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(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
W 0000
Bldg. 00
This visit was for the post certification revisit
(PCR) to the investigation of complaint
#IN00253006 completed on 2/6/18.
Complaint #IN00253006: Not Corrected.
This visit was in conjunction with a PCR to the
investigation of complaint #IN00252316 completed
on 1/31/18.
This visit was in conjunction with a PCR to the
PCR completed on 1/31/18 to the investigation of
complaint #IN00242153 completed on 11/14/17.
Survey Date: March 20, 2018.
Facility Number: 001009
Provider Number: 15G495
AIM Number: 100244970
These deficiencies also reflect state findings in
accordance with 460 IAC 9.
Quality review of this report completed March 22,
2018 by #09182.
W 0000
483.410
GOVERNING BODY AND MANAGEMENT
The facility must ensure that specific
governing body and management
requirements are met.
W 0102
Bldg. 00
Based on observation, record review, and
interview, the facility failed to meet the Condition
of Participation: Governing Body for 3 of 4
sampled clients (A, B, and D), plus 2 additional
clients (E and G).
W 0102 W102
1. 1. The facility does have a
functioning QIDP. A new QIDP
was hired for this home and is
functioning in the full QIDP
capacity. The Area Director is
04/08/2018 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: 3CGF12 Facility ID: 001009
TITLE
If continuation sheet Page 1 of 27
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
The governing body neglected to implement the
facility's written policy and procedures to
investigate thoroughly an allegation of staff to
client A physical abuse, failed to ensure LPN #1
was retrained utilizing a licensed supervisory
personnel, and failed to ensure clients B, D, E, and
G were examined on a quarterly basis by a nurse.
The governing body failed to exercise general
policy, budget and operating direction over the
facility to ensure the facility met the Condition of
Participation: Client Protections for 1 of 4 sampled
clients (A).
Findings include:
1. The governing body failed to implement its Plan
Of Correction (POC) dated 3/8/18 for the complaint
survey #IN00253006 completed on 2/6/18. The
governing body neglected to implement the
facility's written policy and procedures to
investigate thoroughly an allegation of staff to
client A physical abuse, failed to ensure LPN #1
was retrained utilizing a licensed supervisory
personnel, and failed to ensure clients B, D, E, and
G were examined on a quarterly basis by a nurse.
Please see W104.
2. The governing body failed to meet the
Condition of Participation: Client Protections for 1
of 4 sampled clients (A). The facility neglected to
implement the facility's written policy and
procedures to investigate thoroughly an
allegation of staff to client A physical abuse.
Please see W122.
This deficiency was cited on 2/6/18. The facility
failed to implement a systemic plan of correction
to prevent recurrence.
providing supervision to the
assigned QIDP. The Director of
Nursing Services, who is a
Registered Nurse, will be providing
retraining to the Program Nurse on
all areas identified in the Plan of
correction to ensure compliance.
2. 2. The previous Regional
Quality Improvement Manager is
no longer with the company. The
previous Regional Director is no
longer in a position of reviewing
investigations.
The Lead Area Director and new
Regional Director will provide
ongoing oversight of all incidents
to ensure those that require
investigations to be completed are
done so following the facilities
policies. The Lead Area Director
and new Regional Director will
monitor the next five investigations
to ensure they are thorough and
the completed investigation and
results are shared with the
administrator within five working
days, and will continue routine
monitoring ongoing thereafter.
Any investigations regarding any
abuse, neglect and/or exploitation
will receive a final review by the
New Regional Director and Lead
Area Director. This will ensure a
minimum of two people are
reviewing each investigation for
thoroughness.
3. 3. The previous Regional
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 2 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
This federal tag relates to complaint #IN00253006.
9-3-1(a)
Quality Improvement Manager is
no longer with the company. The
previous Regional Director is no
longer in a position of reviewing
investigations.
The Lead Area Director and new
Regional Director will provide
ongoing oversight of all incidents
to ensure those that require
investigations to be completed are
done so following the facilities
policies. The Lead Area Director
and new Regional Director will
monitor the next five investigations
to ensure they are thorough and
the completed investigation and
results are shared with the
administrator within five working
days, and will continue routine
monitoring ongoing thereafter.
Any investigations regarding any
abuse, neglect and/or exploitation
will receive a final review by the
New Regional Director and Lead
Area Director. This will ensure a
minimum of two people are
reviewing each investigation for
thoroughness.
4. 4. The Director of Nursing
Services, who is a Registered
Nurse, will retrain the Facility
Nurse on ensuring timely
assessment and care following
changes in medical status or
multiple visits to the Emergency
Room. The expectation is that a
Nurse assesses an individual
within 24 hours of a change in
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 3 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
medical status or ER visit, or
requests the individual be
transported to the emergency
room immediately should the
health need require this. For head
injuries, the Facility Nurse will
ensure that staff initiate head
tracking monitoring until the Nurse
can assess the individual within 24
hours. Should there be any
concerns noted on the head
tracking, such as a fever or
disorientation, then the individual
would be immediately transported
to the Emergency Room. Staff
will be retrained to take the
Kardex with them to medical
appointments and/or ER visits.
