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(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
W 0000
Bldg. 00
This visit was for the investigation of
complaint number #IN00204044.
Complaint #IN00204044: Substantiated,
federal/state deficiencies related to the
allegation are cited at W104, W149,
W154, W186, W249, and W436.
Dates of Survey: 8/8, 8/9, 8/10, 8/11, and
8/12/16.
Provider Number: 15G534
AIM Number: 100245410
Facility Number: 001048
The following federal deficiencies also
reflect state findings in accordance with
460 IAC 9.
Quality review of this report completed
8/23/16 by #09182.
W 0000 Corrective Actions are stated
under each regulation tag entry
483.410(a)(1)
GOVERNING BODY
The governing body must exercise general
policy, budget, and operating direction over
the facility.
W 0104
Bldg. 00
Based on observation, record review, and
interview, for 3 of 3 sample clients
(clients A, B, and C) and 4 additional
clients (clients D, E, F, and G), the
governing body failed to exercise
W 0104 What corrective action (S) will be
accomplished for these residents
found to have been affected by
the deficient practice?
1. On 9/1/16, the Day Services
Team Leader will rearrange the
furniture in the current day
09/12/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete
Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that
other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to
continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
_____________________________________________________________________________________________________Event ID: CVCY11 Facility ID: 001048
TITLE
If continuation sheet Page 1 of 28
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
operating direction over the facility to
ensure clients at the facility owned day
services had sufficient space to provide
day services and to ensure maintenance
and repairs were completed at the group
home for client G's broken bed frame and
the worn and stained carpet for clients A,
B, C, D, E, F, and G.
Findings include:
1. On 8/9/16 from 9:00am until 1:20pm,
observation and interviews were
conducted at the facility owned day
program at the agency. During the
observation period, clients C and F were
2 of 15 clients sitting in one room at the
day services along with five long style
conference length tables. From 9:00am
until 1:20pm, clients C and F sat at tables
in one room and Workshop Staff (WKS)
#1 stated the room was "small" for fifteen
clients and four staff in the same room.
WKS #1 indicated the room had five
conference length tables and each table
was "over nine feet long and three feet
wide." WKS #1 stated clients A, B, C,
D, E, F, and G "all" attended the same
room at the facility owned day services.
WKS #1 stated clients who were
dependent on staff for transfers to/from
their wheelchairs and for client G who
needed to use a urinal, those clients were
"to use" the back storage room for
services’ room, so that there is
ample room for clients and staff
to move about the room. The new
room design has removed the
conference room tables and now
includes a variety of different
sized tables, for individual and
small group facility use. Clients
can easily walk around the room
or use their wheelchair and
walkers with ease throughout the
room.
2. On 9/1/16, the Day Services
Team leader will post a room
schedule, so that clients may be
divided into small groups and
may utilize the two other day
services rooms during the day.
On September 12, 2016 day
services will move to a new larger
facility.
3. On 8/30/16 Pathfinder’s
Property Manager inspected the
carpets and came to the
conclusion that the carpet in the
living room and hallways was only
a few years old and rather than
needing replaced, needed a
professional cleaning.
Professional carpet cleaning
throughout the entire house will
take place on 9/9/16. Quarterly
carpet cleanings will take place
starting 9/9/16 and monitored by
the Assistant Director.
4. On 9/1/16 the storage room
usage for the toilet chair and use
of the toilet chair was
discontinued. The client utilizing
the chair is currently attending a
different day services. New
handicapped accessible
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 2 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
toileting. At 9:30am, WKS Supervisor
showed the surveyor the back storage
room at the day services. When WKS #1
unlocked the storage room with a key,
stacks of bags, boxes, a mop bucket with
brown water, a portable toilet, and loose
items were visible inside the room. WKS
#1 indicated the portable toilet had urine
located in the bowl of the portable toilet
from the previous day and should have
been cleaned out after every use. WKS
#1 indicated the storage closet had no
running water and no handwashing area
for clients to wash their hands. At
10:20am, the WKS Supervisor stated the
agency "knew the room for day services
was too small" for clients and the agency
was waiting for their new building to
finish its remodel. The WKS Supervisor
indicated the agency had been waiting for
completion of the remodel of the other
location since before March, 2016.
On 8/11/16 at 9:57am, an interview with
the Community Supports Assistant
Director (CSAD) was conducted. The
CSAD indicated clients A, B, C, D, E, F,
and G attended the facility owned day
services during the weekdays. The
CSAD stated clients A, B, C, D, E, F, and
G attended the facility owned "day
services a few days a week" and attended
a second agency "contracted" day
services "a few days a week." The CSAD
bathrooms will be available for all
clients at the new facility starting
9/12/16.
How will other residents having
the potential to be affected by the
same deficient practice be
identified and what corrective
action will take place?
1 The Day Services is moving to
a new facility on September 12,
2016. This facility’s day services
rooms are much larger, allowing
for more room per person. If the
day services adds more clients to
its programs, room use will be
evaluated by the Day Services
Team Leader and the Assistant
Director and room use schedules
will be adjusted according to the
number of participants.
2. A cleaning contract will be
made with the professional carpet
cleaners to clean the carpets
every quarter year. This will
assure that clients’ carpets will be
cleaned and maintained
throughout the year.
3. The Day Services is moving to
a new facility on September 12,
2016. This facility’s day services
will have regular and
handicapped accessible toilets.
