W 0000 - inrefresher training on Mandt, preventive techniques to deescalate behavioral situations and avoid potential physical aggression. (Director of Quality Assurance, Director

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

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FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

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

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

SOUTH BEND, IN 46601

15G291 08/31/2018

LOGAN COMMUNITY RESOURCES INC

119 SPRUCE ST

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

#IN00269811.

Complaint #IN00269811: Substantiated, Federal

and State deficiency related to the allegation is

cited at W154.

Dates of Survey: August 27, 28, 29, 30, and 31,

2018

Facility Number: 000810

Provider Number: 15G291

AIMS Number: 100249070

These deficiencies also reflect state findings in

accordance with 460 IAC 9.

Quality Review of this report completed by #15068

on 9/20/18.

W 0000

483.410

GOVERNING BODY AND MANAGEMENT

The facility must ensure that specific

governing body and management

requirements are met.

W 0102

Bldg. 00

Based on observation, record review and

interview, the facility's Governing Body failed to

meet the Condition of Participation: Governing

Body, for 2 of 4 sampled clients (clients A and B)

plus 3 additional clients (F, G and H). The

governing body failed to protect client A from

physical aggression by client B. The Governing

Body failed to prevent client to client abuse and

to conduct thorough investigations in regard to

W 0102 In order to meet this Condition, the

Governing Body will ensure the

facility conducts thorough

investigations in regard to client to

client aggression, allegations of

staff abuse and unknown injuries

of clients. The facility will ensure

this citation is being met by

thoroughly completing all

investigations on an Investigation

09/29/2018 12:00:00AM

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

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

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

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

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

continued program participation.

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

_____________________________________________________________________________________________________Event ID: EKHU11 Facility ID: 000810

TITLE

If continuation sheet Page 1 of 30

(X6) DATE




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client to client aggression, an allegation of staff

abuse, and unknown injuries (clients A, B, F, G

and H).

Findings include:

Please refer to W122. The facility's governing

body failed to meet the Condition of Participation:

Client Protections, for 2 of 4 sampled clients

(clients A and B). The governing body failed to

protect client A from physical aggression from

client B. The Governing Body failed to prevent

client to client abuse and to conduct thorough

investigations in regard to client to client

aggression, an allegation of staff abuse and

unknown injuries (clients A, B, F, G and H).

Please refer to W104. The Governing Body

neglected to exercise general policy and operating

direction over the facility to prevent client to

client abuse for 2 of 4 sampled clients (clients A

and B). The governing body failed to protect

client A from physical aggression from client B.

The Governing Body failed to prevent client to

client abuse and to conduct thorough

investigations in regard to client to client


unknown injuries (clients A, B, F, G and H).

9-3-1(a)

Template developed by the

Director of Quality Assurance

including: injuries of unknown

origin, physical abuse, verbal

abuse, sexual abuse, emotional

abuse, neglect, and exploitation.

The investigation template

includes name of parties involved,

statements made by parties

involved, written account of the

incident, additional information

acquired during the course of the

investigation, conclusion and

corrective action.

The facility will ensure clients are

not subjected to physical, verbal,

sexual or psychological abuse by

developing, training and

implementing appropriate

behavioral support plans that

address physical aggression. The

staff at this home have had

preliminary training on this

individual's revised behavioral

support plan including physical

aggression. This plan also

includes approved Mandt

techniques (Logan approved

program in which staff are trained

on techniques in an effort to

deescalate and prevent

aggression). Staff will be retrained

on Human Rights Committee

approved behavioral support plan

including approved Mandt

techniques in an effort to


aggression. On an annual basis,

or more often as needed, staff

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EKHU11 Facility ID: 000810 If continuation sheet Page 2 of 30




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have a refresher training on the

definitions of abuse, neglect and

exploitation and reporting

requirements and the definition of

client rights. Staff will be given

preventive strategies to avoid

abuse, neglect and exploitation.

On an annual basis, or more often

as necessary, staff will have a

refresher training on Mandt,

preventive techniques to

deescalate behavioral situations

and avoid potential physical

aggression.

(Director of Quality Assurance,

Director of Group Living, Program

Manager/QIDP and Program

Coordinator responsible)

483.410(a)(1)

GOVERNING BODY

The governing body must exercise general

policy, budget, and operating direction over

the facility.

W 0104

Bldg. 00


interview, the Governing Body neglected to

exercise general policy and operating direction

over the facility for 2 of 4 sampled clients (clients

A and B) and 3 additional clients (clients F, G and

H). The governing body failed to protect client A

from physical aggression from client B. The

Governing Body neglected to ensure the facility

conducted thorough investigations in regard to

client to client aggression, an allegation of staff

abuse and unknown injuries for clients A, B F, G

and H.

Findings include:

W 0104 The Governing Body will ensure

the facility conducts thorough

investigations in regard to client to

client aggression, allegations of

staff abuse and unknown injuries

of clients.

The facility will ensure this citation

is being met by thoroughly

completing all investigations on an

Investigation Template developed

by the Director of Quality

Assurance including: injuries of

unknown origin, physical abuse,

verbal abuse, sexual abuse,

emotional abuse, neglect, and

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Please refer to W127. The governing body failed

for 2 of 4 sampled clients (clients A and B), to

protect client A from physical aggression by

client B.