The QIDP and/or Nurse will be
accessible by phone while
individuals are at medical
appointments and/or the ER in
order to relay important medical
information and historical
background details as needed.
The Facility Nurse will ensure that
individuals are taken to medical
appointments as ordered by a
physician or as the medical
condition warrants. Should there
ever be an instance where there
might be a delay in obtaining
medical care, the staff will contact
an ambulance so that the
individual can be seen by a
medical professional as required.
The Director of Nursing Services
will retrain the Facility Nurse to
ensure discharge paperwork is
reviewed and staff are trained on
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 4 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
any protocols/measures that need
to be implemented following the
discharge. The Director of Nursing
Services will also train the Facility
Nurse on ensuring all individuals
are examined at least on a
quarterly basis.
Ongoing the Area Director will
monitor the Facility Nurse’s
quarterly assessments to verify
one has been completed for each
individual. Ongoing the Area
Director will monitor discharge
paperwork from the hospital to
ensure the Facility Nurse
implemented any needed
protocols or measures
recommended following discharge.
5. 5. The facility has policies
and procedures in place to ensure
nursing services include a review
of their health status which must
be on a quarterly or more frequent
basis depending on client need.
The Director of Nursing Services
will train the Facility Nurse on
ensuring all individuals are
examined at least on a quarterly
basis.
Ongoing the Area Director and
Director of Nursing services will
monitor the Facility Nurse’s
quarterly assessments to verify
one has been completed for each
individual.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 5 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
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 record review and interview for 3 of 4
sample clients (A, B, and D), and 2 additional
clients (E and G), the governing body failed to
implement its Plan Of Correction (POC) dated
3/8/18 for the survey of complaint #IN00253006
completed on 2/6/18, neglected to implement the
facility's written policy and procedures to
investigate thoroughly an allegation of staff to
client A physical abuse, failed to ensure LPN #1
was retrained utilizing licensed supervisory
personnel, and failed to ensure clients B, D, E, and
G were examined on a quarterly basis by a nurse.
Findings include:
1. The facility's Plan of Correction dated 3/8/18
was reviewed on 3/20/18 at 12:30 PM. The review
indicated the following:
- For W104:
"The Area Director will retrain the facility nurse
on ensuring timely assessment and care following
changes in medical status or multiple visits to the
Emergency Room (ER). The expectation is that the
nurse assess an individual within 24 hours of a
change in medical status or ER visit...".
"The Area Director will retrain the facility nurse to
ensure discharge paperwork is reviewed and staff
are trained on any protocols/measures that need
to be implemented following the discharge (from a
hospital)."
W 0104 W104
1. 1. The facility does have a
functioning QIDP. A new QIDP
was hired for this home and is
functioning in the full QIDP
capacity. The Area Director is
providing supervision to the
assigned QIDP. The Director of
Nursing Services, who is a
Registered Nurse, will be providing
retraining to the Program Nurse on
all areas identified in the Plan of
correction to ensure compliance.
2. 2. The previous Regional
Quality Improvement Manager is
no longer with the company. The
previous Regional Director is no
longer in a position of reviewing
investigations.
The Lead Area Director and new
Regional Director will provide
ongoing oversight of all incidents
to ensure those that require
investigations to be completed are
done so following the facilities
policies. The Lead Area Director
and new Regional Director will
monitor the next five investigations
to ensure they are thorough and
the completed investigation and
results are shared with the
administrator within five working
days, and will continue routine
04/08/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 6 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
"The Area Director will also train the facility nurse
on ensuring all individuals are examined at least
on a quarterly basis."
- For W336: "The Area Director will also train the
facility nurse on ensuring all individuals are
examined at least on a quarterly basis."
Area Director (AD) #1 was interviewed on 3/20/18
at 1:00 PM. AD #1 indicated the POC should be
implemented as written. AD #1 indicated the home
does not have a Qualified Intellectual Disabilities
Professional (QIDP). AD #1 indicated she was
acting as the QIDP in the home. AD #1 indicated
the QIDP was responsible for implementing the
POC. AD #1 was unable to provide
documentation of facility nurse training as
indicated in the POC.
2. The governing body neglected to implement the
facility's written policy and procedures to
investigate thoroughly an allegation of staff to
client A physical abuse. Please see W149.
3. The governing body failed to thoroughly
investigate an allegation of staff to client A
physical abuse. Please see W154.
4. The governing body failed to ensure LPN #1
was retrained utilizing licensed supervisory
personnel. Please see W192.
5. The governing body failed to ensure clients B,
D, E, and G were examined on a quarterly basis by
a nurse. Please see W336.
This deficiency was cited on 2/6/18. The facility
failed to implement a systemic plan of correction
to prevent recurrence.
monitoring ongoing thereafter.
Any investigations regarding any
abuse, neglect and/or exploitation
will receive a final review by the
New Regional Director and Lead
Area Director. This will ensure a
minimum of two people are
reviewing each investigation for
thoroughness.
3. 3.The previous Regional
Quality Improvement Manager is
no longer with the company. The
previous Regional Director is no
longer in a position of reviewing
investigations.
