Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
W 0000
Bldg. 00
This visit was for a pre-determined full
recertification and state licensure survey. This
visit included the Covid-19 focused infection
control survey.
Dates of Survey: June 16, 17, 22 and 23, 2020.
Facility Number: 000971
Provider Number: 15G457
AIM Number: 100244800
These deficiencies also reflect state findings in
accordance with 460 IAC 9.
Quality Review of this report completed by #15068
on 7/1/20.
W 0000
483.430(e)(2)
STAFF TRAINING PROGRAM
For employees who work with clients, training
must focus on skills and competencies
directed toward clients' health needs.
W 0192
Bldg. 00
Based on observation, record review and
interview for 1 of 3 sampled clients (#3), the
facility failed to ensure staff demonstrated
competence in reporting client #3's high blood
pressure to the agency nurse as indicated in the
hypertension (high blood pressure) risk plan.
Findings include:
On 6/16/20 from 4:00 PM to 6:15 PM an
observation was conducted at the group home. At
4:05 PM, staff #4 took client #3's blood pressure.
Client #3's blood pressure reading was 171/104.
The nurse was not notified.
On 6/17/20 from 5:55 AM to 7:55 AM an
W 0192 Name and Address of Provider: McSherr, Inc., 4412 S
B St, Richmond
Date Survey Complete:
06/23/2020
Provider Identification Number:
15G457
Survey Event ID: O9MO11
Finding: W 192 The facility
failed to ensure staff
demonstrated competence in
reporting high blood pressure
to the agency nurse as
indicated in the hypertension
risk plan.
07/23/2020 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete
Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin
other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to
continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
_____________________________________________________________________________________________________Event ID: O9MO11 Facility ID: 000971
TITLE
If continuation sheet Page 1 of 22
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
observation was conducted at the group home.
At 6:15 AM, staff #1 took client #3's blood
pressure. Client #3's blood pressure reading was
168/95. The nurse was not notified. At 7:10 AM,
staff #1 took client #3's blood pressure again and
the reading was 148/86.
On 6/22/20 at 2:00 PM, client #3's record was
reviewed. Client #3's 6/8/20 hypertension risk
plan indicated: "Supports and Interventions: All
staff will be trained on risk plan prior to working in
the home, as needed, and a minimum of annually.
Signs of Hypertension: blood pressure of greater
than 150/90. Symptoms of Hypertension:
headache, blurry vision, dizziness or syncope
(fainting), dyspnea (shortness of breath) or chest
pain, excessive fatigue (tiredness) and weakness.
Staff will monitor twice daily blood pressure
readings. Staff will also monitor [client #3] for
signs of hypertension as stated above. Nurse or
home management will notify physician or nurse
practitioner for appointment or for orders if
hypertension is not well controlled. Nurse will
coordinate with PCP (primary care physician) for
routine medical appointments and labs as ordered.
Nurse will coordinate with dietary manager to
ensure that [client #3] is on the appropriate diet
for diagnosis of hypertension. Monitoring and
(sic) Notification and Documentation: Staff will
notify manager if signs of hypertension are
observed or if [client #3] complains of symptoms.
If no response from home manager after 30
minutes then call nurse. Staff will document blood
pressure twice daily on log. -IF TOP NUMBER IS
> (greater than) 200, HAVE HIM REST AND
REPEAT B/P (blood pressure) IN ONE HOUR. If it
is still elevated: notify nurse if blood pressure is
greater than 150/90 or if systolic (top number) is
150 or over and if diastolic (bottom number) is 90
or over. Staff will notify nurse if systolic BP is
What corrective action(s) will
be accomplished for these
residents found to have been
affected by the deficient
practice?
·Staff will be retrained to call the
agency nurse when blood
pressure top number is above 150
or below 90.
·House Management team will
monitor through in-house
observations, reporting process
and meetings
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
How will McSherr identify other
residents having the potential
to be affected by the same
deficient practice and what
corrective action will be taken?
All South B clients have the
potential to be affected.
·Staff will be retrained to call the
agency nurse when blood
pressure top number is above 150
or below 90.
·House Management team will
monitor through in-house
observations, reporting process
and meetings
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 2 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
less than 110 prior to administering his Metoprolol
(for high blood pressure) and hold med
(medication) if Systolic is less than 110. Home
mgmt (management) team will review daily notes
and report any documented signs of
hypertension. Staff will contact 911 if [client #3]
has chest pain or shortness of breath...."