Please refer to W154. The governing body failed

for 2 of 4 sampled clients and 3 additional clients

(clients A, B, F, G and H), to ensure thorough

investigations were completed in regard to client

to client aggression, an allegation of staff abuse

and injuries of unknown origin.

9-3-1(a)

exploitation. The investigation

template includes name of parties

involved, statements made by

parties involved, written account of

the incident, additional information



corrective action.

The facility will ensure clients are















aggression. Staff will be retrained




















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aggression.





483.420

CLIENT PROTECTIONS

The facility must ensure that specific client

protections requirements are met.

W 0122

Bldg. 00


interview, the facility failed to meet the Condition

of Participation: Client Protections, for 2 of 4

sampled clients (clients A and B) and 3 additional

clients (F, G and H). The facility neglected to

protect client A from physical aggression from

client B. The facility failed to conduct thorough

investigations of client to client aggression, an

allegation of staff abuse, and injuries of unknown

origin for clients A, B, F, G and H.

Findings include:

Please refer to W127. The facility failed for 2 of 4

sampled clients (clients A and B), to protect client

A from physical aggression from client B.

Please refer to W154. The facility failed for 2 of 4

sampled clients and 3 additional clients (clients A,

B, F, G and H), to ensure thorough investigations

were completed in regard to client to client


injuries of unknown origin.

W 0122 The facility will be compliance with

this Condition by ensuring clients

are not being subjected to

physical, verbal, sexual or

psychological abuse by
















including approved approved

Mandt techniques in an effort to



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9-3-2(a) or more often as needed, staff














aggression.

The facility ensure this citation is

being met by thoroughly

completing all investigations on an

Investigation Template developed

by the Director of Quality

Assurance including: injuries of

unknown origin, physical abuse,

verbal abuse, sexual abuse,

emotional abuse, neglect, and

exploitation. The investigation

template includes reason for

investigation, name of parties

involved, statements made by

parties involved, written account of

the incident, additional information



corrective action.









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483.420(a)(5)

PROTECTION OF CLIENTS RIGHTS

The facility must ensure the rights of all

clients. Therefore, the facility must ensure

that clients are not subjected to physical,

verbal, sexual or psychological abuse or

punishment.

W 0127

Bldg. 00


interview, the facility failed for 2 of 4 sampled

clients (clients A and B), to protect client A from

physical aggression by client B.

Findings include:

An evening observation was conducted at the

group home on 8/27/18 from 4:30 P.M. until 8:30

P.M.. At 5:05 P.M., client B approached the

surveyor and asked, "What are you doing here?

Are you here to check out what I did to-" and

then pointed at client A who was sitting at the

dining table. Client A was observed to have pink,

faded scratches to the side of her face and tan

bruising under her left eye. The Program

Coordinator (PC) prompted client B that the

surveyor was just visiting. During the entire

observation period, client B was observed to walk

around the house with no direct staff supervision.

An interview with the Program Coordinator was

conducted on 8/27/18 at 7:00 P.M.. When asked

what happened to client A's face, the PC stated

"[Client B] attacked her and scratched her up

really bad. It looks a lot better than it did." When

asked when the incident occurred, she stated

"Last week." When asked if this was the first time

this had happened, the PC stated "No, for some

reason she targets [Client A]." When asked what

measures had been put in place to protect client A

from further incidents of physical aggression, the

W 0127 The facility will ensure clients are







behavior support plan will address

proactive strategies that will

incorporate staff supervision and

active treatment. The staff at

this home have had preliminary

training on this individual's revised

behavioral support plan including

physical aggression. This plan

also includes approved Mandt


















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PC stated "[Client B] was hospitalized after seeing

her psychiatrist after the incident and she just

returned back to the home today. She seems

happier now. I have her going to individual

counseling that will start in a couple of weeks

too." During the observation there was no

observed direct supervision of client B.

A morning observation was conducted at the

group home on 8/28/18 from 6:00 A.M. until 8:30

A.M.. Upon arriving at the group home Direct

Support Professional #3 opened the door. DSP #3

was the only staff working the overnight shift. At

6:45 A.M., the PC arrived and entered into the

kitchen to begin preparing breakfast. At 7:15

A.M., client B approached surveyor and pointed

at surveyor's face while looking at the PC and

asked "What is she doing back here again?" The

PD redirected client B stating "Do not point in her

face, that is rude." Client B then walked into the

kitchen, took her plate of food and sat at the

dining table directly across from client A. The PC

redirected client B back to the other dining room

and stated "You know you sit at the other table."

Client B picked up her belongings and walked

over to the other dining area, where she ate her

breakfast. During the observation there was no


A request for the facility's internal reportables,

Bureau of Developmental Disabilities Services

(BDDS) reports and investigation records was

made on 8/27/18 at 12:30 P.M.. A review of the

facility's BDDS reports indicated:

-BDDS report dated 5/15/18 involving clients A

and B indicated: "On 5/15/18 the QIDP was

contacted regarding an incident that occurred

between [Client B] and [Client A]. Staff reported

that [Client B] was upset at [Client A] getting the







aggression.

Management staff will make

unannounced visits to the home to

observe staff quality of care is

being met in a safe environment.



