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(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
A 0000
Bldg. 00
This visit was for a Federal recertification
survey
Facility Number: 005199
Survey Dates: 2/12/2018 to 2/15/2018
QA: 2/21/18
A 0000
482.25(b)(3)
UNUSABLE DRUGS NOT USED
§482.25(b)(3) - Outdated, mislabeled, or
otherwise unusable drugs and
biologicals must not be available for patient
use
A 0505
Bldg. 00
Based on document review, observation
and interview, the facility failed to ensure
that unusable drugs were not available for
patient use at the off-site Medication
Clinic.
Findings include:
1. Review of the hospital policy entitled,
"Medication Management-Pharmacy",
policy number 29.1.005S, indicated the
Medication Clinic outpatient stock and
sample drugs "shall be checked by the
A 0505 1. & 2. Director of Nursing and
Med Clinic Lead RN began
inspection of each medication
clinic office to monitor for any
outdated, expired medication left
in the office. This began the week
of 2/19/18. Any outdated
medication found was destroyed.
This will continue weekly for one
month, then monthly for 3
months, then quarterly. DON
responsible.
All medication clinic offices have
been checked and all expired
meds have been removed by
2/23/18.
03/31/2018 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 determined that
other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to
continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
_____________________________________________________________________________________________________Event ID: 5TSM11 Facility ID: 005199
TITLE
If continuation sheet Page 1 of 37
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
nursing staff on a regular basis to monitor
for expiration dates". Any expired
medication should be destroyed by the
nursing staff. This policy was last revised
on 08/01/2016.
2. Review of the hospital policy entitled,
"Stock Drugs-Acute Care Unit", policy
number 11.2.058CC, indicated "unused
or damaged drugs must be destroyed". A
nurse must destroy such drugs in the
presence of another nurse, or drugs may
be returned to the pharmacist for
destruction. This policy was last revised
on 06/08/2012.
3. Review of the pharmacy contract
entitled, "PROFESSIONAL SERVICES
AGREEMENT-EXHIBIT D-Pharmacy
Consultant Services", effective date
10/01/2012, indicated a consultant
pharmacist would be provided to "review
the issues related to storage, and perform
quarterly inspections of medication
storage".
4. During the facility tour of the F # 1
(Medication Clinic) on 02/13/2018 at
approximately 12:30 pm, with
administrative staff member A # 4
(Quality Assurance Associate), the
following patient's medications were
observed inside the refrigerator and/or
cabinet of the nurses office and marked
Director of Nursing and ACU
Lead Nurse will be responsible to
check this weekly for one month,
then monthly for 3 months, then
quarterly. DON responsible.
First check completed by ACU
Lead RN on 3/1/18
4. On the day of such 2/13/18, all
noted medications were
destroyed by DON and Med Clinic
Lead RN. An investigation was
started on 2/13/18 and was
completed on 2/23/18. It was
noted the written policy was not
clear so policy has been updated
to include disposal of all
discontinued medication. Upon
Board approval, this policy will be
sent out to all nurses via Relias to
ensure they understand the
policy. DON responsible.
2/13/18 All nursing staff report
never having used any of said
medication.
DON and Med Clinic Lead RN
shall .... See A505 above 2/13/18
5. 2/16/18 All nursing personnel
denied ever using these
medications. All nurses were See
above for training
policy/procedure. Shall be
completed with all nurses having
viewed and understand the policy
by 3/31/18. All nursing personnel
were reminded by email on 3/1/18
until policy is approved and out
for training.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 2 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
EXTRA:
a. Three (3) boxes of Risperdal 25
milligram (mg) intramuscular (IM)
injections.
b. One (1) box of Risperdal 50 mg IM
injection.
c. One (1) box of Risperdal 50 mg IM
injection with an expiration date of
01/2018.
d. One (1) box of Abilify 300 mg IM
injection.
e. One (1) box of Abilify 400 mg IM
injection.
f. One (1) box of Aristada 662 mg IM
injection with an expiration date of
12/21/2016.
g. Five (5) boxes of Invega Sustenna
156 mg IM injections.
h. Two (2) boxes of Invega Sustenna
234 mg IM injections.
i. Four (4) boxes of Fluphenexine 125
mg IM injections.
5. On 02/13/2018 at approximately 12:45
pm with nursing staff member S # 2
(Registered Nurse), confirmed that F # 1
keeps the unused patients medications,
which has been discontinued and/or dose
has been changed, and marked them as
EXTRA. F # 1 then used the EXTRA
supply for patients that may have
received an order for that type of
medication.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 3 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
6. On 02/13/2018 at approximately 2:10
pm with administrative staff member A #
3 (Vice President of Quality
Compliance), confirmed that PH # 1
(Pharmacy) had not been to F # 1 in 2016
and 2017 to perform their quarterly
inspections.
482.27(a)
ADEQUACY OF LABORATORY SERVICES
The hospital must have laboratory services
available, either directly or through a
contractual agreement with a certified
laboratory that meets the requirements of
part 493 of this chapter.
A 0582
Bldg. 00
Based on document review, observation,
and staff interview, the hospital
laboratory services failed to meet the
requirements of 42 CFR 493 for two of
two glucometers observed.
Findings include:
1. Review of the hospital's CLIA
(Clinical Laboratory Improvement
Amendments) certificate indicated they
had a current "Certificate of Waiver."
2. Review of 42 CFR 493.15(e) read:
"Laboratories eligible for a certificate of
waiver must -- (1) Follow manufacturers'
instructions for performing the test..."
A 0582 3. Director of Nursing responsible
for new form titled Glucometer
Control/Test Strip Log. This form
is to be used daily when
glucometer is in use. On this
form, when a new control bottle is
opened, the date it was opened
goes on the form, the Lot number
and expiration date (3 months
from opening per manufactures
instructions or expiration date on
bottle -whichever is sooner) will
be listed. When test strips are
opened, the range values will be
listed of the form. One control
(normal, high, low) will be tested
every day it is in use. If out of
range, the other two will be tested
and both must be within range or
machine cannot be used. This
began on 2/15/18. DON
03/31/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 4 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
3. On 2-12-2018 at 2:20, while on tour
of the inpatient unit at the hospital's main
campus, a "Contour" glucometer was
observed in the "Med Room," available
for use. One opened bottle of test strips,
lot number "DW7JJ3B04C," expiration
date "2019-09-30" for the Contour
glucometer was observed near the
glucometer, available for use. An opened
low control, lot number "6BW1B03,"
expiration date "2018-08," normal
control, lot number "7BW2C07,"
expiration date "2019-04-30," and high
control, lot number "6BW3K02,"
expiration date "2018-07," were observed
near the glucometer, without the open
date indicated on the bottle.