Client #3's blood pressure form dated June 2020
was reviewed and indicated the following blood
pressure readings were not reported to the nurse
by staff:
6/1/20: 6:00 AM: 191/88 177/74
6/2/20: 6:00 AM: 188/82 174/71
6/3/20: 6:00 AM: 182/96
6/4/20: 6:00 AM: 174/96 164/92 4:00 PM: 160/82
6/8/20: 6:00 AM: 181/92 172/71
6/9/20: 6:00 AM: 182/87 164/70 4:00 PM: 152/91
6/10/20: 6:00 AM: 191/76 180/69
6/11/20: 6:00 AM: 175/100 129/76 4:00 PM:
177/98 160/82
6/12/20: 4:00 PM: 162/102
6/13/20: 6:00 AM: 167/98 4:00 PM: 151/86
6/14/20: 6:00 AM: 155/99
6/15/20: 6:00 AM: 157/95
6/16/20: 6:00 AM: 158/92 4:00 PM: 171/104
6/17/20: 6:00 AM: 148/86 (initial reading not
documented)
On the bottom of the form the following statement
was highlighted in yellow marker: "Call nurse if
blood pressure is: Top number is above 150 or
below 90. Bottom number is above 90 or below
60".
On 6/16/20 at 4:05 PM, staff #4 was interviewed
and stated client #3's blood pressure "normally
runs high and he takes a pill for it". Staff #4
indicated all they do is document the reading on
the form.
monthly IDT
What measures will be put into
place or what systemic
changes you will make to
ensure that the deficient
practice does not recur?
·Staff will be retrained to call the
agency nurse when blood
pressure top number is above 150
or below 90.
·House Management team will
monitor through in-house
observations, reporting process
and meetings
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
How will the corrective
action(s) be monitored to
ensure that the deficient
practice will not recur (quality
assurance program, etc.) and
how will it be put into place?
·Staff will be retrained to call the
agency nurse when blood
pressure top number is above 150
or below 90.
·House Management team will
monitor through in-house
observations, reporting process
and meetings
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 3 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
On 6/17/20 at 7:15 AM, staff #1 was interviewed.
Staff #1 indicated the nurse should be notified if
the top number is over 190 and they document the
reading on the form when it's less than 190. Staff
#1 was asked to review the highlighted section of
the blood pressure form. Staff #1 stated, "She
changed it and didn't tell staff". Staff #1 indicated
the nurse should be notified when the blood
pressure is above 150. Staff #1 indicated he
hadn't been contacting the nurse because he
wasn't aware of the change.
On 6/17/20 at 9:00 AM, the RM (Residential
Manager) was interviewed. The RM stated, "I
know it's changed so I have to look at it. I
thought it was over 190 (top number)". The RM
indicated staff should be trained on when to call
the nurse about client #3's blood pressure.
On 6/22/20 at 4:00 PM, the CEO (Chief Executive
Officer), QIDP (Qualified Intellectual Disabilities
Professional), RN (Registered Nurse) and the SSC
(Social Services Coordinator) were interviewed.
The RN indicated she should be notified if client
#3's blood pressure was over 150 or below 90 (top
number). The RN indicated staff need to be
retrained on client #3's risk plan. The RN
indicated the protocol hasn't been changed in
over one year and all staff working in the home
have been trained on the protocol.
9-3-3(a)
monthly IDT
What is the date by which the
systemic changes will be
implemented?
·7/23/2020
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
W 0249
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 4 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
number and frequency to support the
achievement of the objectives identified in the
individual program plan.
Based on observation, record review and
interview for 3 of 3 sampled clients (#1, #2 and #3)
and 5 additional clients (#4, #5, #6, #7 and #8), the
facility failed to implement the clients' ISP
(Individual Support Plan) training objectives and
educate clients #1 and #3 regarding their
medications when formal and/or informal training
opportunities existed.
Findings include:
1. On 6/16/20 from 4:00 PM to 6:15 PM, an
observation was conducted at the group home.
At 4:45 PM, staff #4 walked to the basement to get
a box of frozen fish and a bag of broccoli to fix for
dinner. Staff #4 turned the oven on to preheat
and opened the boxes of macaroni and cheese.