Manage/QIDP. and Program






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mail. [Client B] proceeded to call [Client A] a b----

and they became physically aggressive with one

another. [Client A] grabbed [Client B]'s left hand

and bent it backwards causing a bruise smaller

than a dime on the top of her hand by her ring

finger and a very faint bruise on the top of her

hand just above her thumb about the size of a

quarter. In response to [Client A] grabbing her

hand, [Client B] picked up a large lamp and

through (sic) it hitting [Client A] in the left hand.

This caused a bruise on [Client A]'s hand smaller

than the size of a quarter. Plan to Resolve:

Although the incident occurred very fast (sic) the

staff were able to get them separated so that no

further physical aggression occurred and no one

else was hurt. Neither individual required any of

medical treatment. The QIDP (Qualified

(Intellectual Disabilities Professional) spoke to

both individuals about the incident. [Client A]

could only report that [Client B] was mad and

threw the lamp. It was difficult to understand

whether to (sic) not her getting the mail had

anything to do with the situation. After speaking

with [Client B] it was discovered that [Client B]

was quite upset after a situation that occurred on

a visit to her father's house just a few days prior

to this incident. She was able to recognize that

throwing the lamp was wrong and the QIDP

discussed with her other options for how she

could have handled the situation. At a recent

appointment with her psychiatrist, there was

discussion about individual counseling to assist

[Client B] to work through issues. This process

has been started but a specific counselor has not

been established yet. [Client A] currently has

physical aggression in her behavior support plan.

[Client B] does not have physical aggression in

her behavior plan but it will be added to the

monthly tracking to establish a baseline and the

behavior support plan can be revised. The staff





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responded appropriately so that neither lady or

any other clients were (sic) hurt."


and B indicated: "...On 7/18/18, it was reported by

[client B] that she got into an altercation with

[client A] and the [Program Coordinator] had

'grabbed' her hair and her upper left arm hard and

pushed her into the wall. She said that after she

pushed her into the wall [Program Coordinator]

forcefully pushed her into a chair. On 7/18/18

[Client B]'s arm was looked at and there was a

bruise about 6 inches long on the back of her left

shoulder. Plan to Resolve: An investigation was

started immediately and [Program Coordinator]

was suspended pending the outcome of the

investigation. [Client A] was checked out and did

not suffer any injuries from the incident and

continued with her regular program both at home

and at day program the next day. [Client B] was

also checked out and outside of the bruise did not

suffer any other injuries. She also continued with

her regular program both at home and at the

workshop the next day...The Qualified Intellectual

Disabilities Professional (QIDP) spoke with [Client

B] at great length regarding the incident that

occurred. The following is an explanation of how

[Client B] received the bruise on her arm. When

asked how the situation began, [Client B] stated

that it started when she got on the van to come

home from the work shop and no one was in the

correct seat and she was asked to move. Upon

arriving home, [Client B] was attempting to get a

snack in the kitchen and she felt that one of her

housemates was in the way and [Client B] told her

to get out of the way. This upset her as well.

[Client B] took her snack into the dining room and

another one of her housemates [Client A] was

also in the dining room. When [Client A]

attempted to talk with her, [Client B] began to say





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things like 'leave me alone' and 'I hate you b----'.

[Client B] was re-directed and asked to move to

another room and maybe try some of the

relaxation techniques that [Client B] and her

counselor have been discussing. While sitting in

the other room, [Client A] went into the bathroom

and did not close the door, [Client B] again

became upset yelling 'close the door, no one

wants to see that s---.' When [Client A] didn't

close the door, [Client B] got up and went to close

the door and was pulling the door back and forth

with [Client A] trying to shut it. Again [Client B]

was upset by this interaction and was re-directed

back to where she had been sitting. After coming

out of the bathroom, [Client A] left the house with

staff for an activity. She had forgotten a bottle of

water and came back into the house to get one.

While reaching into the closet, [Client B] grabbed

a wooden decoration and came up to [Client A]

from behind on the right hand side and began

swinging the wooden decoration at her trying to

hit her. When [Program Coordinator] saw this

happening she made an attempt to separate

[Client B] and [Client A]. She initially got in

between them with her back to [Client B] and used

her hand and arm to block her swings and

separate them but [Client B] kept pushing against

her to get to [Client A]. When [Client B]

continued to push against [Program Coordinator],

[Program Coordinator] turned around facing

[Client B] and used her hand and arm to block her

swings and separate them. [Program Coordinator]

used MANDT (crisis intervention) blocking

technique. [Program Coordinator] was finally able

to escort [Client B] to a chair so that [Client A]

could get out of harm's way. [Program

Coordinator] explained that in the process of

physically escorting [Client B] who was still very

actively engaged, she physically guided her to the

chair. At no time did [Program Coordinator]





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actually grab her arm or her hair. The bruise that

[Client B] received on her shoulder did not

resemble a fingers (sic) or hand like she might

have been grabbed but was one circular oblong

bruise that could have occurred from hitting the

top of the chair or even the wall when she finally

sat down in the chair....The allegation of staff

actually putting their hands was substantiated but

it was not a willful infliction to cause harm.