The use of a storage room and
toilet chair will no longer be an
issue. If a toilet chair is preferred
by a client, then the Day Services
Team Leader will train staff on
the proper use and cleaning of
the toilet chair.
What measures will be put into
place or what systemic changes
you will make to ensure that the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 3 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
indicated the agency had the potential to
have eighteen (18) or more clients from
the agency operated group homes and
additional clients from the community in
the same room at the agency for day
services at any one time. The CSAD
stated the single room for the facility
owned day services "was small" and a
"temporary" location because the agency
had secured a building at a different
location which was being remodeled.
The CSAD indicated five conference
long tables were in the same room with
clients attending the day services at the
agency location. The CSAD stated the
new location "was not ready" for use and
no completion date was available.
On 8/12/16 at 3:28am, the CSAD stated
the room for day services at the agency
was "twenty-three feet wide by
twenty-three feet, ten inches long."
2. Observations and interviews were
conducted at the group home on 8/8/16
from 4:15pm until 5:55pm. Clients A, B,
C, D, E, F, and G were observed at the
group home. During the observation
period the following needed repairs were
observed with the Residential Manager
(RM):
-On 8/8/16 at 4:30pm, the RM stated 2 of
2 hallways and clients A, B, and C's
deficient practices does not
recur?1- The Day Services Team
Leader will post a room use
schedule daily for staff to utilize
and will monitor room use daily to
assure that the clients coming to
day services are not crowded into
one room.
2. The Assistant Director will do
quarterly building inspections,
checking the condition and
cleanliness of the carpets. If the
building inspection reports show a
need for replacement, repair or
cleaning of carpets, the Assistant
Director will make arrangements
for replacement, repairs or
cleaning to take place.
3. The Day Services Staff were
trained on 8/15/16 on the proper
cleaning of the toilet chair. The
storage room is no longer being
used for toilet use.
How will the corrective actions will
be monitored to ensure the
deficient practice will not recur,
what quality assurance program
will be put into place?1- The Day
Services Team Leader will review
the room use schedule each
morning with the day services
staff. Each staff will be assigned
to lead a small group activity and
each group assigned a room.
2. A Quarterly Carpet Cleaning
Schedule for will be utilized by the
group home managers and
monitored by the Assistant
Director. A carpet cleaning is
scheduled for 9/9/16.
3. If a toilet chair is preferred by a
client, then the Day Services
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 4 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
bedroom had "worn and stained" floor
carpet. The RM indicated the group
home was in the process of obtaining
bids for the carpet throughout the group
home to be replaced. The RM stated the
carpet was "discolored, stained," and was
worn.
-The RM indicated client G's bed frame
to support his mattress was broken and
needed to be replaced.
On 8/11/16 at 9:57am, an interview with
the Community Supports Assistant
Director (CSAD) was conducted. The
CSAD indicated clients A, B, C, D, E, F,
and G lived in the group home and the
carpets were stained, worn, and needed to
be replaced. The CSAD indicated she
was not aware of client G's bed frame
being broken.
This federal tag relates to complaint
#IN00204044.
9-3-1(a)
Team Leader will train staff on
the proper use for that client and
will monitor the cleaning of the
toilet chair, which will occur after
each use. The Day Services is
moving to a new facility on
September 12, 2016. This
facility’s day services will have
regular and handicapped
accessible toilets. The use of a
storage room and toilet chair at
the current day services location
is no longer be an issue, as the
client currently is not attending
Pathfinder’s day services.
What is the date by which the
systemic changes will be
completed?9/12/16
483.420(d)(1)
STAFF TREATMENT OF CLIENTS
The facility must develop and implement
written policies and procedures that prohibit
mistreatment, neglect or abuse of the client.
W 0149
Bldg. 00
Based on observation, interview, and
record review, for 1 of 3 sample clients
W 0149 What corrective action(s) will be
accomplished for these residents
found to have been affected by
09/02/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 5 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
(client A) who had staff supervision
needs related to her choking risk and
removing items from the trash, the
facility neglected to implement its
Abuse/Neglect/Mistreatment policy to
thoroughly investigate and to ensure
sufficient numbers of facility staff
supervised client A according to her
identified need.
Findings include:
On 8/8/16 at 2:25pm, the facility's BDDS
(Bureau of Developmental Disabilities
Services) reports were reviewed for the
period from 5/1/16 through 8/8/16 and
indicated the following for client A:
-An 8/5/16 BDDS report for an incident
on 8/4/16 at 11:15pm, indicated client A
"was sweeping in the kitchen, while staff
went into the bathroom to assist another
client. [Client A] went into the garbage
can and ate Watermelon that was thrown
away and ended up choking on it. No
hands on intervention was used or needed
by staff. [Client A] was taken to the ER
(Emergency Room) by ambulance for
choking incident, due to possibility of
aspiration." Client A was discharged
around 1:15am on 8/5/16. The report
indicated client A "will not be left in the
kitchen and living room area with any
food on the countertop or in the garbage
can without staff in sight."
the deficient practice?
1.The residential Manager will
complete a weekly staffing
schedule that will have no less
than two staff scheduled to work
during waking hours.
2.The Assistant Director will
review staffing schedules weekly.
3.On 9/2/16 the nurse trained
staff on Client A’s choking
protocol which now has two staff
on duty during waking hours at all
times and someone observing
Client A at all times.