The Lead Area Director and new
Regional Director will provide
ongoing oversight of all incidents
to ensure those that require
investigations to be completed are
done so following the facilities
policies. The Lead Area Director
and new Regional Director will
monitor the next five investigations
to ensure they are thorough and
the completed investigation and
results are shared with the
administrator within five working
days, and will continue routine
monitoring ongoing thereafter.
Any investigations regarding any
abuse, neglect and/or exploitation
will receive a final review by the
New Regional Director and Lead
Area Director. This will ensure a
minimum of two people are
reviewing each investigation for
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 7 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
This federal tag relates to complaint #IN00253006.
9-3-1(a)
thoroughness.
4. 4. The Director of Nursing
Services, who is a Registered
Nurse, will retrain the Facility
Nurse on ensuring timely
assessment and care following
changes in medical status or
multiple visits to the Emergency
Room. The expectation is that a
Nurse assesses an individual
within 24 hours of a change in
medical status or ER visit, or
requests the individual be
transported to the emergency
room immediately should the
health need require this. For head
injuries, the Facility Nurse will
ensure that staff initiate head
tracking monitoring until the Nurse
can assess the individual within 24
hours. Should there be any
concerns noted on the head
tracking, such as a fever or
disorientation, then the individual
would be immediately transported
to the Emergency Room. Staff
will be retrained to take the
Kardex with them to medical
appointments and/or ER visits.
The QIDP and/or Nurse will be
accessible by phone while
individuals are at medical
appointments and/or the ER in
order to relay important medical
information and historical
background details as needed.
The Facility Nurse will ensure that
individuals are taken to medical
appointments as ordered by a
physician or as the medical
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 8 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
condition warrants. Should there
ever be an instance where there
might be a delay in obtaining
medical care, the staff will contact
an ambulance so that the
individual can be seen by a
medical professional as required.
The Director of Nursing Services
will retrain the Facility Nurse to
ensure discharge paperwork is
reviewed and staff are trained on
any protocols/measures that need
to be implemented following the
discharge. The Director of Nursing
Services will also train the Facility
Nurse on ensuring all individuals
are examined at least on a
quarterly basis.
Ongoing the Area Director will
monitor the Facility Nurse’s
quarterly assessments to verify
one has been completed for each
individual. Ongoing the Area
Director will monitor discharge
paperwork from the hospital to
ensure the Facility Nurse
implemented any needed
protocols or measures
recommended following discharge.
5. 5.The facility has policies
and procedures in place to ensure
nursing services include a review
of their health status which must
be on a quarterly or more frequent
basis depending on client need.
The Director of Nursing Services
will train the Facility Nurse on
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 9 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
ensuring all individuals are
examined at least on a quarterly
basis.
Ongoing the Area Director and
Director of Nursing services will
monitor the Facility Nurse’s
quarterly assessments to verify
one has been completed for each
individual.
483.420
CLIENT PROTECTIONS
The facility must ensure that specific client
protections requirements are met.
W 0122
Bldg. 00
Based on record review and interview, the facility
failed to meet the Condition of Participation: Client
Protections for 1 of 4 sampled clients (A). The
facility neglected to implement the facility's
written policy and procedures to investigate
thoroughly an allegation of staff to client A
physical abuse.
Findings include:
1. The facility neglected to implement the facility's
written policy and procedures to investigate
thoroughly an allegation of staff to client A
physical abuse. Please see W149.
2. The facility failed to thoroughly investigate an
allegation of staff to client A physical abuse.
Please see W154.
This deficiency was cited on 2/6/18. The facility
failed to implement a systemic plan of correction
to prevent recurrence.
W 0122 W122
1. The previous Regional
Quality Improvement Manager is
no longer with the company. The
previous Regional Director is no
longer in a position of reviewing
investigations.
The Lead Area Director and new
Regional Director will provide
ongoing oversight of all incidents
to ensure those that require
investigations to be completed are
done so following the facilities
policies. The Lead Area Director
and new Regional Director will
monitor the next five investigations
to ensure they are thorough and
the completed investigation and
results are shared with the
administrator within five working
days, and will continue routine
monitoring ongoing thereafter.
04/08/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 10 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
This federal tag relates to complaint #IN00253006.
9-3-2(a)
Any investigations regarding any
abuse, neglect and/or exploitation
will receive a final review by the
New Regional Director and Lead
Area Director. This will ensure a
minimum of two people are
reviewing each investigation for
thoroughness.
2. The previous Regional
Quality Improvement Manager is
no longer with the company. The
previous Regional Director is no
longer in a position of reviewing
investigations.
The Lead Area Director and new
Regional Director will provide
ongoing oversight of all incidents
to ensure those that require
investigations to be completed are
done so following the facilities
policies. The Lead Area Director
and new Regional Director will
monitor the next five investigations
to ensure they are thorough and
the completed investigation and
results are shared with the
administrator within five working
days, and will continue routine
monitoring ongoing thereafter.