Therefore the allegation of physical abuse was

not substantiated. The staff was using MANDT

techniques but because of the wall decoration

being used as a weapon and [Client A] having her

back to [Client B] she needed to get them apart

quickly with the least amount of harm done to

anyone. [Program Coordinator]'s use of the escort

techniques resulted in [Client B] being physically

guided to the chair was the least restrictive way to

separate the individuals and cause the least

amount of harm to everyone involved...."

-Internal incident report dated 8/19/18 involving

clients A and B indicated: "[Client A] said

something to [Client B]. [Client B] became upset

and scratched [Client A]'s face and neck. Staff

redirected both clients. [Client B] went in her

bedroom. Staff cleaned [Client A]'s face and

notified on call. Client A presented with

scratches to the left side of her face ranging from

1/2 inch to 8 centimeters in length. They are red,

dry with no drainage. 7 centimeter scratch to left

temple. [Client A]'s right side of face presented

with 5 scratches approximately 1/2 inch to 6

centimeters in length. They are red with no

drainage and are dry. Chest abrasion appears

approximately 3 centimeters in diameter noted with

3 scratches to her neck approximately 5

centimeters long with no drainage. Client denies

pain or discomfort."





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A review of client B's most current Behavior

Support Plan (BSP) dated 10/25/17 submitted for

review was conducted on 8/28/18 at 4:00 P.M..

Review of the BSP indicated: "Targeted

Behaviors: A. Specific Target Behaviors to be

addressed: Depressive behaviors: Persistently

sad or lethargic mood decreased levels of activity

or increased sleep, refusing to complete

tasks...Verbal Aggression: yelling and arguing,

making rude or impolite statements-could be a

result of anxiety...Anxiety: unable to sit still or

relax, nervous about upcoming plans." Further

review of client B's BSP neglected to address her

identified behavior of physical aggression. There

was no documentation in client B's record to

indicate the facility was addressing/tracking her

identified behaviors of physical aggression and

targeting of client A.

An interview with the Qualified Intellectual

Disabilities Professional was conducted on

8/31/18 at 2:15 P.M.. When asked if any measures

had been put in place to protect client A from

being aggressed upon by client B, the QIDP

stated "[Client B] was hospitalized after the last

incident and she will begin individual counseling

soon." When asked if client B's submitted BSP

addressed her identified physical aggression, the

QIDP stated "No."

9-3-2(a)

483.420(d)(3)

STAFF TREATMENT OF CLIENTS

The facility must have evidence that all

alleged violations are thoroughly investigated.

W 0154

Bldg. 00

Based on record review and interview, the facility

failed for 6 of 6 incidents involving 2 of 4 sampled

clients and 3 additional clients (clients A, B, F, G

W 0154 The facility ensure this citation is

being met by thoroughly

completing and documenting all

investigations on an Investigation

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and H), to ensure investigations were completed

in regard to client to client aggression, an

allegation of staff abuse and injuries of unknown

origin.

Findings include:




made on 8/27/18 at 12:30 P.M.. One investigation

record dated 3/21/18 was submitted for review. A

review of the facility's BDDS reports indicated:

1. BDDS report dated 4/5/18 involving client F

and an injury of unknown origin indicated: "On

the morning of 4/5/18 at 8:30 A.M., [Staff] reported

that [Client F] woke up with a bruise on her right

eyelid. No falls were reported. Qualified

Intellectual Disabilities Professional (QIDP) will

follow up with staff that worked with [Client F] in

the last 24 hours to see if anything occurred to

cause the bruising." No investigation record was

submitted for review to indicate the facility

conducted a thorough investigation which

indicated all staff and all clients were interviewed

in regard to this injury of unknown origin.

2. BDDS report dated 4/12/18 involving client G

and an injury of unknown origin indicated:

"...When [Client G] arrived to day programming

the morning of April 11th day staff noticed a small

bruise measuring about 1/2 inch under her right

eye. When questioned, neither of the residential

staff who transported [Client G] to day program

were aware of how the bruise occurred. Plan to

Resolve: Information regarding the bruise has

been sent to the Program Manager, she will

complete an investigation to determine the cause

of the bruise and if there are any preventive

Template developed by the

Director of Quality Assurance

including: injuries of unknown

origin, physical abuse, verbal

abuse, sexual abuse, emotional

abuse, neglect, and exploitation.

The investigation template

includes reason for investigation,

name of parties involved,

statements made by parties

involved, written account of the

incident, additional information



corrective action.









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measures that may be put in place." No

investigation record was submitted for review to

indicate the facility conducted a thorough

investigation which indicated all staff and all

clients were interviewed in regard to this injury of

unknown source.

3. BDDS report dated 5/15/18 involving clients A

and B and client to client aggression indicated:

"On 5/15/18 the QIDP was contacted regarding an

incident that occurred between [Client B] and

[Client A]. Staff reported that [Client B] was upset

at [Client A] getting the mail. [Client B] proceeded

to call [Client A] a b--- and they became

physically aggressive with one another. [Client

A] grabbed [Client B]'s left hand and bent it

backwards causing a bruise smaller than a dime on

the top of her hand by her ring finger and a very

faint bruise on the top of her hand just above her

thumb about the size of a quarter. In response to

[Client A] grabbing her hand, [Client B] picked up

a large lamp and through (sic) it hitting [Client A]

in the left hand. This caused a bruise on [Client

A]'s hand smaller than the size of a quarter. Plan

to Resolve: Although the incident occurred very

fast (sic) the staff were able to get them separated

so that no further physical aggression occurred

and no one else was hurt. Neither individual

required any of medical treatment. The QIDP

spoke to both individuals about the incident.

