owned "day

services a few days a week" and attended

a second agency "contracted" day

services "a few days a week." The CSAD

indicated the agency had the potential to

have eighteen (18) or more clients from

the agency operated group homes and





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additional clients from the community in

the same room at the agency for day

services at any one time. The CSAD

stated "No" adaptive equipment was

available for dining at the facility owned

day services. The CSAD indicated she

was not aware the clients did not have

their adaptive equipment to eat with.





client A "There are dining plan change.

Seen (sic) Speech therapist for eating

concerns (sic). Risk plan updated with

prompts increased (sic). [Client A] is to

put silverware down between bites. She






it..." Client A's 2/2/2015







table during meals. All meats and

sandwiches will be cut into bites for

[client A] and staff will encourage her to

put the eating utensil down between





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bites. Staff will give cues to swallow

food prior to taking drinks of water

during the meal. Staff may use gentle

verbal prompting such as slow down and

chew thoroughly....[Client A] will use a

rocker knife, small fork, and a small

spoon with a smaller bowl. This will aid

in taking the appropriate sized bites

(sic)...When [client A] is in the main

living areas of the home, she should be

carefully monitored by staff as she will

go into the kitchen and pantry area and

forage for snacks. This presents the

opportunity for choking...When [client

A] is taking out any trash, staff will

monitor her by walking with her to the

dumpster and watching her place the tied

trash bag inside the dumpster. This




Client C's record was reviewed on

8/10/16 at 12:20pm. Client C's 1/26/16

ISP (Individual Support Plan) indicated

client C used a bowl and small silverware

to dine to control her rate of eating and to

decrease her risk to choke on food.

Client C's 1/16 Dining Plan indicated

staff were to supervise client C because

of her risk to choke and client C was to

use small silverware to consume food.






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#IN00204044.

9-3-7(a)


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