Any investigations regarding any
abuse, neglect and/or exploitation
will receive a final review by the
New Regional Director and Lead
Area Director. This will ensure a
minimum of two people are
reviewing each investigation for
thoroughness.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 11 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
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 for 1 of 4
sampled clients (A), the facility neglected to
implement the facility's written policy and
procedures to investigate thoroughly an
allegation of staff to client A physical abuse.
Findings include:
The facility's BDDS (Bureau of Developmental
Disabilities Services) reports and investigations
were reviewed on 3/20/18 at 10:50 AM. The review
indicated the following:
BDDS report dated 1/31/18 at 8:00 AM indicated,
"While [client A] was at day program, he was
complaining of pain. One of [client A's]
housemates told the day program supervisor that
a 'black guy' pushed [client A] down. Program
Supervisor notified group home Area Director.
Area Director arranged for staff to pick up [client
A] for evaluation. [Client A] was taken to ER
(Emergency Room) and was diagnosed with a
concussion. It is unclear how concussion
occurred."
Plan to Resolve: "Male staff working in the
morning were suspended pending investigation.
Program Nurse, AD (Area Director) will follow ER
discharge instructions. [Client A] will continue to
be monitored for a minimum of 48 hours to insure
no further injury occurs."
Client A's record was reviewed on 3/20/18 at 10:40
AM. Client A's record indicated the following:
W 0149 W149
The previous Regional Quality
Improvement Manager is no longer
with the company. The previous
Regional Director is no longer in a
position of reviewing
investigations.
The Lead Area Director and new
Regional Director will provide
ongoing oversight of all incidents
to ensure those that require
investigations to be completed are
done so following the facilities
policies. The Lead Area Director
and new Regional Director will
monitor the next five investigations
to ensure they are thorough and
the completed investigation and
results are shared with the
administrator within five working
days, and will continue routine
monitoring ongoing thereafter.
Any investigations regarding any
abuse, neglect and/or exploitation
will receive a final review by the
New Regional Director and Lead
Area Director. This will ensure a
minimum of two people are
reviewing each investigation for
thoroughness.
04/08/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 12 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
- Client A's ER Admission Information (ERAI)
indicated an arrival date of 1/31/18 at 11:20 AM.
The ERAI indicated, "Chief Complaint: Fall from
group home. Hit head. Unsure if he lost
consciousness. Caregiver with him states he
wasn't there when patient fell, but states patient is
at baseline."
The Mentor Network Report Form for Internal
Investigation (MNRFII) dated 3/15/18 indicated
the investigation regarding the 1/31/18 incident
involving client A was completed 2/1/18 to 2/6/18
by Regional Quality Improvement Manager
(RQIM) #1. The MNRFII indicated the following:
"Interview [client D], person served 2/5/18: Upon
entering the home at 8:45 AM, the investigator
attempted to interview [client D] but he refused.
He appeared agitated. Later in the morning, [client
D] agreed to speak with the investigator. When
asked how [client A] got hurt, [client D] forcefully
replied, 'I don't know nothing.' When asked if he
heard [client A] fall, he said, 'I heard fighting.'
When asked if he heard [client A] yelling he
stated again very forcefully, 'I don't know
nothing.' After [Area Director (AD) #1] returned
to the home, we again approached [client D] to
ask more specifically abut his previous statements
to her that a tall black man had pushed [client A].
In response [client D] stated that a, 'tall back guy
dressed up with a golf hat on' had hurt [client A]...
When asked if it was [staff #3], he would not
respond. When asked if it was [Home Manager
(HM) #1], [client D] stated '[HM #1] wasn't here'...
He also volunteered that at one point [client A]
got up from the table and ran toward [client A's]
room to 'get away.' "
"Interview [Day Service Program Director (DSPD)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 13 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
#1] on 2/6/18: When asked to describe the events
of 1/31/18, [DSPD #1] stated she observed [client
A's] neck leaning to the side and complaining of
pain. [DSPD #1] stated that [client D] told her that
staff had done something to [client A]. That he
heard [client A] yelling then heard a thump but,
'didn't see nothing.' [DSPD #1] states she reported
the information to [AD #2]."
"Interview [Staff #4] on 2/6/18: When asked if she
had concerns about any staff behavior towards
[client A], [staff #4] stated that [staff #3] seemed
to want to demonstrate that he could control
[client A]. She further stated that she had
observed [staff #3] use a closed grip on [client
A's] arms to redirect him physically instead of
using an open hand as trained... Said she has not
reported this to anyone."
"Interview [HM #1] on 2/6/18: When asked [HM
#1] stated she works the overnight shift and was
on duty 1/31/18. She stated that she got [client A]
up in the morning and gave him a shower. She
stated that he did not fall while showering. She
stated after she gave him a shower and assisted
him to dress (sic) she took him to the living room
to sit. [HM #1] then states she went to another
person's room to clean it and remained there until
it was time to leave for workshop at 8:00 AM. She
stated that [staff #3] provided breakfast to people.
She states [client A] did not show any problems
that morning... When asked if she saw staff do
anything to [client A] or yell at him [HM #1]
stated she didn't see or hear anything as she was
in a back bedroom cleaning... When asked if she
had noticed [client A's] head tilting over, she said
no. Said she does not know how [client A] may
have obtained the concussion."
