PRINTED: 12/15/2017 DEPARTMENT OF HEALTH … indicated the findings of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DVD711 Facility ID: 001106 If continuation sheet Page

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

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FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

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B. WING

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

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

BRAZIL, IN 47834

15G592 11/02/2017

NORMAL LIFE OF INDIANA

107 A VILLA CT

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W 0000

Bldg. 00

This visit was for a fundamental

recertification and state licensure survey.

Dates of Survey: October 25, 26, and 27

and November 2, 2017.

Facility Number: 001106

Provider Number:15G592

AIMS Number: 100240070

These deficiencies also reflect state

findings in accordance with 460 IAC 9. Quality Review of this report completed by

#15068 on 11/15/17.

W 0000

483.420(d)(4)

STAFF TREATMENT OF CLIENTS

The results of all investigations must be

reported to the administrator or designated

representative or to other officials in

accordance with State law within five

working days of the incident.

W 0156

Bldg. 00

Based on record review and interview for

3 of 5 allegations of abuse, neglect or

mistreatment reviewed, the facility failed

to report the results of an investigation of

alleged client to client physical abuse

between clients #2 and #3, and two

separate instances of client to client

W 0156 Agency has policy in place

stating written documentation

shall be gathered from all staff

witnessing or taking part in

alleged abuse or neglect. All

documentation shall be

gathered by the QIDP,

reviewed, and conclusion

forwarded to the Area

12/15/2017 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: DVD711 Facility ID: 001106

TITLE

If continuation sheet Page 1 of 23

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physical abuse between clients #1 and #5

to the administrator within 5 business

days of the alleged events.

Findings include:

The facility's BDDS (Bureau of

Developmental Disabilities Services)

reports and investigations were reviewed

on 10/25/17 at 12:35 PM. The review

indicated the following:

1. BDDS report dated 9/8/17 indicated,

"On the evening of September 7, 2017

[client #1] was sitting on the couch nest

(sic) to [client #5] on the east side of the

living room, when [client #1] leaned over

to the left and bit [client #5] on the right

arm just about an inch away from the

elbow. There is no skin tears or bleeding

but there was a bruise 2 inch by 2 inch."

The Client to Client Aggression

Investigation (CCAI) dated 9/11/17 did

not indicate the administrator was

notified within 5 business days of the

results of the investigation.


"On September 25, 2017 staff reported

that [client #3 ] was having a behavior.

He pinched [client #2] on the back of the

neck, staff attempted to use the YSIS

(You're Safe, I'm Safe) blocking

Supervisor and/or his/her

designee within a reasonable

time frame, but at least within

five working days. The QIDP

will be retrained on this policy

to ensure timely submissions

of all internal investigations.

The next three investigations

will be monitored by the QA

manager to ensure they are

completed within five working

days. The QA department will

begin tracking all initial

incidents of client on client

aggression through to

completion to ensure all

investigations are being

completed within the specified

timeframe.

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techniques to block [client #3] from

pinching [client #2]. Staff safely pulled

the van over and was able to separate

[clients #2 and #3]."

The CCAI for the incident of client to

client aggression between clients #2 and

#3 indicated a completion date of 10/5/17

for the 9/25/17 incident. The CCAI did

not indicate the administrator was

notified within 5 business days of the

results of the investigation.


"While [client #5] was sitting on the

couch watching TV, [client #1] reached

over and grabbed [client #5's] right arm

and bit him on the forearm. Staff

immediately redirected [client #1] and

assessed [client #5's] arm. The bite did

not break the skin of (sic) [client #5's]

arm."

The CCAI dated 10/5/17 did not indicate

the administrator was notified within 5

business days of the results of the

investigation.

AS (Area Supervisor) #1 was interviewed

on 10/26/17 at 2:33 PM. AS #1 indicated

an investigation should begin

immediately and should be completed in

5 business days of the alleged event. AS

#1 indicated the findings of





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investigations of allegations of abuse,

neglect or mistreatment should be

reported to the facility administrator

within 5 business days of the alleged

event.

9-3-2(a)

483.430(a)

QUALIFIED MENTAL RETARDATION

PROFESSIONAL

Each client's active treatment program must

be integrated, coordinated and monitored by

a qualified mental retardation professional.