[Client A] could only report that [Client B] was

mad and threw the lamp. It was difficult to

understand whether to (sic) not her getting the

mail had anything to do with the situation, After

speaking with [Client B] it was discovered that

[Client B] was quite upset after a situation that

occurred on a visit to her father's house just a few

days prior to this incident. She was able to

recognize that throwing the lamp was wrong and

the QIDP discussed with her other options for





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how she could have handled the situation. At a

recent appointment with her psychiatrist, there

was discussion about individual counseling to

assist [Client B] to work through issues. This

process has been started out specific counselor

has not been established yet. [Client A] currently

has physical aggression in her behavior support

plan. [Client B] does not have physical

aggression in her behavior plan but it will be

added to the monthly tracking to establish a

baseline and the behavior support plan can be

revised. The staff responded appropriately so

that neither lady or any other clients were hurt."

No investigation record was submitted for review

to indicate the facility conducted a thorough

investigation which indicated all staff and all

clients were interviewed in regard to this incident

of client to client aggression.

4. BDDS report dated 6/19/18 involving client H

and an allegation of inappropriate touch indicated:

"[Client H] informed staff that 'he (day program

client) was touching her bottom' and she did not

like it. When staff inquired who was touching,

[Client H] could not name names, but was able to

point out to staff which peer it was. [Client H]

also indicated that it had happen (sic) a day

before as well. Plan to Resolve: The two were

kept separated during lunch break and other staff

were informed to keep closer eye on the two.

[Client H] and the peer are allocated to different

groups. [Client H] was encouraged to let staff

know immediately if anything happens. [Client H]

indicated that she understood." No investigation

record was submitted for review to indicate the

facility conducted a thorough investigation which

indicated all staff and all clients were interviewed

in regard to this allegation of inappropriate touch.

5. BDDS report dated 7/17/18 involving clients A





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and B and an incident of client to client

aggression indicated: "...On 7/18/18, it was

reported by [client B] that she got into an

altercation with [client A] and the [Program

Coordinator] had 'grabbed' her hair and her upper

left arm hard and pushed her into the wall. She

said that after she pushed her into the wall

[Program Coordinator] forcefully pushed her into

a chair. On 7/18/18 [Client B]'s arm was looked at

and there was a bruise about 6 inches long on the

back of her left shoulder. Plan to Resolve: An

investigating was started immediately and

[Program Coordinator] was suspended pending

the outcome of the investigation. [Client A] was

checked out and did not suffer any injuries from

the incident and continued with her regular

program both at home and at day program the next

day. [Client B] was also checked out and outside

of the bruise did not suffer any other injuries. She

also continued with her regular program both at

home and at the workshop the next day....The

Qualified Intellectual Disabilities Professional

(QIDP) spoke with [Client B] at great length

regarding the incident that occurred. The

following is an explanation of how [Client B]

received the bruise on her arm. When asked how

the situation began, [Client B] stated that it

started when she got on the van to come home

from the work shop and no one was in the correct

seat and she was asked to move. Upon arriving

home, [Client B] was attempting to get a snack in

the kitchen and she felt that one of her



[Client B] took her snack into the dinning room

and another one of her housemates [Client A] was









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another room and maybe try so of the relaxation

techniques that [Client B] and her counselor have

been discussing. While sitting in the other room,

[Client A] went into the bathroom and did not

close the door, [Client B] again became upset

yelling 'close the door, no one wants to see that s-

--.' When [Client A] didn't close the door, [Client

B] got up and went to close the door and was

pulling the door back and forth with [Client A]

trying to shut it. Again [Client B] upset by this

interaction and was re-directed back to where she

had been sitting. After coming out of the

bathroom, [Client A] left the house with staff for

an activity. She had forgotten a bottle of water

and came back into the house to get one. While

reaching into the closet, [Client B] grabbed a

wooden decoration and came up to [Client A]




























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amount of harm to everyone involved...." No

investigation record was submitted for review to

indicate the facility conducted a thorough

investigation in regard to interviewing all clients

and staff who may have witnessed the allegation

of staff abuse.

6. Internal incident report dated 8/19/18 involving

clients A and B and an incident of client to client

aggression with injury indicated: "[Client A] said

something to [Client B]. [Client B] became upset

and scratched [Client A]'s face and neck. Staff

redirected both clients. [Client B] went in her

bedroom. Staff cleaned [Client A]'s face and

notified on call. Client A presented with

scratches to the left side of her face ranging from

1/2 inch to 8 centimeters in length. They are red,

dry with no drainage. 7 centimeter scratch to left

temple. [Client A]'s right side of face presented

with 5 scratches approximately 1/2 inch to 6

centimeters in length. They are red with no

drainage and are dry. Chest abrasion appears

approximately 3 centimeters in diameter noted with





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3 scratches to her neck approximately 5

centimeters long with no drainage. Client denies

pain or discomfort." No investigation record was

submitted for review to indicate the facility

conducted a thorough investigation in regard to

interviewing all clients and staff who may have

witnessed the incident of client to client

aggression with injury.