"Interview [Staff #3] on 2/6/18: [Staff #3] stated he
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 14 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
worked the night shift on 1/31/18. He stated when
he arrived that [client A] was asleep and slept
through the night. [Staff #3] stated that [HM #1]
awakened [client A] and gave him a shower and
got him dressed. [Staff #3] stated he was giving
medications and when he called for [client A] to
come he didn't respond so [staff #3] went to the
living room where he found [client A] asleep.
[Staff #3] stated he woke up [client A] up (sic) and
gave him his medication then went back to finish
giving the rest of the people their medications.
[Staff #3] stated that [HM #1] gave the people
breakfast, he continued to deny it saying that he
was giving medications. He said he didn't even
see [client A] until it was time to get on the wan to
day program. He volunteered that he didn't see
anything because he was in the 'med' room. [Staff
#3] stated he does not know how [client A]
obtained the concussion."
"Conclusion of Fact: While it is clear that [client
A] was in pain on 1/31/18, it is not clear how a
concussion was diagnosed... [Client D] provided
different accounts of the events at different times
to different people. This lack of consistency and
lack of corroboration results in the allegation of
abuse being unsubstantiated... There is a
significant discrepancy between [staff #3 and HM
#1's] account of the events of the morning of
1/31/18. It isn't clear if breakfast was not served by
either staff or if something occurred that one or
both of them are not willing to discuss."
The MNRFII indicated the investigation was
reviewed by AD #2 on 2/6/18.
Area Director (AD) #1 was interviewed on 3/20/18
at 1:00 PM. AD #1 indicated the conclusion to the
investigation still has unanswered questions
regarding staff #3's and HM #1's account of the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 15 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
morning. AD #1 indicated RQIM #1 should have
clarified the remaining questions during her
investigation. AD #1 indicated the investigation
of the allegation of physical abuse by staff to
client A was not a thorough investigation. AD #1
indicated she was unsure if client A fell or was
physically abused by staff.
The facility's policy for Abuse and Neglect dated
9/17 was reviewed on 3/20/18 at 6:00 PM. The
policy indicated, "Alleged suspected, or actual
abuse, neglect, or exploitation of an individual. An
incident in this category shall also be reported to
Adult Protective Services or Child Protective
Services as applicable. The provider shall
suspend staff involved in an incident from duty
pending investigation by the provider. This may
include: 4. (h.) Injury to an individual when the
origin or cause of the injury is unknown and could
be indicative of abuse, neglect or exploitation; (e.)
Failure to provide appropriate supervision, care or
training; (i.) Injury to the individual when the
origin or cause of the injury is unknown and the
injury required medical evaluation or treatment; (j.)
A significant injury to an individual, including: (6.)
contusions or lacerations which require more than
basic first aid.
This deficiency was cited on 2/6/18. The facility
failed to implement a systemic plan of correction
to prevent recurrence.
This federal tag relates to complaint #IN00253006.
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 16 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
Based on record review and interview for 1 of 1
allegations of abuse, neglect and mistreatment
reviewed, the facility failed to thoroughly
investigate an allegation of staff to client A
physical abuse.
Findings include:
The facility's BDDS (Bureau of Developmental
Disabilities Services) reports and investigations
were reviewed on 3/20/18 at 10:50 AM. The review
indicated the following:
BDDS report dated 1/31/18 at 8:00 AM indicated,
"While [client A] was at day program, he was
complaining of pain. One of [client A's]
housemates told the day program supervisor that
a 'black guy' pushed [client A] down. Program
Supervisor notified group home Area Director.
Area Director arranged for staff to pick up [client
A] for evaluation. [Client A] was taken to ER
(Emergency Room) and was diagnosed with a
concussion. It is unclear how concussion
occurred."
Plan to Resolve: "Male staff working in the
morning were suspended pending investigation.
Program Nurse, AD (Area Director) will follow ER
discharge instructions. [Client A] will continue to
be monitored for a minimum of 48 hours to insure
no further injury occurs."
The Mentor Network Report Form for Internal
Investigation (MNRFII) dated 3/15/18 indicated
the investigation of the 1/31/18 incident involving
client A was completed 2/1/18 to 2/6/18 by
Regional Quality Improvement Manager (RQIM)
#1. The MNRFII indicated the following:
"Interview [client D], person served 2/5/18: Upon
W 0154 W154
The previous Regional Quality
Improvement Manager is no longer
with the company. The previous
Regional Director is no longer in a
position of reviewing
investigations.
The Lead Area Director and new
Regional Director will provide
ongoing oversight of all incidents
to ensure those that require
investigations to be completed are
done so following the facilities
policies. The Lead Area Director
and new Regional Director will
monitor the next five investigations
to ensure they are thorough and
the completed investigation and
results are shared with the
administrator within five working
days, and will continue routine
monitoring ongoing thereafter.
Any investigations regarding any
abuse, neglect and/or exploitation
will receive a final review by the
New Regional Director and Lead
Area Director. This will ensure a
minimum of two people are
reviewing each investigation for
thoroughness.