How will other residents having
the potential to be affected by the
same deficient practice be
identified and what corrective
action will take place?
1.QDDP will identify how many
staff are needed for each client.
2.The Residential Manager will
complete a weekly staffing
schedule that will have no less
than two staff scheduled to work
during waking hours.
3.The Assistant Director will
review staffing schedules weekly.
4.The nurse or QDDP will
review choking protocols with the
dietitian at each dietitian review
visit or before if needed.
What measures will be put into
place or what systemic changes
will you make to ensure that
deficient practices do not recur?
1.The Assistance Director will
review staffing schedules weekly
(Residential Managers must turn
in staffing schedules a week
ahead) to assure that two staff
are scheduled during waking
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 6 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
On 8/8/16 from 4:15pm until 5:55pm,
client A was observed at the group home.
From 4:15pm until 5:55pm, client A and
six (6) additional clients were observed at
the group home with two facility staff.
Client A's record was reviewed on 8/9/16
at 10:30am. Client A's 1/12/16 ISP
(Individual Support Plan) and 2/1/16 BSP
(Behavior Support Plan) indicated client
A "There are dining plan change. Seen
Speech therapist for eating concerns (sic).
Risk plan updated with prompts
increased (sic). [Client A] is to put
silverware down between bites. She
needs to slow down with eating. She
needs to chew more thoroughly and take
drinks in between bites. [Client A] needs
to be watched when she is taking out the
trash to make sure she is not getting into
it..." Client A's 2/2/2015
"Choking/Dining Protocol" indicated
client A was at risk to choke, required
staff supervision when around food
and/or the kitchen, and "...Preventative
supports and strategies to manage risk:
Staff will sit with [client A] at the dinner
table during meals...When [client A] is in
the main living areas of the home, she
should be carefully monitored by staff as
she will go into the kitchen and pantry
area and forage for snacks. This presents
the opportunity for choking...When
hours.
2.The nurse will update choking
protocols as needed and train
staff whenever changes are
made.
How will corrective actions be
monitored to ensure the deficient
practice will not recur, i.e. what
quality assurance program will be
put into place?
1.The Assistant Director will
monitor staffing schedules for
each week to assure that two
staff are scheduled during all
waking hours.
2.The nurse will review any
incidents of choking to check if
choking protocols were followed.
If needed she will retrain staff on
dining plans. She will consult with
the dietitian if dining plans need
changes made to them.
What is the date by which the
systemic changes will be
completed?
9/2/16
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 7 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
[client A] is taking out any trash, staff
will monitor her by walking with her to
the dumpster and watching her place the
tied trash bag inside the dumpster. This
should help deter [client A] from
foraging for food in the trash and
possible choking on that food."
On 8/9/16 at 11:00am, an interview with
the QIDP (Qualified Intellectual
Disabilities Professional) was conducted.
The QIDP stated the facility was to have
"at least" two staff "always" on duty. The
QIDP indicated on 8/4/16 there were two
staff on duty at the group home, the
second staff had left the facility, and the
remaining one staff person did not know
she was alone in the group home at the
time. The QIDP stated the lone staff
person was in the bathroom assisting
another client when client A had been
sweeping the kitchen, got into the trash,
and choked on the watermelon when
client A was left unsupervised by the
staff. The QIDP stated the incident took
place at "8:15pm not 11:15pm" and
indicated she put in the wrong numbers
by error when submitting the report. The
QIDP indicated staff neglected to
supervise client A according to her
identified needs on 8/4/16. The QIDP
indicated the facility neglected to ensure
there were sufficient staff on duty to
supervise client A on 8/4/16. The QIDP
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 8 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
indicated the facility followed the BDDS
reporting and investigating guidelines for
abuse, neglect, and/or mistreatment. The
QIDP indicated she interviewed the staff
on duty at the group home, stated she
"discovered" one staff was left alone to
supervise seven clients, and did not
document a written investigation into the
8/4/16 incident.
On 8/9/16 at 11:30am, the QIDP
provided an 8/4/16 at 11:00pm "e-mail
Re: [client A]...had a choking incident on
Thursday that sent her to the hospital.
She got watermelon out of the trash can
when the house was down to one staff
and that staff was assisting another client
in the bathroom...Never leave [client A]
out of sight with access to food in the
garbage or on the counter top. She has a
history of getting food out of the
garbage...I also would not like to see staff
go down to one until the clients have all
went to bed."
On 8/11/16 at 9:57am, an interview with
the CSC (Community Supports
Coordinator) was conducted. The CSC
indicated the facility followed the BDDS
reporting guidelines and the agency's
policy and procedures for abuse, neglect,
and/or mistreatment to protect clients
from abuse, neglect, and/or mistreatment.
The CSC stated client A "should not be
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 9 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
left alone" around food. The CSC
indicated it was staff neglect for the
failure to provide staff supervision while
client A did not have facility staff to
supervise her one on one in the kitchen.
On 8/8/16 at 2:15pm, a review of the
facility's records indicated the facility's
undated "Handling client Abuse, Neglect,
and Injuries of Unknown Origin & (and)
BDDS Incident Reporting" policy which
indicated "It is Pathfinder Services, Inc.
policy to provide a service where clients
are free from abuse, neglect, or
exploitation. In the event that any of
these conditions are suspected, an
investigation will immediately be
conducted...Any alleged, suspected, or
actual abuse-physical, sexual, emotional,
or domestic improper treatment,
neglect-failure to provide appropriate
care, environment, food, medical care, or
supervision, exploitation or any other
mistreatment must be immediately
reported...."