W 0159

Bldg. 00


1 of 4 sample clients (#2), the Qualified

Intellectual Disabilities Professional

(QIDP) failed to convene the

Interdisciplinary Team (IDT) to address

concerns regarding client #2's recurrent

skin breakdown and ambulation needs.

Findings include:

Observations were conducted at the

group home on 10/25/17 from 6:14 AM

to 7:51 AM, 10/25/17 from 9:12 AM to

10:14 AM, and 10/25/17 from 4:23 PM

to 5:16 PM. At 6:19 AM, staff #1

indicated client #2 attended the wound

care center weekly for treatment of his

legs. Client #2's bilateral lower legs had

edema graded +2 (slight indentation of

W 0159 All current QIDP’s will receive

training on the coordination

and monitoring of client

treatment programs. This

training will include protocols

for analyzing and compiling

collected data timelines for

completing reports on the

result. On a quarterly basis, the

QIDP facilitates a meeting with

the IDT to review progress and

needs with the team members.

The QIDP will be responsible to

see that all monitoring and

plans are current.

The Area Supervisor will

oversee that the QIDP provides

continuous integration,

coordination and monitoring of

client services by way of

monthly tracking and quarterly

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pitting edema) with discoloration on his

left shin, and the right shin with an open

area per staff #1. At 7:24 AM, staff #1

applied bacitracin (antibiotic ointment)

and gauze to client #2's right shin. At

7:48 AM, staff #1 and staff #2 ambulated

client #2 to the medication room. Client

#2 walked with a contracted gait. Staff #1

and #2 provided maximum assistance to

client #2 during the ambulation period.

Staff #1 and Staff #2 both had to hold

client #2's gait belt to guide client #2

during his period of walking. At 4:40

PM, staff #3 and #4 walked client #2 into

the home from the van. Client #2

required maximum assistance from the

staff #3 and #4. Staff #3 indicated client

#2 was difficult to move because he

stiffens up. At 5:03 PM, staff #3 and #4

walked client #2 from the living room

couch to the medication room. Staff #3

and #4 utilized a walker during the

ambulation of client #2. Client #2

required the walker and both staff #3 and

#4's assistance to ambulate to the

medication room. When inside the

medication room, client #2 stopped and

crossed his legs. Staff #3 and #4 quickly

balanced him and lowered him to the

chair so client #2 didn't fall.

Client #2's record was reviewed on

10/26/17 at 12:56 PM. Client #2's record


meetings with the

interdisciplinary team by

conducting at least a quarterly

audit of each Individual

Support Plan and following up

accordingly. The Program

Manager will conduct training

with the QIDP and Area

Supervisors as to their

responsibilities in the

coordination and monitoring of

treatment plans. The Program

Manager will be responsible for

implementing further training

or corrective measure in

stances where the

expectations for providing and

monitoring of client’s treatment

programs are not met.

This will be monitored via Site

Supervisor audits up to 5 days

a week, weekly QIDP audits,

monthly Area Supervisor

audits and twice monthly site

visits by a member of the

leadership team.





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- Client #2's Primary Care Physician

(PCP) visit dated 5/17/17 indicated client

#2 was seen due to a left hip wound. PCP

indicated a follow up was needed only if

the wound became worse.

-Client #2's Wound Care Center (WCC)

visit dated 8/23/17 indicated client #2

was seen to be treated for three separate

wounds on client #2's bilateral lower

extremities and left hip.

-Client #2's WCC visit dated 9/20/17

indicated client #2 was seen to be treated

for a left lower extremity venous ulcer

measuring 1.5 Centimeters (CM) by 1.3

CM by 0.1 CM. WCC documentation

indicated the venous ulcer was obtained

on 8/11/17.

- Client #2's WCC visit dated 9/28/17


for a left lower extremity wound which

was compression wrapped by the WCC

staff. WCC documentation indicated a

mepilex (specialized wound dressing)

was applied to client #2's left hip.



for both right and left lower extremity

wounds which were compression

wrapped with an unna boot (specialized





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compression dressing wrap). WCC

documentation indicated a mepilex was

applied to client #2's left hip for

protection.