04/08/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 17 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
entering the home at 8:45 AM, the investigator
attempted to interview [client D] but he refused.
He appeared agitated. Later in the morning, [client
D] agreed to speak with the investigator. When
asked how [client A] got hurt, [client D] forcefully
replied, 'I don't know nothing.' When asked if he
heard [client A] fall, he said, 'I heard fighting.'
When asked if he heard [client A] yelling he
stated again very forcefully, 'I don't know
nothing.' After [Area Director (AD) #1] returned
to the home, we again approached [client D] to
ask more specifically abut his previous statements
to her that a tall black man had pushed [client A].
In response [client D] stated that a, 'tall back guy
dressed up with a golf hat on' had hurt [client A]...
When asked if it was [staff #3], he would not
respond. When asked if it was [Home Manager
(HM) #1], [client D] stated '[HM #1] wasn't here'...
He also volunteered that at one point [client A]
got up from the table and ran toward [client A's]
room to 'get away.' "
"Interview [Day Service Program Director (DSPD)
#1] on 2/6/18: When asked to describe the events
of 1/31/18, [DSPD #1] stated she observed [client
A's] neck leaning to the side and complaining of
pain. [DSPD #1] stated that [client D] told her that
staff had done something to [client A]. That he
heard [client A] yelling then heard a thump but,
'didn't see nothing.' [DSPD #1] states she reported
to the information to [AD #2]."
"Interview [Staff #4] on 2/6/18: When asked if she
had concerns about any staff behavior towards
[client A], [staff #4] stated that [staff #3] seemed
to want to demonstrate that he could control
[client A]. She further stated that she had
observed [staff #3] use a closed grip on [client
A's] arms to redirect him physically instead of
using an open hand as trained... Said she has not
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 18 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
reported this to anyone."
"Interview [HM #1] on 2/6/18: When asked [HM
#1] stated she works the overnight shift and was
on duty 1/31/18. She stated that she got [client A]
up in the morning and gave him a shower. She
stated that he did not fall while showering. She
stated after she gave him a shower and assisted
him to dress (sic) she took him to the living room
to sit. [HM #1] then states she went to another
person's room to clean it and remained there until
it was time to leave for workshop at 8:00 AM. She
stated that [staff #3] provided breakfast to people.
She states [client A] did not show any problems
that morning... When asked if she saw staff do
anything to [client A] or yell at him [HM #1]
stated she didn't see or hear anything as she was
in a back bedroom cleaning... When asked if she
had noticed [client A's] head tilting over, she said
no. Said she does not know how [client A] may
have obtained the concussion."
"Interview [Staff #3] on 2/6/18: [Staff #3] stated he
worked the night shift on 1/31/18. He stated when
he arrived that [client A] was asleep and slept
through the night. [Staff #3] stated that [HM #1]
awakened [client A] and gave him a shower and
got him dressed. [Staff #3] stated he was giving
medications and when he called for [client A] to
come he didn't respond so [staff #3] went to the
living room where he found [client A] asleep.
[Staff #3] stated he woke up [client A] up (sic) and
gave him his medication then went back to finish
giving the rest of the people their medications.
[Staff #3] stated that [HM #1] gave the people
breakfast, he continued to deny it saying that he
was giving medications. He said he didn't even
see [client A] until it was time to get on the wan to
day program. He volunteered that he didn't see
anything because he was in the 'med' room. [Staff
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 19 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
#3] stated he does not know how [client A]
obtained the concussion."
"Conclusion of Fact: While it is clear that [client
A] was in pain on 1/31/18, it is not clear how a
concussion was diagnosed... [Client D] provided
different accounts of the events at different times
to different people. This lack of consistency and
lack of corroboration results in the allegation of
abuse being unsubstantiated... There is a
significant discrepancy between [staff #3 and HM
#1's] account of the events of the morning of
1/31/18. It isn't clear if breakfast was not served by
either staff or if something occurred that one or
both of them are not willing to discuss."
The MNRFII indicated the investigation was
reviewed by AD #2 on 2/6/18.
Area Director (AD) #1 was interviewed on 3/20/18
at 1:00 PM. AD #1 indicated all allegations of
abuse, neglect, mistreatment should be
investigated thoroughly. AD #1 indicated the
conclusion to the investigation still has
unanswered questions regarding staff #3's and
HM #1's account of the morning. AD #1 indicated
RQIM #1 should have clarified the remaining
questions during her investigation. AD #1
indicated the investigation of the allegation of
physical abuse by staff to client A was not a
thorough investigation.
This federal tag relates to complaint #IN00253006.
9-3-2(a)
483.430(a)
QIDP
Each client's active treatment program must
be integrated, coordinated and monitored by
W 0159
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 20 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
a qualified intellectual disability professional.
Based on observation, record review and
interview for 4 of 4 sample clients (A, B, C, and D),
plus 3 additional clients (E, F, and G), the QIDP
(Qualified Intellectual Disabilities Professional)
neglected to implement the facility's written policy
and procedures to investigate thoroughly an
allegation of staff to client A physical abuse, and
failed to ensure Licensed Practical Nurse (LPN)
#1was retrained utilizing a licensed supervisory
personnel.