This federal tag relates to complaint
#IN00204044.
9-3-2(a)
483.420(d)(3)
STAFF TREATMENT OF CLIENTS
W 0154
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 10 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
The facility must have evidence that all
alleged violations are thoroughly
investigated.
Bldg. 00
Based on observation, interview, and
record review, for 1 of 1 BDDS (Bureau
of Developmental Disabilities Services)
reports reviewed for 1 of 3 sample clients
(client A), the facility failed to implement
its Abuse/Neglect/Mistreatment policy to
thoroughly investigate client A's choking
incident at the group home.
Findings include:
On 8/8/16 at 2:25pm, the facility's BDDS
(Bureau of Developmental Disabilities
Services) reports were reviewed for the
period from 5/1/16 through 8/8/16 and
indicated the following for client A:
-An 8/5/16 BDDS report for an incident
on 8/4/16 at 11:15pm, indicated client A
"was sweeping in the kitchen, while staff
went into the bathroom to assist another
client. [Client A] went into the garbage
can and ate Watermelon (sic) that was
thrown away and ended up choking on it.
No hands on intervention was used or
needed by staff. [Client A] was taken to
the ER (Emergency Room) by ambulance
for choking incident, due to possibility of
aspiration." Client A was discharged
around 1:15am on 8/5/16. The report
indicated client A "will not be left in the
kitchen and living room area with any
W 0154 What corrective action(s) will be
accomplished for these residents
found to have been affected by
the deficient practice?
1.The residential Manager will
complete a weekly staffing
schedule that will have no less
than two staff scheduled to work
during waking hours.
2.The Assistant Director will
review staffing schedules weekly.
3.On 9/2/16 the nurse trained
staff on Client A’s choking
protocol which now has two staff
on duty during waking hours at all
times and someone observing
Client A at all times.
How will other residents having
the potential to be affected by the
same deficient practice be
identified and what corrective
action will take place?
1.QDDP will identify how many
staff are needed for each client.
2.The residential Manager will
complete a weekly staffing
schedule that will have no less
than two staff scheduled to work
during waking hours.
3.The Assistant Director will
review staffing schedules weekly.
4.The nurse or QDDP will
review choking protocols with the
dietitian at each dietitian review
visit or before if needed.
What measures will be put into
place or what systemic changes
will you make to ensure that
deficient practices o not recur?
09/02/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 11 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
food on the countertop or in the garbage
can without staff in sight."
On 8/8/16 from 4:15pm until 5:55pm,
client A was observed at the group home.
From 4:15pm until 5:55pm, client A and
six (6) additional clients were observed at
the group home with two facility staff.
On 8/9/16 at 11:00am, an interview with
the QIDP (Qualified Intellectual
Disabilities Professional) was conducted.
The QIDP stated the facility was to have
"at least" two staff "always" on duty. The
QIDP indicated on 8/4/16 there were two
staff on duty at the group home, the
second staff had left the facility, and the
remaining one staff person did not know
she was alone in the group home at the
time. The QIDP stated the lone staff
person was in the bathroom assisting
another client when client A had been
sweeping the kitchen, got into the trash,
and choked on the watermelon when
client A was left unsupervised by the
staff. The QIDP stated the incident took
place at "8:15pm not 11:15pm" and
indicated she put in the wrong numbers
by error when submitting the report. The
QIDP indicated the facility failed to
ensure there were sufficient staff on duty
to supervise client A on 8/4/16. The
QIDP indicated the facility followed the
BDDS reporting and investigating
1.The Assistance Director will
review staffing schedules weekly
(Residential Managers must turn
in staffing schedules a week
ahead) to assure that two staff
are scheduled during waking
hours.
2.The nurse will update choking
protocols as needed and train
staff whenever changes are
made.
How will corrective actions be
monitored to ensure the deficient
practice will not recur, i.e. what
quality assurance program will be
put into place?
1.The Assistant Director will
monitor staffing schedules for
each week to assure that two
staff are scheduled during all
waking hours.
2.The nurse will review any
incidents of choking to check if
choking protocols were followed.
If needed she will retrain staff on
dining plans. She will consult with
the dietitian if dining plans need
changes made to them.
What is the date by which the
systemic changes will be
completed?
9/2/16
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 12 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
guidelines for abuse, neglect, and/or
mistreatment. The QIDP indicated she
interviewed the staff on duty at the group
home, stated she "discovered" one staff
was left alone to supervise seven clients,
and did not document a written
investigation into client A's 8/4/16
incident.
On 8/9/16 at 11:30am, the QIDP
provided a 8/4/16 at 11:00pm "e-mail Re:
[client A]...had a choking incident on
Thursday that sent her to the hospital.
She got Watermelon (sic) out of the trash
can when the house was down to one
staff and that staff was assisting another
client in the bathroom...Never leave
[client A] out of sight with access to food
in the garbage or on the counter top. She
has a history of getting food out of the
garbage...I also would not like to see staff
go down to one until the clients have all
went to bed."
On 8/11/16 at 9:57am, an interview with
the CSC (Community Supports
Coordinator) was conducted. The CSC
indicated the facility followed the BDDS
reporting guidelines and the agency's
policy and procedures for abuse, neglect,
and/or mistreatment to protect clients
from abuse, neglect, and/or mistreatment.