-Client #2's Physician's Orders (PO)'s

dated 10/1/17 through 10/31/17 indicated

orders to, "Avoid crossing legs to prevent

skin breakdown." Client #2's PO's

indicated client #2 required ambulation

assistance of a walker and gait belt.

- Client #2's Health Care Plans included

plans for edema, falls, constipation,

seizure disorder, allergies, reducing the

decrease in functioning level, and

Gastroesophageal Reflux Disease

(GERD).

- Client #2's undated Health Care Plan

indicated a risk plan for falls.

-Client #2's record review did not

indicate any IDT meetings regarding

client #2's ambulation or his skin

integrity issues.

Licensed Practical Nurse (LPN) #1 and

Area Supervisor (AS) #1 were

interviewed on 10/26/17 at 2:33 PM.

LPN #1 indicated she has observed client

#2 in the home. LPN #1 indicated client

#2 has an unsteady gait. LPN #1

indicated the last time she observed him,





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he was in a wheelchair. LPN #1 indicated

client #2 has not been evaluated by PT

since 2008. LPN #1 indicated client #2

should be evaluated by specialists if need

is demonstrated. LPN #1 indicated client

#2 had been attending the WCC since

early August 2017. LPN #1 indicated he

attends the WCC weekly. AS #1

indicated the QIDP is on vacation at this

time. AS #1 indicated she oversees the

QIDP. AS #1 indicated the QIDP should

convene the IDT for changes in client

#2's status including ambulation needs or

recurrent skin integrity issues.

9-3-3(a)

483.440(c)(3)(v)

INDIVIDUAL PROGRAM PLAN

The comprehensive functional assessment

must include sensorimotor development.

W 0218

Bldg. 00

Based on observation, record review, and

interview for 1 of 3 sampled clients (#2),

the facility failed to assess client #2's

sensorimotor skills in regards to client

#2's ambulation needs and/or needs for

adaptive equipment.

Findings include:


W 0218 The facility will ensure that all

high risk plans (HRP) are

followed to ensure client

safety, the Area Supervisor and

SGL nurse will ensure training

is completed with Site

Supervisor and SGL staff on

client all consumers of the

homes high risk plans. To

ensure compliance the facility

will perform on-going audits as

followed; Site supervisor will

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to 7:51 AM, 10/25/17 from 9:12 AM to

10:14 AM, and 10/25/17 from 4:23 PM

to 5:16 PM. At 7:48 AM, staff #1 and

staff #2 ambulated client #2 to the

medication room. Client #2 walked with

a contracted gait. Staff #1 and #2

provided maximum assistance to client

#2 during the ambulation period. At 4:40

PM, staff #3 and #4 walked client #2 into

the home from the van. Client #2

required maximum assistance from the

staff #3 and #4. Staff #3 and #4 both had

to utilize the gait belt of client #2 and

provide guidance while they walked him.

Staff #3 indicated client #2 was difficult

to move because he stiffens up. At 5:03

PM, staff #3 and #4 walked client #2

from the living room couch to the

medication room. Staff #3 and #4 utilized

a walker during the ambulation of client

#2. Client #2 required the walker and

both staff #3 and #4's assistance to

ambulate to the medication room. When

inside the medication room, client #2

stopped and crossed his legs. Staff #3 and

#4 quickly balanced him and lowered

him to the chair so client #2 didn't fall.




- Client #2's undated Health Care Plan

indicated a risk plan for falls.

be responsible for

observations up to 5 times per

week, QIDP weekly, Area

Supervisors monthly and twice

monthly visits from a member

of the leadership team.





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- Client #2's most recent Physical

Therapy (PT) evaluation was completed

on 5/2008.

- Client #2's Physician Orders (PO)'s


client #2 required ambulation assistance

of a walker and gait belt at all times.

Licensed Practical Nurse (LPN) #1 was


LPN #1 indicated she has observed client

#2 in the home. LPN #1 indicated client

#2 has an unsteady gait. LPN #1

indicated the last time she observed him,

he was in a wheelchair. LPN #1 indicated

client #2 has not been evaluated by PT

since 2008. LPN #1 indicated a client #2

should be evaluated by specialists if need

is demonstrated.