Findings include:
1. The QIDP neglected to implement the facility's
written policy and procedures to investigate
thoroughly an allegation of staff to client A
physical abuse. Please W149.
2. The QIDP failed to thoroughly investigate an
allegation of staff to client A physical abuse.
Please see W154.
3. The QIDP failed to ensure LPN #1 was retrained
utilizing a licensed supervisory personnel. Please
see W192.
This federal tag relates to complaint #IN00253006.
9-3-3(a)
W 0159 W159
1. 1.The previous Regional
Quality Improvement Manager is
no longer with the company. The
previous Regional Director is no
longer in a position of reviewing
investigations.
The Lead Area Director and new
Regional Director will provide
ongoing oversight of all incidents
to ensure those that require
investigations to be completed are
done so following the facilities
policies. The Lead Area Director
and new Regional Director will
monitor the next five investigations
to ensure they are thorough and
the completed investigation and
results are shared with the
administrator within five working
days, and will continue routine
monitoring ongoing thereafter.
Any investigations regarding any
abuse, neglect and/or exploitation
will receive a final review by the
New Regional Director and Lead
Area Director. This will ensure a
minimum of two people are
reviewing each investigation for
thoroughness.
2. 2. The previous Regional
Quality Improvement Manager is
no longer with the company. The
previous Regional Director is no
longer in a position of reviewing
investigations.
The Lead Area Director and new
Regional Director will provide
04/08/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 21 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
ongoing oversight of all incidents
to ensure those that require
investigations to be completed are
done so following the facilities
policies. The Lead Area Director
and new Regional Director will
monitor the next five investigations
to ensure they are thorough and
the completed investigation and
results are shared with the
administrator within five working
days, and will continue routine
monitoring ongoing thereafter.
Any investigations regarding any
abuse, neglect and/or exploitation
will receive a final review by the
New Regional Director and Lead
Area Director. This will ensure a
minimum of two people are
reviewing each investigation for
thoroughness.
3. 3. The Director of Nursing
Services, who is a Registered
Nurse, will retrain the Facility
Nurse on ensuring timely
assessment and care following
changes in medical status or
multiple visits to the Emergency
Room. The expectation is that a
Nurse assesses an individual
within 24 hours of a change in
medical status or ER visit, or
requests the individual be
transported to the emergency
room immediately should the
health need require this. For head
injuries, the Facility Nurse will
ensure that staff initiate head
tracking monitoring until the Nurse
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 22 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
can assess the individual within 24
hours. Should there be any
concerns noted on the head
tracking, such as a fever or
disorientation, then the individual
would be immediately transported
to the Emergency Room. Staff
will be retrained to take the
Kardex with them to medical
appointments and/or ER visits.
The QIDP and/or Nurse will be
accessible by phone while
individuals are at medical
appointments and/or the ER in
order to relay important medical
information and historical
background details as needed.
The Facility Nurse will ensure that
individuals are taken to medical
appointments as ordered by a
physician or as the medical
condition warrants. Should there
ever be an instance where there
might be a delay in obtaining
medical care, the staff will contact
an ambulance so that the
individual can be seen by a
medical professional as required.
The Director of Nursing Services
will retrain the Facility Nurse to
ensure discharge paperwork is
reviewed and staff are trained on
any protocols/measures that need
to be implemented following the
discharge. The Director of Nursing
Services will also train the Facility
Nurse on ensuring all individuals
are examined at least on a
quarterly basis.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 23 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
Ongoing the Area Director will
monitor the Facility Nurse’s
quarterly assessments to verify
one has been completed for each
individual. Ongoing the Area
Director will monitor discharge
paperwork from the hospital to
ensure the Facility Nurse
implemented any needed
protocols or measures
recommended following discharge.
483.430(e)(2)
STAFF TRAINING PROGRAM
For employees who work with clients, training
must focus on skills and competencies
directed toward clients' health needs.
W 0192
Bldg. 00
Based on record review and interview for 4 of 4
sample clients (A, B, C, and D), plus 3 additional
clients (E, F, and G) the facility failed to ensure
LPN #1 was retrained utilizing licensed
supervisory personnel.
Findings include:
The facility's Plan of Correction dated 3/8/18 was
reviewed on 3/20/18 at 12:30 PM for the survey of
complaint #IN00253006 completed on 2/6/18. The
review indicated the following:
- For W104:
"The Area Director will retrain the facility nurse
on ensuring timely assessment and care following
changes in medical status or multiple visits to the
Emergency Room (ER). The expectation is that the
nurse assess an individual within 24 hours of a
change in medical status or ER visit...".
"The Area Director will retrain the facility nurse to
W 0192 W192
The Director of Nursing Services,
who is a Registered Nurse, will
retrain the Facility Nurse on
ensuring timely assessment and
care following changes in medical
status or multiple visits to the
Emergency Room. The
expectation is that a Nurse
assesses an individual within 24
hours of a change in medical
status or ER visit, or requests the
individual be transported to the
emergency room immediately
should the health need require
this. For head injuries, the
Facility Nurse will ensure that staff
initiate head tracking monitoring
until the Nurse can assess the
individual within 24 hours. Should
there be any concerns noted on
the head tracking, such as a fever
04/08/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 24 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
ensure discharge paperwork is reviewed and staff
are trained on any protocols/measures that need
to be implemented following the discharge."