The CSC stated client A "should not be
left alone" around food and no formal
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 13 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
investigation was available for review.
The CSC indicated it was staff neglect
for the failure to provide staff supervision
while client A did not have facility staff
to supervise her one on one in the
kitchen.
This federal tag relates to complaint
#IN00204044.
9-3-2(a)
483.430(d)(1-2)
DIRECT CARE STAFF
The facility must provide sufficient direct
care staff to manage and supervise clients in
accordance with their individual program
plans.
Direct care staff are defined as the present
on-duty staff calculated over all shifts in a
24-hour period for each defined residential
living unit.
W 0186
Bldg. 00
Based on observation, interview, and
record review, for 1 of 3 sampled clients
(client A) who had staff supervision
needs related to her choking risk and
removing items from the trash, the
facility failed to ensure sufficient
numbers of facility staff supervised client
A according to her identified need.
Findings include:
On 8/8/16 at 2:25pm, the facility's BDDS
W 0186 What corrective action(s) will be
accomplished for these residents
found to have been affected by
the deficient practice?
1.The residential Manager will
complete a weekly staffing
schedule that will have no less
than two staff scheduled to work
during waking hours.
2.The Assistant Director will
review staffing schedules weekly.
3.On 9/2/16 the nurse trained
staff on Client A’s choking
protocol which now has two staff
on duty during waking hours at all
09/02/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 14 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
(Bureau of Developmental Disabilities
Services) reports were reviewed for the
period from 5/1/16 through 8/8/16 and
indicated the following for client A:
-An 8/5/16 BDDS report for an incident
on 8/4/16 at 11:15pm, indicated client A
"was sweeping in the kitchen, while staff
went into the bathroom to assist another
client. [Client A] went into the garbage
can and ate Watermelon (sic) that was
thrown away and ended up choking on it.
No hands on intervention was used or
needed by staff. [Client A] was taken to
the ER (Emergency Room) by ambulance
for choking incident, due to possibility of
aspiration." Client A was discharged
around 1:15am on 8/5/16. The report
indicated client A "will not be left in the
kitchen and living room area with any
food on the countertop or in the garbage
can without staff in sight."
On 8/8/16 from 4:15pm until 5:55pm,
client A was observed at the group home.
From 4:15pm until 5:55pm, client A and
six (6) additional clients were observed at
the group home with two facility staff.
Client A's record was reviewed on 8/9/16
at 10:30am. Client A's 1/12/16 ISP
(Individual Support Plan) and 2/1/16 BSP
(Behavior Support Plan) indicated for
client A "There are dining plan change.
Seen Speech therapist for eating concerns
times and someone observing
Client A at all times.
How will other residents having
the potential to be affected by the
same deficient practice be
identified and what corrective
action will take place?
1.QDDP will identify how many
staff are needed for each client.
2.The residential Manager will
complete a weekly staffing
schedule that will have no less
than two staff scheduled to work
during waking hours.
3.The Assistant Director will
review staffing schedules weekly.
4.The nurse or QDDP will
review choking protocols with the
dietitian at each dietitian review
visit or before if needed.
What measures will be put into
place or what systemic changes
will you make to ensure that
deficient practices o not recur?
1.The Assistance Director will
review staffing schedules weekly
(Residential Managers must turn
in staffing schedules a week
ahead) to assure that two staff
are scheduled during waking
hours.
2.The nurse will update choking
protocols as needed and train
staff whenever changes are
made.
How will corrective actions be
monitored to ensure the deficient
practice will not recur, i.e. what
quality assurance program will be
put into place?
1.The Assistant Director will
monitor staffing schedules for
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 15 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
(sic). Risk plan updated with prompts
increased (sic). [Client A] is to put
silverware down between bites. She
needs to slow down with eating. She
needs to chew more thoroughly and take
drinks in between bites. [Client A] needs
to be watched when she is taking out the
trash to make sure she is not getting into
it..." Client A's 2/2/2015
"Choking/Dining Protocol" indicated
client A was at risk to choke, required
staff supervision when around food
and/or the kitchen, and "...Preventative
supports and strategies to manage risk:
Staff will sit with [client A] at the dinner
table during meals...When [client A] is in
the main living areas of the home, she
should be carefully monitored by staff as
she will go into the kitchen and pantry
area and forage for snacks. This presents
the opportunity for choking...When
[client A] is taking out any trash, staff
will monitor her by walking with her to
the dumpster and watching her place the
tied trash bag inside the dumpster. This
should help deter [client A] from
foraging for food in the trash and
possible choking on that food."
On 8/9/16 at 11:00am, an interview with
the QIDP (Qualified Intellectual
Disabilities Professional) was conducted.
The QIDP stated the facility was to have
"at least" two staff "always" on duty. The
each week to assure that two
staff are scheduled during all
waking hours.
2.The nurse will review any
incidents of choking to check if
choking protocols were followed.
If needed she will retrain staff on
dining plans. She will consult with
the dietitian if dining plans need
changes made to them.
What is the date by which the
systemic changes will be
completed?