9-3-4(a)

483.440(d)(1)

PROGRAM IMPLEMENTATION

As soon as the interdisciplinary team has

formulated a client's individual program plan,

each client must receive a continuous active

treatment program consisting of needed

interventions and services in sufficient

number and frequency to support the

achievement of the objectives identified in

the individual program plan.

W 0249

Bldg. 00

Based on observation, record review, and

interview for 2 of 4 sample clients (#1

W 0249 The facility will ensure that all high

risk plans (HRP) are followed to

12/15/2017 12:00:00AM





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and #2), the facility failed to ensure staff

continuously implemented client #1's

protocol regarding his seating after

feeding and client #2's treatment plan for

his skin breakdown.

Findings include:

1. Observations were conducted at the


to 7:51 AM, 10/25/17 from 9:12 AM to

10:14 AM, and 10/25/17 from 4:23 PM

to 5:16 PM. From 6:25 AM through 6:46

AM, client #1 was asleep on side on the

couch. At 6:46 AM, staff #5 wakes client

#1 for morning medication pass and

feeding through his Gastrostomy Tube

(stomach feeding tube). At 7:20 AM,

client #1 was laying flat on his side

asleep on the couch.




-Client #1's Emergency Room Discharge

Instructions dated 8/31/17 indicated,

"Keep patient semi recumbent at least 30

degrees elevation at all times." The

discharge instructions indicated this was

due to the potential of client #1 to

aspirate.


ensure client safety, the Area

Supervisor will ensure training is

completed with Site Supervisor and

SGL staff on client #1 and #2 HRP.

The facility will monitor the site to

ensure the training objective is

implemented by Site Supervisors

monitoring up to 5 times a weekly,

weekly QIDP audits, monthly Areas

supervisor audits and twice

monthly site visits from a member

of the leadership team.





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orders to keep, "Head of bed elevated 30

degrees."

2. Observations were conducted at the


to 7:51 AM, 10/25/17 from 9:12 AM to

10:14 AM, and 10/25/17 from 4:23 PM

to 5:16 PM. At 6:19 AM, client #2's

bilateral legs were crossed and wounds

were uncovered. Staff #1 indicated client

#2 attended the wound care center weekly

for treatment of his legs. Client #2's

bilateral lower legs had edema graded +2

(slightly indented pitting edema) with

discoloration on his left shin, and the

right shin with an open area per staff #1.

At 7:24 AM, staff #1 applied bacitracin

(antibiotic ointment) and gauze to client

#2's right shin.
















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on 8/11/17.
















protection.

-Client #2's PO's dated 10/1/17 through

10/31/17 indicated orders to, "Avoid

crossing legs to prevent skin breakdown."

- Client #2's review of Health Care Plans





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included plans for edema, falls,

constipation, seizure disorder, allergies,

reducing the decrease in functioning

level, and Gastroesophageal Reflux

Disease (GERD).



LPN #1 indicated she is covering the

home, and she is not normally in the

home. LPN #1 indicated client #1 should

not lay flat and after feedings client #1

should sit upright for 20 minutes. LPN #1

indicated staff should encourage client #2

to avoid crossing his legs to prevent skin

breakdown. LPN #1 indicated client #2

should have his legs wrapped as soon as

he gets up in the morning, and

unwrapped when he goes to bed at night.

LPN #1 indicated recommendations for

clients #1 and #2 from specialists should

be followed.

9-3-4(a)

483.440(d)(2)

PROGRAM IMPLEMENTATION

The facility must develop an active treatment

schedule that outlines the current active

treatment program and that is readily

available for review by relevant staff.

W 0250

Bldg. 00

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4 of 4 sample clients (#1, #2, #3, and #4),

the facility failed to create and implement

personalized Active Treatment (AT)

schedules for clients #1, #2, #3 and #4.

Findings include:



did not include a personalized AT

schedule.




schedule.




schedule.




schedule.

Area Supervisor (AS) #1 was interviewed

on 10/ 26/17 at 2:33 PM. AS #1 indicated

an AT schedule was created for the

home. AS #1 indicated clients #1, #2, #3,

and #4 all follow the same AT schedule.