An interview with the facility's Director of Quality

Assurance (DQA) was conducted at the facility's

administrative office on 8/28/18 at 3:00 P.M.. A

request for the facility's investigations was made

again. The DQA stated she only conducted one

investigation and she submitted it. The

investigation submitted was for an incident dated

3/21/18. No further documentation was submitted

for review to indicate thorough investigations had

been completed, to include all clients and staff

had been interviewed in regard to the mentioned

incidents.



8/31/18 at 2:15 P.M.. The QIDP indicated the

investigation record dated 3/21/18 was the only

investigation record available for review. When

asked if the incidents should have been

investigated, she stated "Yes."

This federal tag relates to complaint #IN00269811.

9-3-2(a)

483.440(c)(4)

INDIVIDUAL PROGRAM PLAN

The individual program plan states the

specific objectives necessary to meet the

client's needs, as identified by the

comprehensive assessment required by

W 0227

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paragraph (c)(3) of this section.


interview, the facility failed for 1 of 2 sampled

clients (client B), to ensure client B's Behavior

Support Plan (BSP) addressed the client's

identified behavior of physical aggression.

Findings include:



P.M.. At 5:05 P.M., client B approached the

surveyor and asked "What are you doing here?

Are you here to check out what I did to-" and

then pointed at client A who was sitting at the

dining table. Client A was observed to have pink,

faded scratches to the side of her face and tan

bruising under her left eye. The Program

Coordinator (PC) prompted client B that the

surveyor was just visiting. During the entire

observation period, client B was observed to walk

around the house with no direct staff supervision.

An interview with the Program Coordinator was

conducted on 8/27/18 at 7:00 P.M.. When asked

what happened to client A's face, the PC stated

"[Client B] attacked her and scratched her up

really bad. It looks a lot better than it did." When

asked when the incident occurred, she stated

"Last week." When asked if this was the first time

this had happened, the PC stated "No, for some

reason she targets [Client A]." When asked what

measures had been put in place to protect client A

from further incidents of physical aggression, the

PC stated "[Client B] was hospitalized after seeing

her psychiatrist after the incident and she just

returned back to the home today. She seems

happier now. I have her going to individual

counseling that will start in a couple of weeks

W 0227 The facility will ensure this tag is

met by addressing physical

aggression as a target behavior in

client B's behavioral support plan.

B continues to see a counselor

once a week to deal and manager

her target behaviors. The

behavioral support plan will include

strategies that incorporate staff

supervision and active treatment.

The counselor has given her a

"tool box" of interventions for B to

use when the behaviors are

occurring including: tapping,

taking deep breaths, stating "I"

statements. In addition, proactive

strategies to help avoid both verbal

and physical aggression will be

incorporated into the behavioral

support plan such as: "Do you

need to take a break?" "Do you

want to go to your room for a

while?" "Do you want to go for a

walk?

The QIDP has provided preliminary

training on a revised Behavioral

Support Plan which includes

aggression as a target behavior.

The plan will go through Human

Rights Committee on 10/8/18 for

final approval. She is

emancipated and not in need of a

guardian signature.

In the future, the facility will

develop formal behavioral support

plans to address maladaptive

behaviors included but not limited

to aggression, self injurious

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too." During the observation there was no




A.M.. Upon arriving at the group home Direct

Support Professional #3 opened the door. DSP #3

was the only staff working the overnight shift. At

6:45 A.M., the PC arrived and entered into the

kitchen to begin preparing breakfast. At 7:15

A.M., client B approached the surveyor and

pointed at surveyor's face while looking at the PC

and asked "What is she doing back here again?"

The PD redirected client B stating "Do not point

in her face, that is rude." Client B then walked

into the kitchen, took her plate of food and sat at

the dining table directly across from client A. The

PC redirected client B back to the other dining

room and stated "You know you sit at the other

table." Client B picked up her belongings and

walked over to the other dining area, where she

consumed her breakfast. During the observation

there was no observed enhanced supervision of

client B.




made on 8/27/18 at 12:30 P.M.. A review of the

facility's BDDS reports indicated:


and B indicated: "On 5/15/18 the QIDP was

contacted regarding an incident that occurred

between [Client B] and [Client A]. Staff reported

that [Client B] was upset at [Client A] getting the

mail. [Client B] proceeded to call [Client A] a b----

and they became physically aggressive with one

another. [Client A] grabbed [Client B]'s left hand

and bent it backwards causing a bruise smaller

behavior, anxiety, etc. These

plans will include proactive and

reactive strategies for staff to

consistently implement.

Management staff will make

unannounced visits to the home to

observe staff quality of care is

being met in a safe environment.

(Program Manager/QIDP, Program

Coordinator and DSPs

responsible)





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than a dime on the top of her hand by her ring

finger and a very faint bruise on the top of her

hand just above her thumb about the size of a

quarter. In response to [Client A] grabbing her

hand, [Client B] picked up a large lamp and

through (sic) it hitting [Client A] in the left hand.