"The Area Director will also train the facility nurse
on ensuring all individuals are examined at least
on a quarterly basis."
- For W336: "The Area Director will also train the
facility nurse on ensuring all individuals are
examined at least on a quarterly basis."
Area Director (AD) #1 was interviewed on 3/20/18
at 1:00 PM. AD #1 indicated LPN #1 had not be
retrained for the POC. AD #1 stated, "There is no
good answer for why she (LPN #1) was not
retrained. We had trouble figuring out who was
going to train her." AD #1 indicated the POC
showed she would retrain LPN #1 regarding
nursing care for clients A, B, C, D, E, F, and G. AD
#1 indicated she does not have adequate nursing
knowledge to train LPN #1 to care for clients A, B,
C, D, E, F, and G.
Regional Director (RD) #1 was interviewed on
3/20/18 at 1:00 PM. RD #1 indicated Nursing
Services Director (NSD) #1 was a registered nurse
and supervised LPN #1's care of clients A, B, C, D,
E, F, and G. RD #1 indicated NSD #1 should train
LPN #1 on nursing issues regarding clients A, B,
C, D, E, F, and G, not AD #1 as the POC indicated.
This federal tag relates to complaint #IN00253006.
9-3-3(a)
or disorientation, then the
individual would be immediately
transported to the Emergency
Room. Staff will be retrained to
take the Kardex with them to
medical appointments and/or ER
visits. The QIDP and/or Nurse will
be accessible by phone while
individuals are at medical
appointments and/or the ER in
order to relay important medical
information and historical
background details as needed.
The Facility Nurse will ensure that
individuals are taken to medical
appointments as ordered by a
physician or as the medical
condition warrants. Should there
ever be an instance where there
might be a delay in obtaining
medical care, the staff will contact
an ambulance so that the
individual can be seen by a
medical professional as required.
The Director of Nursing Services
will retrain the Facility Nurse to
ensure discharge paperwork is
reviewed and staff are trained on
any protocols/measures that need
to be implemented following the
discharge. The Director of Nursing
Services will also train the Facility
Nurse on ensuring all individuals
are examined at least on a
quarterly basis.
Ongoing the Area Director will
monitor the Facility Nurse’s
quarterly assessments to verify
one has been completed for each
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 25 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
individual. Ongoing the Area
Director will monitor discharge
paperwork from the hospital to
ensure the Facility Nurse
implemented any needed
protocols or measures
recommended following discharge.
483.460(c)(3)(iii)
NURSING SERVICES
Nursing services must include, for those
clients certified as not needing a medical
care plan, a review of their health status
which must be on a quarterly or more
frequent basis depending on client need.
W 0336
Bldg. 00
Based on record review and interview for 2 of 4
sample clients (B and D), plus 2 additional clients
(E and G), the facility's nursing services failed to
ensure clients B, D, E, and G were examined on a
quarterly basis.
Findings include:
Client B's record was reviewed on 3/20/18 at 10:10
AM. Client B's record review did not indicate
documentation of any quarterly nursing reviews
for client B for 2017 or 2018.
Client D's record was reviewed on 3/20/18 at 9:45
AM. Client D's record review did not indicate
documentation of any quarterly nursing reviews
for client D for 2017 or 2018.
Client E's record was reviewed on 3/20/18 at 9:50
AM. Client E's record review did not indicate
documentation of any quarterly nursing reviews
for client E for 2017 or 2018.
Client G's record was reviewed on 3/20/18 at 10:00
W 0336 W336
The facility has policies and
procedures in place to ensure
nursing services include a review
of their health status which must
be on a quarterly or more frequent
basis depending on client need.
The Director of Nursing Services
will train the Facility Nurse on
ensuring all individuals are
examined at least on a quarterly
basis.
Ongoing the Area Director and
Director of Nursing services will
monitor the Facility Nurse’s
quarterly assessments to verify
one has been completed for each
individual.
04/08/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 26 of 27
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
04/09/2018PRINTED:
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
INDIANAPOLIS, IN 46220
15G495 03/20/2018
REM-INDIANA INC
6338 GRAHAM RD
00
AM. Client G's record review did not indicate
documentation of any quarterly nursing reviews
for client G for 2017 or 2018.
Licensed Practical Nurse (LPN) #1 was
interviewed on 3/20/18 at 1:00 PM. LPN #1
indicated clients B, D, E, and G should be
evaluated on a quarterly basis by nursing staff.
LPN #1 was unable to provide documentation of
clients B, D, E, and G's quarterly nursing
assessments for 2017 or 2018.
This deficiency was cited on 2/6/18. The facility
failed to implement a systemic plan of correction
to prevent recurrence.
This federal tag relates to complaint #IN00253006.
9-3-6(a)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3CGF12 Facility ID: 001009 If continuation sheet Page 27 of 27