AS #1 indicated clients #1, #2, #3 and #4

do not have personalized AT schedules.

structured activity calendar for

client #1,#2,#3,#4 will be

created to ensure alternative

day program active treatment

services are provided. Staff will

be trained on the newly

structured alternative day

program for each client. For

monitoring and quality

assurance active treatment

observations will be conducted

at the facility during times of

opportunity for each resident

of the facility. Eight

observations will be conducted

each week for a period of six

weeks. During these

observations, immediate

coaching will occur throughout

the observation to ensure staff

members understand how to

implement active treatment,

and the behavior plans. If after

six weeks, staff competency

has improved, the

observations will taper down to

four observations per week for

two weeks. If after two weeks,

staff competency has been

established, two observations

will be conducted per week on

an ongoing basis for

monitoring purposes. Each

observation will be

documented on a specific form

for the facility and submitted to

the Program Manager for

additional monitoring

purposes.





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9-3-4(a)

483.440(f)(2)

PROGRAM MONITORING & CHANGE

At least annually, the comprehensive

functional assessment of each client must

be reviewed by the interdisciplinary team for

relevancy and updated as needed.

W 0259

Bldg. 00


1 of 4 sample clients (client #2), the

facility failed to annually complete and

review client #2's Comprehensive

Functional Assessments (CFA's).

Findings include:



included an undated CFA.

Area Supervisor (AS) #1 was interviewed

on 10/26/17 at 2:33 PM. AS #1 indicated

CFA's should be completed upon

admission and reviewed annually. AS #1

was unable to provide documentation

client #2's CFA was reviewed annually.

9-3-4(a)

W 0259 The Comprehensive Functional

Assessment will be reviewed

by the QIPD for each of the

individuals in the home to

assure that they are accurate

and current. The CFA is to be

reviewed by the

Interdisciplinary Team at least

annually or as needs change

for an individual. The Area

Supervisor is responsible to

see that the CFA is updated

and reviewed on at least an

annual basis. The Area

Supervisor and QIDP will

receive training on the

completion and documentation

expectations in reviewing

client comprehensive

functional assessments. The

Program Manager will

implement this training.

The Program Manager will

oversee that Area Supervisor

and QIDP provide continuous

integration, coordination, and

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monitoring of client services

by way of on-going tracking

that includes annual ISP’s,

comprehensive functional

assessment reviews, and

quarterly review

documentation of client

services.

483.460(a)(3)(iv)

PHYSICIAN SERVICES

The facility must provide or obtain annual

physical examinations of each client that at a

minimum includes tuberculosis control,

appropriate to the facility's population, and in

accordance with the recommendations of

the American College of Chest Physicians or

the section on diseases of the chest of the

American Academy of Pediatrics, or both.

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1 of 4 sample clients (#4), the facility

failed to ensure client #4's annual

Tuberculosis (TB) screen was completed.

Findings include:



did not indicate a current TB screening.



LPN #1 indicated clients should have

annual TB screening. LPN #1 indicated

she was unable to locate a current TB

screen for client #4.

W 0327 The Health Services Manager

will train the program nursing

staff on the ensuring that all

components of the physical

exams are completed,

including but not limited to TB

tests being completed

annually. The Program Nurse

will ensure the completion of

the TB test for client #4.

Ongoing, the Health Services

Manager will complete random

quarterly audits to ensure that

all proper medical care is

followed up on and

documented correctly.

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OMB NO. 0938-0391




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9-3-6(a)

483.460(c)

NURSING SERVICES

The facility must provide clients with nursing

services in accordance with their needs.

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Based on observation, record review and

interview for 1 of 4 sample clients (#2),

the facility's nursing services failed to

develop and implement a Skin Integrity

Protocol for client #2 after recurrent skin

breakdown.

Findings include:



to 7:51 AM, 10/25/17 from 9:12 AM to

10:14 AM, and 10/25/17 from 4:23 PM

to 5:16 PM. At 6:19 AM, staff #1

indicated client #2 attended the wound

care center weekly for treatment of his

legs. Client #2's bilateral lower legs had

edema graded +2 (slightly indented

pitting edema) with discoloration on his

left shin, and the right shin with an open

area per staff #1. At 7:24 AM, staff #1

applied bacitracin (antibiotic ointment)

and gauze to client #2's right shin.






staff to ensure they it is their

responsibility to develop and

ensure implementation of

health risk plans for any

identified health issues. This

will include ensuring there are

adequate documentation

systems in place for staff to

record needed information

such as check of skin integrity.