4. On 2-13-2018 at 9:00 AM, while on
tour of off-site #2, a "Breeze 2"
glucometer was observed in the "Med
Room Office," available for use. An
open box of test strip discs, lot number
"1A6820AA," expiration date "2017-09,"
was observed near the glucometer,
available for use. A test strip disc, lot
number "1A6820AA," expiration date
"2017-09" was observed to be loaded into
the glucometer. A normal control, lot
number "5S2D73," expiration date
"2017-12," was observed near the
glucometer without the open date
indicated on the bottle.
responsible.
4. Removed all glucometers from
off site due to non-use in
outpatient setting on 2/19/18.
5. See Above. Policy changed to
meet the manufacturer
requirements of 2 new machine
purchased for the inpatient unit.
Breeze "Contour" machine no
longer in use. Abbott "Freestyle"
machines (2) purchased. New
policy reflects manufactures
instructions. DON responsible.
Policy changed. Awaiting Board
approval for policy 3/31/18.
5b. Manufacturer instructions will
be kept until bottle is empty or
expires. Nurses notified 3/1/18.
Audits will occur weekly. DON
responsible.
6. Policy changed. Policy
matches the manufacturers
instructions for 2 new
glucometers. Awaiting Board
approval 3/31/18.
7. See new procedure written on
#3. Director of Nursing
responsible for new form titled
Glucometer Control/Test Strip
Log. This form is to be used daily
when glucometer is in use. On
this form, when a new control
bottle is opened, the date it was
opened goes on the form, the Lot
number and expiration date (3
months from opening per
manufactures instructions or
expiration date on bottle
-whichever is sooner) will be
listed. When test strips are
opened, the range values will be
listed of the form. One control
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 5 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
5. Review of manufacturers' instructions
for the glucometers indicated the
following:
a. Instructions for the "Contour"
glucometer, copyright 2011, read: "...for
the control solution do not use if it has
been six months (180 days) since you
first opened the bottle..." and "Compare
your control test result with the Normal
Control Range printed on the test strip
bottle label or on the bottom of the test
strip box. Note: Low and High control
range values can be found on the bottom
of the test strip box." and "If your control
test result is out of range, do not use your
meter for blood glucose testing until you
resolve the issue."
b. The facility did not have
manufacturer instructions for the Breeze
2 Normal Control and the Breeze 2 Test
Strips and it could not be determined if
the facility was following manufacturer
instructions for the Breeze 2 normal
control and test strips.
6. Review of policies/procedure titled:
"CLIA Waived Testing," policy number
"26.2.056C," last revised "11/29/17"
read: "Use a control solution (high, low,
or normal) to check the system before use
and daily thereafter..." and "Check
expiration date on the control solution; if
expired or solution has been open for
(normal, high, low) will be tested
every day it is in use. If out of
range, the other two will be tested
and both must be within range or
machine cannot be used. This
began on 2/15/18. DON
responsible.
8. See new procedure #3.
Director of Nursing responsible
for new form titled Glucometer
Control/Test Strip Log. This form
is to be used daily when
glucometer is in use. On this
form, when a new control bottle is
opened, the date it was opened
goes on the form, the Lot number
and expiration date (3 months
from opening per manufactures
instructions or expiration date on
bottle -whichever is sooner) will
be listed. When test strips are
opened, the range values will be
listed of the form. One control
(normal, high, low) will be tested
every day it is in use. If out of
range, the other two will be tested
and both must be within range or
machine cannot be used. This
began on 2/15/18. DON
responsible.
9. Due to non use at off sites, all
glucometers were removed from
outpatient medication clinic
offices as of 2/26/18.
10. See new procedure #3.
Director of Nursing responsible
for new form titled Glucometer
Control/Test Strip Log. This form
is to be used daily when
glucometer is in use. On this
form, when a new control bottle is
opened, the date it was opened
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 6 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
thirty (30) days, dispose of." and "Check
control results with the manufacturer's
range for control results."
7. A handwritten, untitled, document
located on the counter top in the "Med
Room" at the hospital's main campus
read: "Low, Normal, High (sic) Ranges
can vary slightly with lot #s - Ranges are
located on bottom of Contour test strip
boxes. Record Levels for each new box
opened. * Contour test strip bottles
expires 6 mo after opened," and indicated
the control ranges for "test strip lot #
DW7JJ3804C" were: "Low 34-46,"
"Normal 108-149, " and "High 310-427."
The document did not indicated on what
date the test strips were opened, nor did it
include acceptable control ranges for
other test strip lot numbers.
8. Review of "Glucometer Accuracy
Checks" from 9-1-2017 to 2-12-2018
indicated low, normal, and high controls
were routinely performed at the hospital's
main campus for the Contour glucometer.
The document read: "Use at least two
solutions daily when glucometer is in use
to check accuracy - if inaccurate, write in
action taken..." It could not be
determined if control results were within
acceptable ranges, as the lot numbers and
dates of use of test strips used for the
control testing was not documented, nor
goes on the form, the Lot number
and expiration date (3 months
from opening per manufactures
instructions or expiration date on
bottle -whichever is sooner) will
be listed. When test strips are
opened, the range values will be
listed of the form. One control
(normal, high, low) will be tested
every day it is in use. If out of
range, the other two will be tested
and both must be within range or
machine cannot be used. This
began on 2/15/18. DON
responsible.
11. See new procedure #3.
Director of Nursing responsible
for new form titled Glucometer
Control/Test Strip Log. This form
is to be used daily when
glucometer is in use. On this
form, when a new control bottle is
opened, the date it was opened
goes on the form, the Lot number
and expiration date (3 months
from opening per manufactures
instructions or expiration date on
bottle -whichever is sooner) will
be listed. When test strips are
opened, the range values will be
listed of the form. One control
(normal, high, low) will be tested
every day it is in use. If out of
range, the other two will be tested
and both must be within range or
machine cannot be used. This
began on 2/15/18. DON
responsible.
12. Since the glucometers have
not ever been used on a client in
the outpatient Med Clinic sites, all
glucometers were removed and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 7 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
was the open date for the current bottle of
test strips documented. Additionally,
controls were not performed on
10-25-2017.
9. Review of "Glucometer Accuracy
Checks" from 2-15-2017 to 2-12-2018
indicated only a normal control was
routinely performed at off-site #2. It
could not be determined if control results
were within acceptable ranges, as the lot
numbers and dates of use of test strip
discs used for the the control testing was
not documented, nor was the open date
for the current test strip discs
documented.