Client #2 came in from the back yard and staff #4
prompted him to wash his hands to help with
dinner. Client #2 washed his hands then went to
do something else. At 5:00 PM, client #1 was
sorting coins at the kitchen table, client #5 was
working on a puzzle, client #3 was taking a
shower, client #4 was talking to the RM
(Residential Manager), client #6 was reading the
newspaper and clients #7 and #8 were sitting
outside in the swing. Staff did not prompt the
clients to assist with dinner preparation. At 5:20
PM, staff #4 poured the macaroni noodles into a
pan and stirred the noodles. Staff #4 stated to
client #6, "[Client #6], I'd let you help, but I don't
want you to get burnt". Staff #4 poured the
broccoli into the boiling water then got cans of
peaches out of the cabinets. At 5:25 PM, staff #4
stirred the broccoli and noodles then checked the
fish in the oven. At 5:50 PM, staff #3 poured the
macaroni and cheese and peaches into serving
W 0249 Name and Address of Provider: McSherr, Inc., 4412 S
B St, Richmond
Date Survey Complete:
06/23/2020
Provider Identification Number:
15G457
Survey Event ID: O9MO11
Finding: W 249 The facility
failed to implement clients’ ISP
training objectives and educate
clients regarding their
medications when formal
and/or informal training
opportunities existed.
What corrective action(s) will
be accomplished for these
residents found to have been
affected by the deficient
practice?
·All staff will be retrained on
client ISPs and training objectives.
·HSC/Nurse will review client
medication administration goals
and update as needed.
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
How will McSherr identify other
residents having the potential
to be affected by the same
deficient practice and what
corrective action will be taken?
07/23/2020 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 5 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
bowls. At 5:55 PM, staff #3 and #4 carried the
food to the table and staff #4 gave everyone a
slice of cheese for their fish sandwich. The clients
served themselves their food. Staff did not
prompt or encourage clients #1, #2, #3, #4, #5, #6,
#7 and #8 to assist with meal preparation.
On 6/22/20 at 1:00 PM, client #1's record was
reviewed. Client #1's 4/2/20 ISP indicated client #1
had an objective to increase his ability to
participate in meeting his ADL (activities of daily
living) skills.
On 6/22/20 at 12:00 PM, client #2's record was
reviewed. Client #2's 9/5/19 ISP indicated client #2
had an objective to increase his ADL skills.
On 6/22/20 at 2:00 PM, client #3's record was
reviewed. Client #3's 6/8/20 ISP indicated client #3
had an objective to increase his participation in
daily/weekly household tasks.
On 6/22/20 at 2:45 PM, a focused review of client
#4's record was conducted. Client #4's 4/2/20 ISP
indicated client #4 had an objective to increase his
ADL skills.
On 6/22/20 at 2:50 PM, a focused review of client
#5's record was conducted. Client #5's 5/1/20 ISP
indicated client #5 had an objective to increase
her participation in ADL skills.
On 6/22/20 at 2:55 PM, a focused review of client
#6's record was conducted. Client #6's 2/28/20 ISP
indicated client #6 had an objective to increase his
participation in meeting his ADL needs.
On 6/22/20 at 3:00 PM, a focused review of client
#7's record was conducted. Client #7's 2/28/20 ISP
indicated client #7 had an objective to increase his
All South B clients have the
potential to be affected.
·All staff will be retrained on
client ISPs and training objectives.
·HSC/Nurse will review client
medication administration goals
and update as needed.
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
What measures will be put into
place or what systemic
changes you will make to
ensure that the deficient
practice does not recur?
·All staff will be retrained on
client ISPs and training objectives.
·HSC/Nurse will review client
medication administration goals
and update as needed.
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
How will the corrective
action(s) be monitored to
ensure that the deficient
practice will not recur (quality
assurance program, etc.) and
how will it be put into place?
·All staff will be retrained on
client ISPs and training objectives.
·HSC/Nurse will review client
medication administration goals
and update as needed.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 6 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
domestic skills at the group home.
On 6/22/20 at 3:05 PM, a focused review of client
#8's record was conducted. Client #8's 5/2/20 ISP
indicated client #8 had an objective to increase his
ADL skills.
On 6/16/20 at 5:10 PM, staff #4 was interviewed.
Staff #4 stated, "The clients like to cook." Staff #4
indicated the clients should be prompted and
encouraged to help prepare the meals.
On 6/16/20 at 5:20 PM, client #6 was interviewed
and he indicated he liked to cook.
On 6/17/20 at 9:00 AM, the RM was interviewed.
The RM indicated the clients should be prompted
and encouraged to assist with preparing the
meals. The RM indicated all of the clients were
capable of helping.