9/2/16
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 16 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
QIDP indicated on 8/4/16 there were two
staff on duty at the group home, the
second staff had left the facility, and the
remaining one staff person did not know
she was alone in the group home at the
time. The QIDP stated the lone staff
person was in the bathroom assisting
another client when client A had been
sweeping the kitchen, got into the trash,
and choked on the watermelon when
client A was left unsupervised by the
staff. The QIDP stated the incident took
place at "8:15pm not 11:15pm" and
indicated she put in the wrong numbers
by error when submitting the report. The
QIDP indicated staff neglected to
supervise client A according to her
identified needs on 8/4/16. The QIDP
indicated the facility failed to ensure
there were sufficient staff on duty to
supervise client A on 8/4/16.
On 8/9/16 at 11:30am, the QIDP
provided a 8/4/16 at 11:00pm "e-mail Re:
[client A]...had a choking incident on
Thursday that sent her to the hospital.
She got Watermelon (sic) out of the trash
can when the house was down to one
staff and that staff was assisting another
client in the bathroom...Never leave
[client A] out of sight with access to food
in the garbage or on the counter top. She
has a history of getting food out of the
garbage...I also would not like to see staff
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 17 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
go down to one until the clients have all
went to bed."
On 8/11/16 at 9:57am, an interview with
the CSC (Community Supports
Coordinator) was conducted. The CSC
stated client A "should not be left alone"
around food. The CSC indicated it was
staff neglect for the failure to provide
staff supervision while client A did not
have facility staff available to supervise
her one on one in the kitchen. The CSC
indicated two facility staff should have
been on duty at the group home when
clients were awake.
This federal tag relates to complaint
#IN00204044.
9-3-3(a)
483.440(d)(1)
PROGRAM IMPLEMENTATION
As soon as the interdisciplinary team has
formulated a client's individual program plan,
each client must receive a continuous active
treatment program consisting of needed
interventions and services in sufficient
number and frequency to support the
achievement of the objectives identified in
the individual program plan.
W 0249
Bldg. 00
Based on observation, interview, and
record review, for 1 of 3 sample clients
(client A) who had staff supervision
needs related to her choking risk and
W 0249 What corrective action(s) will be
accomplished for these residents
found to have been affected by
the deficient practice?
09/02/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 18 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
removing items from the trash, the
facility failed to implement client A's ISP
(Individual Support Plan) and BSP
(Behavior Support Plan) to ensure facility
staff supervised client A according to her
identified need.
Findings include:
On 8/8/16 at 2:25pm, the facility's BDDS
(Bureau of Developmental Disabilities
Services) reports were reviewed for the
period from 5/1/16 through 8/8/16 and
indicated the following for client A:
-An 8/5/16 BDDS report for an incident
on 8/4/16 at 11:15pm, indicated client A
"was sweeping in the kitchen, while staff
went into the bathroom to assist another
client. [Client A] went into the garbage
can and ate Watermelon (sic) that was
thrown away and ended up choking on it.
No hands on intervention was used or
needed by staff. [Client A] was taken to
the ER (Emergency Room) by ambulance
for choking incident, due to possibility of
aspiration." Client A was discharged
around 1:15am on 8/5/16. The report
indicated client A "will not be left in the
kitchen and living room area with any
food on the countertop or in the garbage
can without staff in sight."
On 8/8/16 from 4:15pm until 5:55pm,
client A was observed at the group home.
1.The QDDP will train staff on
Client's A ISP & BSP,
emphasizing implementation of
goals and methods during formal
and informal opportunities.
2.The residential Manager will
complete a weekly staffing
schedule that will have no less
than two staff scheduled to work
during waking hours.
3.The Assistant Director will
review staffing schedules weekly.
4.On 9/2/16 the nurse trained
staff on Client A’s choking
protocol which now has two staff
on duty during waking hours at all
times and someone observing
Client A at all times.
How will other residents having
the potential to be affected by the
same deficient practice be
identified and what corrective
action will take place?
1.The QDDP will monitor all
clients ISP & BMP goals and
staff's implementation of those
goals through monthly reviews of
goal progress and required in
house observations of staff
working with clients. Immediate
training of staff will take place if
deficient practices are observed.
2.QDDP will identify how many
staff are needed for each client.
3.The residential Manager will
complete a weekly staffing
schedule that will have no less
than two staff scheduled to work
during waking hours.
4.The Assistant Director will
review staffing schedules weekly.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 19 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
From 4:15pm until 5:55pm, client A and
six (6) additional clients were observed at
the group home with two facility staff.
Client A's record was reviewed on 8/9/16
at 10:30am. Client A's 1/12/16 ISP
(Individual Support Plan) and 2/1/16 BSP
(Behavior Support Plan) indicated for
client A "There are dining plan change
(sic). Seen Speech therapist for eating
concerns (sic). Risk plan updated with
prompts increased (sic). [Client A] is to
put silverware down between bites. She
needs to slow down with eating. She
needs to chew more thoroughly and take
drinks in between bites. [Client A] needs
to be watched when she is taking out the
trash to make sure she is not getting into
it..." Client A's 2/2/2015
"Choking/Dining Protocol" indicated
client A was at risk to choke, required
staff supervision when around food
and/or the kitchen, and "...Preventative
supports and strategies to manage risk:
Staff will sit with [client A] at the dinner
table during meals...When [client A] is in
the main living areas of the home, she
should be carefully monitored by staff as
she will go into the kitchen and pantry
area and forage for snacks. This presents
the opportunity for choking...When
[client A] is taking out any trash, staff
will monitor her by walking with her to
the dumpster and watching her place the
5.The nurse or QDDP will
review choking protocols with the
dietitian at each dietitian review
visit or before if needed.