10. Review of inpatient glucometer test
reports indicated:
a. Patient #23 had glucometer testing
performed on 10-19-2017, 10-20-2017,
10-21-2017, 10-22-2017, 10-23-2017,
10-24-2017, and 10-25-2017 (when
controls were not performed), when it
could not be determined the controls
were within acceptable ranges.
b. Patient #30 had glucometer testing
performed on 11-3-2017, 11-4-2017,
11-5-2017, 11-6-2017, and 11-7-2027,
when it could not be determined controls
were within acceptable ranges.
11. In interview on 2-12-2017 at 2:20
PM:
no longer in use.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 8 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
a. Staff person L7 (Registered Nurse)
acknowledged the control bottles for the
Contour glucometer, in use at the
hospital's main campus, were not dated
when opened.
b. Staff person L2 (Lead Nurse)
acknowledged control for the Contour
glucometer must be discarded six months
after opening, per manufacturer's
instructions. L2 further acknowledged
the facility was unable to verify
glucometer control results were within
acceptable ranges, as the lot number and
dates of use, and control ranges were not
documented.
12. In interview on 2-13-2017 at 9:00
AM, staff person L8 (Licensed Practical
Nurse) acknowledged the glucometer test
strip discs and normal control solution in
use at off-site #2 were expired.
482.41
PHYSICAL ENVIRONMENT
The hospital must be constructed, arranged,
and maintained to ensure the safety of the
patient, and to provide facilities for diagnosis
and treatment and for special hospital
services appropriate to the needs of the
community.
A 0700
Bldg. 00
A 0700 Site plans were emailed to
Director of Facilities on 3/5/18
and hard copies will be delivered
on 3/6/18. Plans were at Arkor
03/31/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 9 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
A Life Safety Code Recertification
Survey was conducted by the Indiana
State Department of Health in accordance
with 42 CFR 482.41(b).
Survey Date: 02/14-15/18
Facility Number: 005199
At this Life Safety Code survey, Four
County Counseling Center was found not
in compliance with Requirements for
Participation in Medicare/Medicaid, 42
CFR Subpart 482.41(b), Life Safety from
Fire and the 2012 edition of the National
Fire Protection Association (NFPA) 101,
Life Safety Code (LSC).
Four County Counseling Center is
comprised of the main hospital in
Logansport, In (Building 01), and Market
Street (Building 02), and Stepping Stones
Clubhouse (Building 03).
Four County Counseling Center main
building, Building 01, a two story fully
sprinklered building with a construction
type that could be best determined by
observation and without plans as Type II
(000). The building with a fire alarm
system with partial smoke detection with
a fire alarm system with partial smoke
detection was surveyed with Chapter 19,
Existing Health Care occupancies.
Architects and Engineer. Director
of Facilities responsible.
Director of Facilities is in the
process of locating contractors to
address each area and to have
them visit on site and provide
bids.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 10 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
Building 01 provides overnight care.
Building 01 has a capacity of 15 and had
a census of 7 at the time of this survey.
Based on record review, observation and
interview, the facility was unable to
confirm the building construction type
conformed to health care construction
limitations, the facility to maintain 1 of 1
limited noncombustible rating (see tag
K161), the facility failed to maintain
protection of 1 of 1 stairway in
accordance of 19.3.1. LSC 19.3.1.1
requires where an enclosure is provided,
the construction shall have not less than a
1-hour fire resistance rating and the
facility failed to maintain protection of 2
of 3 ceiling barriers and 1 of 3 stairwells
in accordance of 19.3.1. LSC 19.3.1
requires protection of vertical openings
(see tag K311), the facility failed to
ensure 1 of 1 fire alarm systems was
maintained in accordance with 9.6.1.3.
LSC 9.6.1.3 requires a fire alarm system
to be installed, tested, and maintained
(see tag K345), the facility failed to
ensure the spray pattern for sprinkler
heads was not obstructed in 1 of 1 ACU
Room D, the facility failed to provide
sprinkler coverage for 1 of 1 ACU Water
Heater room, the facility failed to install
sprinkler head deflectors within 12 inches
of the ceiling in 1 of 1 "Old AGS Storage
room, the facility failed to maintain the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 11 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
ceiling construction in 1 of 1 Library in
accordance with 19.3.5.1. LSC 19.3.5.3
requires where required by 19.1.6,
buildings containing hospitals or limited
care facilities shall be protected
throughout by an approved, supervised
automatic sprinkler system (see tag
K351), the facility failed to ensure at
least 1 of 1 smoke/fire dampers in the
facility were inspected and provided
necessary maintenance at least every four
years (see tag K521), the facility failed to
ensure 1 of 1 elevator equipment room
was provided with smoke detection (see
tag K531), the facility failed to ensure 1
of 1 generator was accordance with
6.4.4.1.1.3. 2010 NFPA 110 8.4.2.3
states that diesel-powered EPS
installations that do not meet the
requirements of 8.4.2 shall be exercised
monthly with the available EPSS load
and shall be exercised annually with
supplemental loads at not less than 50
percent of the EPSS nameplate kW rating
for 30 continuous minutes and at not less
than 75 percent of the EPS nameplate kW
rating for 1 continuous hour for a total
test duration of not less than 1.5
continuous hours, the facility failed to
document the transfer time to the
alternate power source on the monthly
load tests for 12 of the past 12 months to
ensure the alternate power supply was
capable of supplying service within 10
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 12 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
seconds, the facility failed to ensure a
written record of weekly inspections of
the starting batteries for the generator
was maintained for 52 of 52 weeks, the
facility failed to ensure a written record
of weekly inspections of the starting
batteries for the generator was maintained
for 52 of 52 weeks, the facility failed to
ensure 1 of 1 emergency diesel powered
generator was allowed a 5 minute cool
down period after a load test (see tag
K918), the facility failed to ensure 19 of
19 power cords was not used as a
substitute for fixed wiring (see tag
K920).
The cumulative effect of these systemic
problems resulted in the hospital's
inability to ensure that all locations from
which it provides services are
constructed, arranged and maintained to
ensure the provision of quality health
care in a safe environment.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 13 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
482.41(a)
MAINTENANCE OF PHYSICAL PLANT
The condition of the physical plant and the
overall hospital environment must be
developed and maintained in such a manner
that the safety and well-being of patients are
assured.