This caused a bruise on [Client A]'s hand smaller

than the size of a quarter. Plan to Resolve:

Although the incident occurred very fast (sic) the

staff were able to get them separated so that no

further physical aggression occurred and no one

else was hurt. Neither individual required any of

medical treatment. The QIDP (Qualified

(Intellectual Disabilities Professional) spoke to

both individuals about the incident. [Client A]

could only report that [Client B] was mad and

threw the lamp. It was difficult to understand

whether to (sic) not her getting the mail had

anything to do with the situation, After speaking

with [Client B] it was discovered that [Client B]

was quite upset after a situation that occurred on

a visit to her father's house just a few days prior

to this incident. She was able to recognize that

throwing the lamp was wrong and the QIDP

discussed with her other options for how she

could have handled the situation. At a recent

appointment with her psychiatrist, there was

discussion about individual counseling to assist

[Client B] to work through issues. This process

has been started but a specific counselor has not

been established yet. [Client A] currently has

physical aggression in her behavior support plan.

[Client B] does not have physical aggression in

her behavior plan but it will be added to the

monthly tracking to establish a baseline and the

behavior support plan can be revised. The staff

responded appropriately so that neither lady or

any other clients were (sic) hurt."






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and B indicated: "...On 7/18/18, it was reported by

[client B] that she got into an altercation with

[client A] and the [Program Coordinator] had

'grabbed' her hair and her upper left arm hard and

pushed her into the wall. She said that after she

pushed her into the wall [Program Coordinator]

forcefully pushed her into a chair. On 7/18/18

[Client B]'s arm was looked at and there was a

bruise about 6 inches long on the back of her left

shoulder. Plan to Resolve: An investigation was

started immediately and [Program Coordinator]

was suspended pending the outcome of the

investigation. [Client A] was checked out and did

not suffer any injuries from the incident and

continued with her regular program both at home

and at day program the next day. [Client B] was

also checked out and outside of the bruise did not

suffer any other injuries. She also continued with

her regular program both at home and at the

workshop the next day...The Qualified Intellectual

Disabilities Professional (QIDP) spoke with [Client

B] at great length regarding the incident that

occurred. The following is an explanation of how

[Client B] received the bruise on her arm. When

asked how the situation began, [Client B] stated

that it started when she got on the van to come

home from the work shop and no one was in the

correct seat and she was asked to move. Upon

arriving home, [Client B] was attempting to get a

snack in the kitchen and she felt that one of her



[Client B] took her snack into the dining room and

another one of her housemates [Client A] was





another room and maybe try some of the

relaxation techniques that [Client B] and her





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counselor have been discussing. While sitting in

the other room, [Client A] went into the bathroom

and did not close the door, [Client B] again

became upset yelling 'close the door, no one

wants to see that s---.' When [Client A] didn't

close the door, [Client B] got up and went to close

the door and was pulling the door back and forth

with [Client A] trying to shut it. Again [Client B]

was upset by this interaction and was re-directed

back to where she had been sitting. After coming

out of the bathroom, [Client A] left the house with

staff for an activity. She had forgotten a bottle of

water and came back into the house to get one.

While reaching into the closet, [Client B] grabbed

a wooden decoration and came up to [Client A]






























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amount of harm to everyone involved...."


and B indicated: "[Client A] said something to

[Client B]. [Client B] became upset and scratched

[Client A]'s face and neck. Staff redirected both

clients. [Client B] went in her bedroom. Staff

cleaned [Client A]'s face and notified on call.

Client A presented with scratches to the left side

of her face ranging from 1/2 inch to 8 centimeters

in length. They are red, dry with no drainage. 7

centimeter scratch to left temple. [Client A]'s right

side of face presented with 5 scratches

approximately 1/2 inch to 6 centimeters in length.

They are red with no drainage and are dry. Chest

abrasion appears approximately 3 centimeters in

diameter noted with 3 scratches to her neck

approximately 5 centimeters long with no

drainage. Client denies pain or discomfort."

A review of client B's most current Behavior

Support Plan (BSP) dated 10/25/17 submitted for

review was conducted on 8/28/18 at 4:00 P.M..

Review of the BSP indicated: "Targeted

Behaviors: A. Specific Target Behaviors to be





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addressed: Depressive behaviors: Persistently

sad or lethargic mood decreased levels of activity

or increased sleep, refusing to complete

tasks...Verbal Aggression: yelling and arguing,

making rude or impolite statements-could be a

result of anxiety...Anxiety: unable to sit still or

relax, nervous about upcoming plans." Further

review of client B's BSP neglected to address her

identified behavior of physical aggression. There

was no documentation in client B's record to

indicate the facility was addressing/tracking her

identified behaviors of physical aggression and

targeting of client A.



8/31/18 at 2:15 P.M.. When asked if any measures

had been put in place to protect client A from

being aggressed upon by client B, the QIDP

stated "[Client B] was hospitalized after the last

incident and she will begin individual counseling

soon." When asked if client B's submitted BSP

addressed her identified physical aggression, the

QIDP stated "No."

9-3-4(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


interview, the facility failed to ensure 1 additional

W 0249 In order to ensure clients are

involved in activity at all times of

opportunity, the QIDP will train,

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client (client F), was involved in activity at times

of opportunity.