What measures will be put into
place or what systemic changes
will you make to ensure that
deficient practices o not recur?
1.The QDDP will monitor all
clients' ISP & BMP goals and
staff's implementation of those
goals through monthly reviews of
goal progress and required in
house observations of staff
working with clients. Observations
will always include observing
clients during meals.
2.The Assistance Director will
review staffing schedules weekly
(Residential Managers must turn
in staffing schedules a week
ahead) to assure that two staff
are scheduled during waking
hours.
3.The nurse will update choking
protocols as needed and train
staff whenever changes are
made.
How will corrective actions be
monitored to ensure the deficient
practice will not recur, i.e. what
quality assurance program will be
put into place?
1.The QDDP will review ISP
and BMP goals and progress
monthly and during required in
house observations. The QDDP
will immediately address through
training of staff, any deficient
practices observed at reviews or
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 20 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
tied trash bag inside the dumpster. This
should help deter [client A] from
foraging for food in the trash and
possible choking on that food."
On 8/9/16 at 11:00am, an interview with
the QIDP (Qualified Intellectual
Disabilities Professional) was conducted.
The QIDP stated the facility was to have
"at least" two staff "always" on duty. The
QIDP indicated on 8/4/16 there were two
staff on duty at the group home, the
second staff had left the facility, and the
remaining one staff person did not know
she was alone in the group home at the
time. The QIDP stated the lone staff
person was in the bathroom assisting
another client when client A had been
sweeping the kitchen, got into the trash,
and choked on the watermelon when
client A was left unsupervised by the
staff. The QIDP stated the incident took
place at "8:15pm not 11:15pm" and
indicated she put in the wrong numbers
by error when submitting the report. The
QIDP indicated staff failed to supervise
client A according to her identified needs
on 8/4/16. The QIDP indicated the
facility failed to ensure there were
sufficient staff on duty to supervise client
A on 8/4/16.
On 8/9/16 at 11:30am, the QIDP
provided an 8/4/16 at 11:00pm "e-mail
during observations.
2.The Assistant Director will
monitor staffing schedules for
each week to assure that two
staff are scheduled during all
waking hours.
3.The nurse will review any
incidents of choking to check if
choking protocols were followed.
If needed she will retrain staff on
dining plans. She will consult with
the dietitian if dining plans need
changes made to them.
What is the date by which the
systemic changes will be
completed?
9/2/16
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 21 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
Re: [client A]...had a choking incident on
Thursday that sent her to the hospital.
She got Watermelon (sic) out of the trash
can when the house was down to one
staff and that staff was assisting another
client in the bathroom...Never leave
[client A] out of sight with access to food
in the garbage or on the counter top. She
has a history of getting food out of the
garbage...I also would not like to see staff
go down to one until the clients have all
went to bed."
On 8/11/16 at 9:57am, an interview with
the CSC (Community Supports
Coordinator) was conducted. The CSC
stated client A "should not be left alone"
around food. The CSC indicated it was
staff neglect for the failure to provide
staff supervision while client A did not
have facility staff to supervise her one on
one in the kitchen.
This federal tag relates to complaint
#IN00204044.
9-3-4(a)
483.470(g)(2)
SPACE AND EQUIPMENT
The facility must furnish, maintain in good
repair, and teach clients to use and to make
informed choices about the use of dentures,
eyeglasses, hearing and other
W 0436
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 22 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
communications aids, braces, and other
devices identified by the interdisciplinary
team as needed by the client.
Based on observation, record review, and
interview, for 2 of 3 sampled clients
(clients A and C) and 2 additional clients
(clients E and G), the facility failed to
have available clients A, C, E, and G's
youth size silverware.
Findings include:
Observations and interviews were
conducted at the group home on 8/8/16
from 4:15pm until 5:55pm. Clients A, C,
E, and G were observed at the group
home. During the observation period
clients A, C, E and G used small youth
size silverware to eat. During the
observation period clients A, C E, and G
served themselves their food portions
with staff assistance and facility staff sat
at the table to supervise clients A, C, E,
and G consume their meal. At 5:50pm,
GHS (Group Home Staff) #2 and the
Residential Manager (RM) both indicated
clients A, C, E, and G required staff
supervision during dining and clients A,
C, E, and G were at risk to choke. At
5:50pm, GHS #2 indicated clients A, C,
E, and G needed youth adaptable utensils
to control their eating rate and bite
portion to prevent choking and aspiration
of food.
W 0436 What corrective action (S) will be
accomplished for these residents
found to have been affected by
the deficient practice?
1 On 8/13/16, adaptive
silverware, special sized bowls
and lip plates, per clients dining
plans, was purchased for use in
day services. The Day Services
Team Leader will monitor daily
that proper adaptive silverware is
used as per each clients’ dining
plan.
How will other residents having
the potential to be affected by the
same deficient practice be
identified and what corrective
action will take place?
1. The dietitian will monitor the
need for adaptive silverware
during her quarterly meal
observations. If different or new
adaptive silverware is needed, the
dietitian will communicate this to
the nurse. The nurse will then
rewrite the dining plan and train
staff, both the group home and
day services, on any new
procedures.