A 0701
Bldg. 00
Based on record review, observation and
interview, the facility was unable to
confirm the building construction type
conformed to health care construction
limitations in accordance with Table
19.1.6.1., the facility to maintain 1 of 1
limited noncombustible rating in
accordance with Table 19.1.6.1. This
deficient practice could affect all
occupants, the facility failed to maintain
protection of 1 of 1 stairway in
accordance of 19.3.1. LSC 19.3.1.1
requires where an enclosure is provided,
and the construction shall have not less
than a 1-hour fire resistance rating. This
deficient practice could affect all
occupants, the facility failed to maintain
protection of 1 of 1 stairway in
accordance of 19.3.1. LSC 19.3.1.1
requires where an enclosure is provided,
the construction shall have not less than a
1-hour fire resistance rating. This
deficient practice could affect all
occupants, the facility failed to maintain
protection of 2 of 3 ceiling barriers and 1
of 3 stairwells in accordance of 19.3.1.
LSC 19.3.1 requires protection of vertical
A 0701 1. Site plans were emailed to
Director of Facilities on 3/5/18
and hard copies will be delivered
on 3/6/18. Plans were at Arkor
Architects and Engineer. 3/6/18
2. Director of Facilities is still
attempting to locate a contractor
to complete. Director of Facilities
responsible 3/31/18.
3. Director of Facilities will be
contacting Moss Engineering out
of Ft. Wayne, IN on 3/5/18 to set
up a site visit to fix problem
areas. Will need bid and
approval. Director of Facilities
responsible 3/31/18.
4. Director of Facilities is still
attempting to locate contractor to
complete. Director of Facilities
responsible 3/31/18.
5. On 3/7/18 Priority One came to
site and looked at dampers,
Director of Facilities responsible.
The agencies HVAC Company
will be coming this month to
address the dampers.
6. On 3/2/18 completed 30
minute Generator test. Will add
the 30 minute Generator test to
the monthly testing procedure.
Director of Facilities responsible.
7. On 3/2/18 completed 30
minute Generator test. Will add
the 30 minute Generator test to
the monthly testing procedure.
03/31/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 14 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
openings. LSC 19.3.1 requires vertical
openings shall be enclosed or protected in
accordance with Section 8.6. LSC 8.6.1
requires every floor that separates stories
in a building shall be constructed as a
smoke barrier. LSC 19.3.1.1 requires
where an enclosure is provided, and the
construction shall have not less than a
1-hour fire resistance rating. This
deficient practice could affect staff only,
the facility failed to ensure at least 1 of 1
smoke/fire dampers in the facility were
inspected and provided necessary
maintenance at least every four years in
accordance with NFPA 90A. LSC 9.2.1
requires heating, ventilating and air
conditioning (HVAC) ductwork and
related equipment shall be in accordance
with NFPA 90A, Standard for the
Installation of Air-Conditioning and
Ventilating Systems. NFPA 90A, 2012
Edition, Section 5.4.8.1 states fire
dampers shall be maintained in
accordance with NFPA 80, Standard for
Fire Doors and Other Opening
Protectives. NFPA 80, 2010 Edition,
Section 19.4.1 states each damper shall
be tested and inspected 1 year after
installation. Section 19.4.1.1 states the
test and inspection frequency shall be
every 4 years except for hospitals where
the frequency is every 6 years. If the
damper is equipped with a fusible link,
the link shall be removed for testing to
Director of Facilities responsible.
8. On 3/2/18 completed 30
minute Generator test. Will add
the 30 minute Generator test to
the monthly testing procedure.
Director of Facilities responsible.
9. On 3/2/18 completed 30
minute Generator test. Will add
the 30 minute Generator test to
the monthly testing procedure.
Director of Facilities responsible.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 15 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
ensure full closure and lock-in-place if so
equipped. The damper shall not be
blocked from closure in any way. All
inspections and testing shall be
documented, indicating the location of
the fire damper, date of inspection, name
of inspector and deficiencies discovered.
The documentation shall have a space to
indicate when and how the deficiencies
were corrected. This deficient practice
could affect all occupants, the facility
failed to ensure 1 of 1 generator was
accordance with 6.4.4.1.1.3. 2010 NFPA
110 8.4.2.3 states that diesel-powered
EPS installations that do not meet the
requirements of 8.4.2 shall be exercised
monthly with the available EPSS load
and shall be exercised annually with
supplemental loads at not less than 50
percent of the EPSS nameplate kW rating
for 30 continuous minutes and at not less
than 75 percent of the EPS nameplate kW
rating for 1 continuous hour for a total
test duration of not less than 1.5
continuous hours. This deficient practice
could affect all occupants, the facility
failed to document the transfer time to
the alternate power source on the
monthly load tests for 12 of the past 12
months to ensure the alternate power
supply was capable of supplying service
within 10 seconds. This deficient
practice could affect all residents, staff
and visitors, the facility failed to ensure a
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 16 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
written record of weekly inspections of
the starting batteries for the generator
was maintained for 52 of 52 weeks.
Chapter 8.3.7 of NFPA 99 requires
storage batteries, including electrolyte
levels or battery voltage, used in
connection with essential electrical
systems shall be inspected weekly and
maintained in full compliance with
manufacturer's specifications. 8.3.7.2
requires defective batteries shall be
repaired or replaced immediately upon
discovery of defects. Chapter 6.4.4.2 of
NFPA 99 requires a written record of
inspection, performance, exercising
period, and repairs for the generator to be
regularly maintained and available for
inspection by the authority having
jurisdiction. This deficient practice could
affect all residents, staff and visitors, the
facility failed to ensure 1 of 1 emergency
diesel powered generator was allowed a 5
minute cool down period after a load test.
NFPA 110 8.4.5(4) requires a minimum
time delay of 5 minutes shall be provided
for unloaded running of the Emergency
Power Supply (EPS) prior to shut down.
This delay provides additional engine
cool down. This deficient practice could
affect all occupants.
Findings include:
1. Based on record review with the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 17 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
Director of Facilities on 02/14/18 at
11:43 a.m., the facility was unable to
provide construction site plan
documentation to review. Based on an
interview at the time of record review,
the Director of Facilities acknowledged
the aforementioned condition and
confirmed that the site plans were sent
out to be scanned.
2. Based on observation with the
Director of Facilities on 02/14/18 at 2:50
p.m., the "Old AGS Storage room" steel
support beams had some multiple spots
adding up to about one square foot where
the protective coating was removed.
Based on observation with the Director of
Facilities on 02/15/18 at 9:32 a.m. then
again at 9:37 a.m., the Maintenance
Storage room steel support beams had
some multiple spots adding up to about
one square foot where the protective
coating was removed. Then again, the
Boiler room steel support beams had
some multiple spots adding up to about
three square feet where the protective
coating was removed.
Based on an interview at the time of each
observation, the Director of Facilities
acknowledged each aforementioned
condition and confirmed that bare metal
was exposed.
3. Based on observation with the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 18 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
Director of Facilities on 02/14/18 at 2:08
p.m., the 2nd floor South stairwell door
did not have a fire resistance rating.