The nurse will ensure the skin

integrity risk plan for client #2

includes a mechanism for

recording changes in his skin

integrity. There will be a

specific document provided for

staff to document the status of

his skin around the effected

site. These assessments will

be documented per agency

procedure. Facility nursing

staff will consult or seek

additional medical consultation

as needed. The facility nurse

will retrain all staff in the

facility on the risk plans for

client #2, including the need to

report changes in skin

integrity. Evidence of this

training will be provided to the

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OMB NO. 0938-0391




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(X3) DATE SURVEY

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on 8/11/17.













Health Services Manager





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protection.



orders to, "Avoid crossing legs to prevent

skin breakdown."

- Client #2's Health Care Plans (HCP's)

included plans for edema, falls,

constipation, seizure disorder, allergies,

reducing the decrease in functioning

level, and Gastroesophageal Reflux

Disease (GERD). Client #2's HCP's did

not include a plan for skin integrity.



LPN #1 indicated client #2 did not have a

skin integrity protocol. LPN #1 indicated

client #2 should have a skin integrity

protocol based on his history of skin

breakdown.

9-3-6(a)

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

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which must be on a quarterly or more

frequent basis depending on client need.


1 of 4 sample clients (#2), the facility's

nursing services failed to ensure client #2

was examined on a quarterly basis.

Findings include:



review indicated quarterly nursing

reviews on 2/10/17 and 10/23/17. Client

#2's quarterly nursing review did not

indicate a second quarter (April through

June 2017) nursing review.



LPN #1 indicated client #2 should be

evaluated on a quarterly basis by nursing

staff. LPN #1 indicated client #2 had not

been evaluated during the second quarter.

9-3-6(a)



staff that includes ensuring

that reviews of consumers

health statues is completed

and documented a minimum of

quarterly.

Ongoing, Program Nurse will

ensure that reviews of all

consumers’ health status are

completed a minimum of

quarterly. Health Services

Manager will complete an audit

of a random sample of

consumers quarterly to ensure

that all reports are being

completed within designated

time frames.

12/15/2017 12:00:00AM

483.470(g)(2)

SPACE AND EQUIPMENT

The facility must furnish, maintain in good

repair, and teach clients to use and to make

informed choices about the use of dentures,

eyeglasses, hearing and other

communications aids, braces, and other

devices identified by the interdisciplinary

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12/15/2017PRINTED:

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team as needed by the client.

Based on observation, record review and

interview for 1 of 6 clients with adaptive

equipment (#1), the facility failed to

ensure client #1 used his helmet and gait

belt.

Findings include:



to 7:51 AM, 10/25/17 from 9:12 AM to

10:14 AM, and 10/25/17 from 4:23 PM

to 5:16 PM. During the observations,

client #1 did not wear his helmet or gait

belt. Client #1 was not prompted by staff

to wear his adaptive equipment during

the observations.


10/26/17 at 3:00 PM. Client #1's

Physician's Orders dated 10/1/17 through

10/31/17 indicated client #1's adaptive

equipment was a helmet and gait belt due

to the diagnosis of microcephaly and

cerebral palsy.



LPN #1 indicated client #1 has a helmet

and gait belt. LPN #1 indicated client #1

should wear his adaptive equipment at all

time and staff should encourage client #1

to use his adaptive equipment.

W 0436 A formal goal will be developed

for Client#1, #2 and #3 to

encourage them appropriate

choices regarding their

adaptive equipment. All staff

will be trained on the

implementation of this goal.

QIDP will receive retraining to

include ensuring that all

consumers have goals in place

to encourage them to use their

adaptive equipment as directed

and how to maintain it in good

working order. Ongoing, QIDP

will ensure that goals and

objectives are developed for

consumers that have

challenges with using their

adaptive equipment as directed

and/or maintaining it in good

working order. These formal

goals will be reviewed for

progress a minimum of

quarterly and revised as

necessary to adapt to progress

achieved.

12/15/2017 12:00:00AM





12/15/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


BRAZIL, IN 47834

15G592 11/02/2017


107 A VILLA CT

00

9-3-7(a)


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