Findings include:



P.M.. From 4:30 P.M. until 5:20 P.M., client F was

observed to be non-verbal and sitting alone on

the couch located in the left living room area

flipping the pages of a magazine repeatedly, with

no interaction from staff or peers. After eating her

dinner client F was observed from 5:50 P.M. until

8:30 P.M., sitting in the left living room with no

activity or interaction from staff or peers. Client F

did not receive any teaching or training during

this observation period.



A.M.. At 6:43 A.M., client F was observed during

medication administration. Direct Support

Professional #3 spoke to client F and asked her

her name, in which client F responded "[Client F]."

DSP #3 then asked who the picture on her

medication box was, client F then pointed to

herself and stated "[Client F]." Client F then

began pointing to different colors on her clothing

and began naming each color as DSP #3 verified

she was correct in regard to each color. Client F

then sat at the dining table as the Program

Coordinator (PC) placed a prepared plate of food

in front of client F so she could eat. From 7:20

A.M. until 8:15 A.M., client F sat on the couch

with her magazines and began flipping through

the pages, with no interaction with her peers and

staff. At 8:15 A.M., surveyor sat next to client F

and began talking to her, asking about the

different colors in her magazine. Client F pointed

to different colors in the pictures and correctly

expect and assure staff provide

active treatment goals and

implement activities with clients

throughout the course of the day

and evening during awake hours.

Staff will be trained on the

definition of Active Treatment to

include discussions and examples

of how to deliver the active

treatment.

To ensure Active Treatment is

occurring at times of opportunity,

the Program Coordinator (manager

of the home) will be present during

morning and afternoon shifts,

along with observing on weekend

shifts sporadically. The Program

Manager/QIDP will make visits to

the home on a monthly, or more

often as needed basis to ensure

active treatment is being

implemented. The Director of

Group Living will make

unannounced visits to see that

active treatment is being

incorporated with the clients.

Active treatment training was

completed on 9/20/18.

(Director of Group Living, Program

Manager/QIDP, Program


responsible)





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identified the colors by saying the colors. During

the observation periods, Program Coordinator

cooked breakfast, served clients and interacted

with other clients. DSP #3 passed medications to

the clients. Client F did not receive any

interaction or teaching during the observed times.

A review of client F's Individual Support Plan

(ISP) dated 6/7/18 was conducted on 8/28/18 at

3:00 P.M. and indicated the following:

"...Proposed Strategy/Activity: [Client F] to work

on the following group home goals designed to

increase skills for independent living and

participation in the community: Goal and

objective to be developed by Program

Manager...Goals: medication administration,

personal hygiene, personal health exercise and

handwashing, mealtime skills, oral hygiene and

financial management..." Review of client F's

Personal Center Plan (PCP) dated 6/7/18 indicated

"...At Home points, facial expressions, likes to

whisper to you, one word occasional sentences,

likes to hug, greetings are good, points most of

the time, will sometimes say words after pointing,

give choices, have [Client F] verbalize choice...."


Disabilities Professional (QIDP) was conducted

on 8/27/18 at 2:05 P.M.. When asked when goals

should be implemented, the QIDP stated "At all

times." When asked if client F should have been

involved in activity during both observations, the

QIDP stated "Yes."

9-3-4(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

W 0488

Bldg. 00





10/04/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G291 08/31/2018


119 SPRUCE ST

00

developmental level.

Based on observation and interview, the facility

failed for 8 of 8 clients residing at the group home

(clients A, B, C, D, E, F, G and H), to ensure the

clients served themselves during meal time.

Findings include:



P.M.. At 5:15 P.M., clients A, B, C, D, E, F, G and

H were serving themselves their evening meal

which consisted of pork chops, pasta salad,

California blend vegetables and white bread. At

6:25 P.M., clients A, B, C, D, E, F, G and H began

eating their meal independently.



A.M.. At 7:12 A.M., the Group Home Coordinator

(GHC) was observed walking out of the kitchen

with prepared plates and placed each plate on the

dining table as clients A, B, C, D, E, F, G and H sat

in the living rooms with no activity. At 7:20 A.M.,

clients A, B, C, D, E, F, G and H were observed to

eat their meal independently.


Disabilities Professional (QIDP) was conducted

on 8/27/18 at 2:05 P.M.. When asked if clients A,

B, C, D, E, F, G and H were capable of serving

themselves independently, the QIDP stated

"Yes." When asked if clients should serve

themselves, the QIDP stated "Yes."

9-3-8(a)

W 0488 The facility will ensure this tag is

met by training staff on allowing

clients to serve themselves at

meal times. Staff will be trained

on allowing clients appropriate

food choices, rather than staff

serve residents. Staff will be

trained on allowing clients to be as

independent as possible when

getting their meals, dishing food

on their plates as they are able to

do so. Staff will be trained on

assisting client, when needed

rather than serving the food for

them. There will be

unannounced observations by the

Program Manager/QIDP on a

monthly, or more often as needed

to ensure staff are allowing clients

independence with serving their

own food at meal times. In

addition, the Director of Group

Living will make unannounced

visits to observe meal times.

This training was completed by

the QIDP on 9/20/18.

(Program Manager/QIDP, Program


responsible).

09/29/2018 12:00:00AM


Documents

W 0000 - inrefresher training on Mandt, preventive techniques to deescalate behavioral situations and avoid potential physical aggression. (Director of Quality Assurance, Director