Based on interview at the time of
observation, the Director of Facilities
confirmed no fire resistance rating could
be found.
4. Based on observation with the
Director of Facilities on 02/14/18
between 1:43 p.m. and 2:35 p.m., the
following was discovered:
a) three separate three eighths inch gap
around piping in the ACS drywall ceiling
b) six separate quarter inch gaps inside
conduit in the Front Office Storage
drywall ceiling
Based on observation with the Director of
Facilities on 02/15/18 at 9:21 a.m., the
following was discovered:
c) three separate five eighths inch gaps
inside conduit in the 1st floor East
Stairwell
Based on interview at the time of each
observation, the Director of Facilities was
unaware of the penetrations and provided
the measurements.
5. Based on record review with the
Director of Facilities on 02/15/18, the
Director of Facilities stated that he did
not believe dampers were in the facility.
Based on observation at 9:39 a.m., the
Maintenance room contained a damper in
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 19 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
the HVAC vent.
6. Based on record review with the
Director of Facilities on 02/14/18 at
10:24 a.m., the monthly testing
documentation did not specify a load
percentage. Based on an interview at the
time of record review, the Director of
Facilities confirmed no load bank test
documentation was available to review.
7. Based on record review with the
Director of Facilities on 02/14/18 at
10:24 a.m., the monthly Generator Load
Tests lacked the generator's transfer time
from normal power to emergency power.
Based on interview at the time of record
review, the Director of Facilities
acknowledged the lack of documentation.
8. Based on record review with the
Director of Facilities on 02/14/18 at
10:24 a.m., no weekly documentation
was not available for review. Based on an
interview at the time of record review,
the Director of Facilities acknowledged
the lack of documentation.
9. Based on record review with the
Director of Facilities on 02/14/18 at
10:24 a.m., the generator log form
documented the generator was tested
monthly for at least 30 minutes under
load, however, there was no
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 20 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
documentation on the form that showed
the generator had a cool down time
following its load test. Based on
interview at the time of record review,
the Director of Facilities acknowledged
the lack of documentation.
482.41(b)
LIFE SAFETY FROM FIRE
Life Safety from Fire
A 0709
Bldg. 00
Based on record review and interview,
the facility failed to ensure 1 of 1 fire
alarm systems was maintained in
accordance with 9.6.1.3. LSC 9.6.1.3
requires a fire alarm system to be
installed, tested, and maintained in
accordance with NFPA 70, National
Electrical Code and NFPA 72, National
Fire Alarm Code. NFPA 72, 14.4.5
Testing Frequencies. NFPA 72,
14.4.5.3.1 states sensitivity shall be
A 0709 1. On 3/7/18 Priority One will be
providing documentation to
Director of Facilities of smoke
detector sensitivities test. Director
of Facilities responsible.
2. Contractor will be on site
3/8/18 to acquire BID for repair,
30 days to repair. Director of
Facilities responsible 3/31/18.
3. Contractor will be on site
3/8/18 to acquire BID for repair,
30 days to repair, Director of
Facilities responsible 3/31/18.
4. Contractor will be on site
3/8/18 to acquire BID for repair,
03/31/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 21 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
checked within 1 year after installation.
NFPA 72, 14.4.5.3.2 states sensitivity
shall be checked every alternate year
thereafter unless otherwise permitted by
compliance with 14.4.5.3.3. This
deficient practice could affect all
occupants, the facility failed to ensure the
spray pattern for sprinkler heads was not
obstructed in 1 of 1 ACU Room D in
accordance with 19.3.5.1. NFPA 13,
2010 edition, Section 8.5.5.1, states
sprinklers shall be located so as to
minimize obstructions to discharge as
defined in 8.5.5.2. and 8.5.5.3 or
additional sprinklers shall be provided to
ensure adequate coverage of the hazard.
Section 8.5.5.2 and 8.5.5.3 do not permit
continuous or noncontinuous obstructions
less than or equal to 18 in. below the
sprinkler deflector that prevent the
pattern from fully developing. This
deficient practice could affect staff and at
least 1 patient, the facility failed to
provide sprinkler coverage for 1 of 1
ACU Water Heater room in accordance
with 19.3.5.1. This deficient practice
could affect staff only, the facility failed
to install sprinkler head deflectors within
12 inches of the ceiling in 1 of 1 "Old
AGS Storage room." NFPA 13, 2010
Edition, Section 8.6.4.1.1.1 under
unobstructed construction, the distance
between the sprinkler deflector and the
ceiling shall be a minimum of 1 inch and
30 days to repair, Director of
Facilities responsible 3/31/18.
5. Contractor will be on site
3/8/18 to acquire BID for repair,
30 days to repair, Director of
Facilities responsible 3/31/18.
6. Contractor will be on site
3/8/18 to acquire BID for repair,
30 days to repair, Director of
Facilities responsible 3/31/18.
7. Documentation of all
appliances are to be plugged in to
wall sockets, not surge protector
and/or extension cords will be put
into policy. Director of Facilities
responsible. Awaiting Board
approval 3/31/18.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 22 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
a maximum of 12 inches throughout the
area of coverage of the sprinkler. This
deficient practice could affect staff only,
the facility failed to maintain the ceiling
construction in 1 of 1 Library in
accordance with 19.3.5.1. LSC 19.3.5.3
requires where required by 19.1.6,
buildings containing hospitals or limited
care facilities shall be protected
throughout by an approved, supervised
automatic sprinkler system in accordance
with Section 9.7. Section 9.7 indicates
that automatic sprinkler system requires
shall be in accordance with NFPA 13.
NFPA 13, 2010 edition, Section 6.2.7
states plates, escutcheons, or other
devices used to cover the annular space
around a sprinkler shall be metallic, or
shall be listed for use around a sprinkler.
This deficient practice could affect staff
only, the facility failed to ensure 1 of 1
elevator equipment room was provided
with smoke detection in accordance with
ASME/ANSI A17.3. This deficient
practice could affect staff only, the
facility failed to ensure 19 of 19 power
cords was not used as a substitute for
fixed wiring according to 33.2.5.1. LSC
33.2.5.1 states utilities shall comply with
Section 9.1. LSC 9.1.2 requires electrical
wiring and equipment shall be in
accordance with NFPA 70, National
Electrical Code. NFPA 70, 2011 Edition,
Article 400.8 requires that, unless
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 23 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
specifically permitted, flexible cords and
cables shall not be used as a substitute for
fixed wiring of a structure. This deficient
practice could affect all occupants.
Findings include:
1. Based on record review with the
Director of Facilities on 02/14/18 at 1:13
p.m., fire alarm smoke detector
sensitivity test was not available for
review. Based on interview at the time of
record review, the Director of Facilities
acknowledged the aforementioned
condition and confirmed no other
documentation was available for review.