What measures will be put into
place or what systemic
changes will you make to ensure
that the deficient practices does
not recur?
1. The nurse will update adaptive
silverware usage whenever there
is a change in dietitian
recommendations and train both
group home and day services
09/02/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 23 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
On 8/9/16 from 9:00am until 1:20pm,
observation and interviews were
conducted at the facility owned day
program at the agency. During the
observation period WKS (Workshop
Staff) #1, WKS #2, WKS #3, and WKS
#4 unpacked client lunches without
clients present, opened lids and packages
from each client's personal lunch box
without clients present, and prepared then
served each client their lunch at the same
table where clients had been sitting
throughout the observation period.
During the observation period, clients C
and E used plastic spoons to consume
their meal, no staff were present at the
table during dining, and no adaptive
equipment was available for use. At
11:40am, WKS #1, WKS #2, WKS #3,
and WKS #4 indicated no adaptive
equipment and no youth size silverware
was available at the agency owned day
services for client use. The four staff
indicated they did not sit at the tables
with clients during dining because they
were preparing their lunches across the
room.
On 8/9/16 at 11:00am, an interview with
the QIDP (Qualified Intellectual
Disabilities Professional) was conducted.
The QIDP indicated staff should
supervise the clients while dining and
staff. The Day Services Team
Leader will monitor daily, through
observation, that proper adaptive
silverware is used as per each
clients’ dining plan.
How will the corrective actions be
monitored to ensure the deficient
practice will not recur, what
quality assurance program will be
put into place?
1. The Day Services Team
Leader will monitor daily, through
observation, that proper adaptive
silverware is used as per each
clients’ dining plan.
What is the date by which the
systemic changes will be
completed? 9/2/16.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 24 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
clients A, C, E, and G were at risk to
choke. The QIDP indicated clients A, C,
E, and G used youth size silverware to eat
meals and each client should have had
their youth size silverware available at
the facility owned day services to eat.
On 8/9/16 at 1:20pm, an interview with
the agency RN (Registered Nurse) was
conducted. The RN stated clients A, C,
E, and G were at risk to choke and
"required" staff supervision "as well as
their adaptive equipment" (youth size
silverware) to eat food. The RN
indicated each house ordered their own
adaptive equipment and she was unsure
about who would monitor the day
services to ensure clients used their
adaptive equipment.
On 8/11/16 at 9:57am, an interview with
the Community Supports Assistant
Director (CSAD) was conducted. The
CSAD indicated clients A, B, C, D, E, F,
and G attended the facility owned day
services during the weekdays. The
CSAD stated clients A, B, C, D, E, F, and
G attended the facility owned "day
services a few days a week" and attended
a second agency "contracted" day
services "a few days a week." The CSAD
indicated the agency had the potential to
have eighteen (18) or more clients from
the agency operated group homes and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 25 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
additional clients from the community in
the same room at the agency for day
services at any one time. The CSAD
stated "No" adaptive equipment was
available for dining at the facility owned
day services. The CSAD indicated she
was not aware the clients did not have
their adaptive equipment to eat with.
Client A's record was reviewed on 8/9/16
at 10:30am. Client A's 1/12/16 ISP
(Individual Support Plan) and 2/1/16 BSP
(Behavior Support Plan) indicated for
client A "There are dining plan change.
Seen (sic) Speech therapist for eating
concerns (sic). Risk plan updated with
prompts increased (sic). [Client A] is to
put silverware down between bites. She
needs to slow down with eating. She
needs to chew more thoroughly and take
drinks in between bites. [Client A] needs
to be watched when she is taking out the
trash to make sure she is not getting into
it..." Client A's 2/2/2015
"Choking/Dining Protocol" indicated
client A was at risk to choke, required
staff supervision when around food
and/or the kitchen, and "...Preventative
supports and strategies to manage risk:
Staff will sit with [client A] at the dinner
table during meals. All meats and
sandwiches will be cut into bites for
[client A] and staff will encourage her to
put the eating utensil down between
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 26 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
bites. Staff will give cues to swallow
food prior to taking drinks of water
during the meal. Staff may use gentle
verbal prompting such as slow down and
chew thoroughly....[Client A] will use a
rocker knife, small fork, and a small
spoon with a smaller bowl. This will aid
in taking the appropriate sized bites
(sic)...When [client A] is in the main
living areas of the home, she should be
carefully monitored by staff as she will
go into the kitchen and pantry area and
forage for snacks. This presents the
opportunity for choking...When [client
A] is taking out any trash, staff will
monitor her by walking with her to the
dumpster and watching her place the tied
trash bag inside the dumpster. This
should help deter [client A] from
foraging for food in the trash and
possible choking on that food."
Client C's record was reviewed on
8/10/16 at 12:20pm. Client C's 1/26/16
ISP (Individual Support Plan) indicated
client C used a bowl and small silverware
to dine to control her rate of eating and to
decrease her risk to choke on food.
Client C's 1/16 Dining Plan indicated
staff were to supervise client C because
of her risk to choke and client C was to
use small silverware to consume food.
This federal tag relates to complaint
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 27 of 28
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
12/30/2016PRINTED:
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE
(X4) ID
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
CULVER, IN 46511
15G534 08/12/2016
PATHFINDER SERVICES INC
605 ACADEMY RD
00
#IN00204044.
9-3-7(a)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVCY11 Facility ID: 001048 If continuation sheet Page 28 of 28