2. Based on observation with the
Director of Facilities on 02/14/18 at 1:50
p.m., ACU Room D sprinkler head
deflector was higher than the drywall.
Based on interview at the time of
observation, the Director of Facilities
acknowledged the aforementioned
condition and confirmed the sprinkler
head was obstructed.
3. Based on observation with the
Director of Facilities on 02/14/18 at 1:43
p.m., the ACU Water Heater room did
not have sprinkler protection installed at
this fully automatic sprinklered building.
Based on interview at the time of
observation, the Maintenance Technician
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 24 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
#1 confirmed the room did not have
sprinkler protection installed.
4. Based on observation with the
Director of Facilities on 02/14/18 at 2:50
p.m., the "Old AGS Storage room"
contains a sprinkler head deflector was
estimated at 48 inches from the ceiling.
Based on interview at the time of
observation, the Director of Facilities
acknowledged the aforementioned
condition and provided the estimated
measurement.
5. Based on observation with the
Director of Facilities on 02/14/18 at 2:04
p.m., the Library had a missing
escutcheon. Based on interview at the
time of observation, the Director of
Facilities acknowledged the missing
escutcheon.
6. Based on observation with the
Director of Facilities on 02/15/18 at 9:39
a.m., the elevator equipment room
contained 1 sprinkler head, a heat
detector but no smoke detector. Based on
interview at the time of observation, the
Director of Facilities confirmed no
smoke detector was present in the
elevator equipment room.
7. Based on observation with the
Director of Facilities on 02/14/18
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 25 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
between 1:40 p.m. and 2:27 p.m., the
following was discovered:
a) a surge protector was powering a
coffee pot in the "CSS Half wall"
b) an extension cord was powering a
microwave in the ACU Case
Management office
c) a surge protector was powering a
coffee pot, toaster, and microwave in the
ACU Rounds room
d) a surge protector was powering
another surge protector powering a
refrigerator and a microwave in office
room 220
e) a surge protector was powering a
microwave and a refrigerator in office
room 213
Based on observation with the Director of
Facilities on 02/15/18 between 9:21 a.m.
and 10:15 a.m., the following was
discovered:
f) a surge protector was powering another
surge protector powering computer
components in the "unmanned IT office"
g) four separate surge protector was
powering another surge protector in the
"MF office"
h) a surge protector was powering a
microwave in the IT room
i) a surge protector was powering a
refrigerator in the Transportation room.
Additionally, a surge protector was
powering a microwave and a coffee pot
Based on interview at the time of
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 26 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
observation, the Director of Facilities was
unaware of regulation and acknowledged
each interconnected surge protector.
482.41(b)(6)
DISPOSAL OF TRASH
The hospital must have procedures for the
proper routine storage and prompt disposal
of trash.
A 0713
Bldg. 00
Based on document review, observation,
and interview, the hospital failed to
properly store biohazard waste in two of
two instances.
Findings include:
1. Review of policy/procedure titled:
"Infectious Waste Handling And
Disposal," policy number "C38.1.002,"
effective "8-27-99," read: "Infectious
waste will be segregated in containers
with a biohazard symbol, will not be
compacted, and will be handled from
point of origin to final disposal in
accordance with the ISBH rule."
2. 410 IAC 1-3-25 reads: "If infectious
A 0713 On 2/16/18 the Director of
Nursing and Director of
Facilities went to all facilities to
ensure that all biohazard waste
were clearly marked and if
needed to be relocated to
locked secure areas that are
not accessible to the public
and/or clients were done so. All
biohazard containers have
been marked and relocated as
of 3/20/18. Director of Facilities
responsible.
The location of the biohazard
containers will be added to the
maintenance monthly walk thru
to ensure that the containers
are maintained behind locked
secure areas that are not
accessible to the public and/or
03/31/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 27 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
waste is stored prior to final disposal, all
persons subject to this rule shall: (1)
store infectious waste in a secure area
that: (A) is locked or otherwise secured
to eliminate access by or exposure to the
general public...(C) has a prominently
displayed biohazard symbol..."
3. On 2-13-2018 at 9:45 AM, while on
tour of off-site #2, biohazard waste was
observed to be stored in an unlocked staff
restroom, without a biohazard symbol
displayed, accessible by a public hallway.
4. On 2-13-2018 at 11:05 AM, biohazard
waste was observed to be stored in the
patient exam room at the main hospital
campus.
5. In interview on 2-13-2018:
a. At 9:55 AM, staff person L6
(Medical Assistant) indicated full sharps
containers are placed in biohazard
containers in the staff restroom at off-site
#2 for storage prior to removal for final
disposal by the contracted biohazard
waste handler.
b. At 11:05 AM, staff person L1
(Director of Nursing) indicated biohazard
waste is stored in a biohazard waste
container in the patient exam room where
patients receive medical exams.
clients. Director of Facilities
responsible 3/31/18.
The Director of Facilities was
responsible for #1 which was
completed on 2/16/18 and #2
the Director of Facilities will be
responsible to maintain 3/31/18
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 28 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
482.41(c)(4)
VENTILATION, LIGHT, TEMPERATURE
CONTROLS
There must be proper ventilation, light, and
temperature controls in pharmaceutical,
food preparation, and other appropriate
areas.
A 0726
Bldg. 00
Based on document review and
interview, the hospital failed to ensure
proper temperature controls for two of
four pharmaceutical and five of five food
refrigerators reviewed.
Findings include:
1. Review of policies and procedures
indicated:
a. A policy/procedure titled:
"Medication Management," policy
number "29.1.005S," last revised
"8-1-16," read: "Acute Care
Unit...Refrigerator temperature is
maintained between 36-46 F." and
"Medication Clinic...All medications
needing refrigeration are maintained in a
refrigerator with temperatures between
36-46 degrees Fahrenheit."
b. A policy/procedure titled:
"Refrigerator/Freezers," policy number
"S38.1.011A," last revised "3-12-09,"
read: "The temperature range of all
refrigerators used for clinical purposes is
to be maintained between 35° and 42° F."
A 0726 1a. All policies will be changed
and forms to match the changes.
All refrigerators with medication
need to be kept at 36 - 46
degrees F. One policy got
changed but the other did not
Policy S38.1.011A will be
changed to meet this and match
MM29.1.005S. The form will
match these temps and be placed
on all the med refrigerators. DON
responsible 3/31/18.
1b, c, d. All policies will be
changed to match as per State
Dept of Health, refrigerated food
needs to be kept between 35 and
41 degrees F. S38.1.013B will be
changed to meet the standard.
Form for food refrigerators will
match. DON responsible 3/31/18.
1b, c, d. All policies will be
changed and forms to match the
changes. All refrigerators with
medication need to be kept at 36
- 46 degrees F. One policy got
changed but the other did not
Policy S38.1.011A will be
changed to meet this and match
MM29.1.005S. The form will
match these temps and be placed
on all the med refrigerators. DON
responsible 3/31/18. All policies
03/31/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 29 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
c. A policy/procedure titled: "Kitchen
Supplies," policy number "11.2.045C,"
last revised "11.3-9-15," read: "All food
item (sic) requiring refrigeration shall be
kept between 35-45 degrees."
d. A policy/procedure titled:
"Refrigerator Temperature for Food
Storage," policy number "31.1.029,"
origination date "3-5-15," read: "Per the
State Department of Health, refrigerated
food requires to be maintained between
35-45 degrees Fahrenheit."
e. A policy/procedure titled:
"Management Plan for Food Safety,"
policy number "S38.1.013B," last revised
"10/15/14," read: "Ensure appropriate
temperatures are met as evidenced by 35
to 42 degrees temperature in refrigerators
for food storage, 0 degrees or below in
freezers for food storage..."
2. Review of 410 IAC 7-24, Sanitary
Standards for the Operation of Retail
Food Establishments, section 187 (a)
read: "...potentially hazardous food shall
be maintained as follows...at forty-one
(41) degrees Fahrenheit or less."
3. Review of "Refrigerator/Freezer
Temperature Monitor" logs for
medication refrigerators indicated the
"safe range" was 35 degrees Fahrenheit
(F) to 44 F. Temperatures were not
within acceptable limits as follows:
will be changed to match as per
State Dept of Health, refrigerated
food needs to be kept between 35
and 41 degrees F. S38.1.013B
will be changed to meet the
standard. Form for food
refrigerators will match. DON
responsible 3/31/18.
1b, c, d. All policies will be
changed and forms to match the
changes. All refrigerators with
medication need to be kept at 36
- 46 degrees F. One policy got
changed but the other did not
Policy S38.1.011A will be
changed to meet this and match
MM29.1.005S. The form will
match these temps and be placed
on all the med refrigerators. DON
responsible 3/31/18. All policies
will be changed to match as per
State Dept of Health, refrigerated
food needs to be kept between 35
and 41 degrees F. S38.1.013B
will be changed to meet the
standard. Form for food
refrigerators will match. DON
responsible 3/31/18.
3. See 1a. All policies will be
changed and forms to match the
changes. All refrigerators with
medication need to be kept at 36
- 46 degrees F. One policy got
changed but the other did not
Policy S38.1.011A will be
changed to meet this and match
MM29.1.005S. The form will
match these temps and be placed
on all the med refrigerators. DON
responsible 3/31/18.
4. These temperatures are out of
range for the new information
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 30 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
a. For the main hospital campus, the
medication room refrigerator (med room
ACU) temperatures were documented as
"34 or less" on the following dates:
12-2-2017; 12-6-2017; 12-13-2017;
12-23-2017; 12-29-2017; 1-5-2018; and
1-13-2018.
b. For off-site #1, the medication
refrigerator (med fridge) temperatures
were documented as "34 or less" on the
following dates: 11-6-2017; 12-27-2017;
and 1-15-2018; and temperatures were
documented as "45 or more" on
12-20-2017.
4. Review of "Refrigerator/Freezer
Temperature Monitor" logs for food
refrigerators read: "If temperature is not
in safe range for (3) consecutive days
notify Infection Control" and indicated
the "safe range" was 35 F to 44 F.
Temperatures were not within acceptable
limits (per 410 IAC 7-24, section 187(a))
as follows:
a. For the main hospital campus:
1. The acute care unit refrigerator
(client): 11-9-2017 (43 F); 11-13-2017
(42 F); 11-16-2017 (42 F); 11-28-2017
(42 F); 12-15-2017 (42 F); 12-29-2017
(42 F); and 1-7-2018 (42 F)
2. The staff food refrigerator (staff):
12-2-2017 (42 F); 12-3-2017 (43 F);
12-4-2017 (42 F); 12-5-2017 (42 F);
1-1-2018 (44 F); 1-2-2018 (44 F);
given that food needs to be at 41
degrees F or less. However, most
of these temps met our current
policy and practice.
New policies will be put in place
where food refrigerator temps will
be kept between 35 and 41
degrees F with a new form that
matches this. DON responsible
3/31/18.
5. Policies to be changed, along
with forms for monitoring to
match the 35 to 41 degrees F
standard. DON responsible
3/31/18.
6. Historically, ISDH never
wanted to look at staff
refrigerators, only those where
clients are affected, so no
infection control report had been
sent for the staff refrigerator.
Managers and nursing personnel
reminded to notify Infection
Control. It is also listed on the
bottom of the temperature log
form. DON responsible 3/31/18.
7. A Medication Log will be kept in
front of each medication
refrigerator. As medications are
put in the refrigerator the will be
signed in and as they are
removed, they will be signed out.
DON responsible 3/31/18.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 31 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
1-4-2018 (43 F); 1-21-2018 (documented
as "45 or more"); 1-22-2018 (documented
as "45 or more"); 1-23-2018 (documented
as "45 or more"); 1-28-2018 (43 F);
1-29-2017 (43 F); and 1-30-2018 (43 F).
3. The kitchenette refrigerator:
11-1-2017 (42 F); 11-2-107 (43 F);
11-3-2017 (42 F); 11-6-2017 (42 F);
11-13-2017 (42 F); 11-14-2017 42 F);
11-15-2017 (42 F); 11-20-217 (42 F);
11-28-2017 (42 F; 11-29-2017 (42 F);
11-30-2017 (42 F); 12-1-2017 (43 F);
12-5-2017 (43 F); 12-14-2017 (42 F);
12-19-2017 (43 F); 12-20-2017 (42 F);
12-26-2017 (42 F); 12-27-2017 (42 F);
1-9-2018 (43 F); 1-18-2018 (42 F);
1-22-2018 (43 F); 1-30-2018 (42 F); and
1-31-2018 (42 F).
b. For off-site #1:
1. The west kitchen food
refrigerator (west kitchen): 11-4-2107
(44 F); 11-10-2017 (43 F); 11-11-2017
(42 F); 11-172017 (44 F); 11-18-2017
(documented as "45 or more");
11-19-2017 (44 F); 11-28-2017 (44 F);
12-2-017 (documented as "45 or more");
12-3-2017 (documented as "45 or more");
12-7-2017 (42 F); 12-8-2017 (42 F);
12-14-2017 (documented as "45 or
more"); 12-28-2018 (documented as "45
or more"); 12-23-2017 (43 F);
12-24-2017 (43 F); 12-25-2017 (42 F);
12-31-2017 (43 F); 1-9-2018 (43 F);
1-15-2018 (43 F); 1-16-2018 (43 F);
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 32 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
1-17-2018 (43 F); and 1-21-2018 (42 F).
2. The east kitchen food
refrigerator (east kitchen): 11-4-2017 (43
F); 11-15-2017 (42 F); 11-17-2017 (44
F); 11-18-2017 (43 F); 11-29-2017 (42
F); 11-20-2017 (42 F); 11-21-2017 (44
F); 11-22-2017 (42 F); 11-26-2017
(documented as "45 or more");
11-27-2017 44 F); 11-28-2017 (44 F);
12-2-2017 (44 F); 12-2-2017 (42 F);
12-7-2017 (44 F); 12-9-2017 (42 F);
12-11-2017 (43 F); 12-12-2017 (44 F);
12-13-2017 (documented as "45 or
more"); 12-14-2017 (documented as 45
or more"); 12-15-2017 (44 F);
12-28-2017 (43 F); 12-31-2017 (42 F);
1-4-2018 (42 F); 1-9-2018 (documented
as "45 or more"); 1-15-2018 (42 F);
1-21-2018 (44 F); 1-25-2018 (42 F); and
1-31-2018 (43 F).
5. In interview on 12-12-2017 at 4:20
PM, staff member L1 (Director of
Nursing) acknowledged there was a
discrepancy with policies and procedures
for medication and food refrigerator
temperature requirements. L1 indicated
the correct temperature range for
medication and food refrigerators is 35 F
- 44 F.
6. On 2-13-2018 at 3:30 PM, staff
member L2 (Lead Nurse) indicated there
was no infection control report generated
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 33 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
for the staff food refrigerator at the main
campus when the temperature was out of
range (per policy) for three consecutive
dates (1-21-2018; 1-22-2018; and
1-23-2018).
7. On 2-14-2018 at 9:30 AM, staff
member L1 indicated the hospital was
unable to determine what medications
were in the medication refrigerators when
the temperatures were out of range.
482.42(a)(1)
INFECTION CONTROL PROGRAM
The infection control officer or officers must
develop a system for identifying, reporting,
investigating, and controlling infections and
communicable diseases of patients and
personnel.
A 0749
Bldg. 00
Based on document review, observation
and interview, the hospital failed to
develop a system for controlling
infections of patients in three instances.
Findings include:
1. Review of "Infection Prevention
During Blood Glucose Monitoring and
Insulin Administration," published by the
Centers for Disease Control and
Prevention (CDC), and last updated on
June 8, 2017, read: "Recommended
A 0749 1. one or more Off Site Clinics
had a fingerstick device that more
that one person could use. These
have been removed from all sites
as of 2/26/18. The Inpatient Unit
only uses individual lancets.
DON responsible.
3. Bayer Breeze 2 meters were
removed from premise in the
Offsite Clinic as of 2/26/18. DON
responsible.
4. Bayer Breeze 2 meters were
removed from premise in the
Offsite Clinic as of 2/26/18. DON
responsible.
5. All glucometers have been
03/02/2018 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 34 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
Practices for Preventing Bloodborne
Pathogen Transmission during Blood
Glucose Monitoring and Insulin
Administration Healthcare
Settings...Restrict use of fingerstick
devices to individual persons. They
should never be used for more than one
person."
2. Review of policy/procedure titled:
"CLIA Waived Testing, General
Clinical" policy number "26.2.056C," last
revised "11/29/17" read: "Follow
manufacturer's direction for inserting
lancet into lancet holder..." and
"Different types of meters have very
different cleaning needs...Follow
manufacturer's directions."
3. Review of manufacturer's instructions
for the Breeze 2 glucometer, copyright
unknown read: "Your Breeze 2 meter
can be cleaned using a moist (not wet)
lint-free tissue with a mild detergent or
disinfection solution (1 part bleach mixed
with 9 parts water). Do not use alcohol."
4. Review of the manufacturer's
directions "Caring for the System", for
the Bayer Contour glucometer indicated
the meter should be cleaned using a moist
(not-wet) lint-free tissue with a mild
detergent or disinfectant solution, such as
one (1) part bleach mixed with nine (9)
removed from Outpatient Med
Clinic Offices as of 2/26/18. The
only glucometers are now on the
Inpatient Unit. DON responsible.
6. Bayer Breeze 2 meters were
removed from premise in the
Offsite Clinic as of 2/26/18. DON
responsible.
7. All Off Site Clinic glucometers
have been removed. Inpatient
glucometer was changed from
Contour to Freestyle from Abbott.
All nurses were inserviced via
video made by manufacturer that
included how to use and how to
clean. Materials present on
Inpatient Unit to clean using
manufacturers instructions. DON
responsible.
8. See #7. All Off Site Clinic
glucometers have been removed.
Inpatient glucometer was
changed from Contour to
Freestyle from Abbott. All nurses
were inserviced via video made
by manufacturer that included
how to use and how to clean.
Materials present on Inpatient
Unit to clean using manufacturers
instructions. DON responsible.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 35 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
parts water then wipe dry with a lint-free
tissue after cleaning.
5. On 2-13-2018 at 9:00 AM, while on
tour of off-site two, a multi-use lancet
device was observed in the "med room"
drawer with a Breeze 2 glucometer. The
lancet device had a dried red substance,
resembling dried blood, on the end of it.
6. On 02/12/2018 at approximately 1:45
PM with administrative staff member A #
1 (Director of Nursing), confirmed that
the nursing staff at off-site one were
using alcohol wipes to clean the Bayer
Contour glucometer
7. In interview on 2-13-2018 at 9:00
AM, staff person L8 (Licensed Practical
Nurse) acknowledged the lancet device
was used to obtain blood samples for
glucometer testing on multiple patients
and appeared to have dried blood on the
end of it. L8 further indicated the lancet
device and glucometer were cleaned with
alcohol preparation pads in between use
with different patients. On the same date
at 9:28 AM, L8 acknowledged the
manufacturer's instructions prohibit the
use of alcohol as a cleaning agent for the
glucometer.
8. On 02/13/2018 at approximately 1:40
PM, with administrative staff member A
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 36 of 37
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
06/22/2018PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
LOGANSPORT, IN 46947
154035 03/14/2018
FOUR COUNTY COUNSELING CENTER
1015 MICHIGAN AVE
00
# 1, confirmed the nursing staff was not
in-serviced on how to properly clean the
glucometer.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet Page 37 of 37