On 6/22/20 at 4:00 PM, the CEO (Chief Executive
Officer), QIDP (Qualified Intellectual Disabilities
Professional), RN (Registered Nurse) and the SSC
(Social Services Coordinator) were interviewed.
The CEO indicated the clients should be in the
kitchen with staff helping prepare the meals. The
CEO indicated all of the clients were capable of
doing something to assist with preparing the
meals. The QIDP indicated the staff needed to be
retrained.
2. On 6/16/20 at 5:45 PM, an observation of client
#1's medication administration was conducted.
Staff #4 administered client #1's medication and
did not explain to client #1 what she was going to
do, how to take the medication, the name of the
medication, the reason for the medication use and
the side effects.
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
What is the date by which the
systemic changes will be
implemented?
·7/23/2020
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 7 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
On 6/17/20 at 6:15 AM and 7:10 AM, observations
of client #3's medication administration was
conducted. Staff #1 administered client #3's
medication and did not explain to client #3 what
he was going to do, how to take the medication,
the name of the medication, the reason for the
medication use and the side effects.
On 6/17/20 at 6:40 AM, an observation of client
#1's medication administration was conducted.
Staff #1 administered client #1's medication and
did not explain to client #1 what he was going to
do, how to take the medication, the name of the
medication, the reason for the medication use and
the side effects.
On 6/22/20 at 1:00 PM, client #1's record was
reviewed. Client #1's 4/2/20 ISP indicated client #1
had an objective to increase his ability to
participate in meeting his ADL skills.
On 6/22/20 at 2:00 PM, client #3's record was
reviewed. Client #3's 6/8/20 ISP indicated client #3
had an objective to increase his participation in
daily/weekly household tasks (medications-
identify AM medication packet).
On 6/22/20 at 4:00 PM, the CEO, QIDP, RN and the
SSC were interviewed. The RN indicated the staff
were all trained on Core A and Core B and the
clients should be educated about their
medications each time medication is administered.
9-3-4(a)
483.440(f)(3)(iii)
PROGRAM MONITORING & CHANGE
The committee should review, monitor and
make suggestions to the facility about its
practices and programs as they relate to drug
W 0264
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 8 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
usage, physical restraints, time-out rooms,
application of painful or noxious stimuli,
control of inappropriate behavior, protection of
client rights and funds, and any other areas
that the committee believes need to be
addressed.
Based on observation, record review, and
interview for 3 of 3 sampled clients (#1, #2 and #3)
and 4 additional clients (#4, #5, #6 and #8), the
facility failed to ensure the HRC (Human Rights
Committee) approved the restrictive practice of
locking laundry supplies and hygiene items in the
hall closet.
Findings include:
On 6/16/20 from 4:00 PM to 6:15 PM and on
6/17/20 from 5:55 AM to 7:55 AM observations
were conducted at the group home. On 6/16/20 at
4:00 PM, client #4 asked staff #4 to unlock the hall
closet so he could start his laundry. At 4:10 PM,
client #4 asked staff #4 to unlock the closet again.
At 4:15 PM, staff #4 unlocked the closet so client
#4 could start his laundry. Throughout the
observations the hall closet door with the hygiene
products and laundry detergent remained locked.
This affected clients #1, #2, #3, #4, #5, #6 and #8.
On 6/22/20 at 1:00 PM, client #1's record was
reviewed. There was no documentation in the
record indicating HRC approval had been
obtained for locking the hygiene products and
laundry detergent in the hall closet.
On 6/22/20 at 12:00 PM, client #2's record was
reviewed. There was no documentation in the
record indicating HRC approval had been
obtained for locking the hygiene products and
laundry detergent in the hall closet.
W 0264 Name and Address of Provider: McSherr, Inc., 4412 S
B St, Richmond
Date Survey Complete:
06/23/2020
Provider Identification Number:
15G457
Survey Event ID: O9MO11
Finding: W 264 The facility
failed to ensure the HRC
approved the restrictive
practice of locking laundry
supplies and hygiene items in
the hall closet.
What corrective action(s) will
be accomplished for these
residents found to have been
affected by the deficient
practice?
·McSherr has obtained HRC
approval for the restrictive practice
of locking laundry supplies and
hygiene items in the hall closet.
·McSherr has obtained guardian
approval for the restrictive practice
of locking laundry supplies and
hygiene items in the hall closet.
·Team will review client
restrictive practices through
monthly IDT
How will McSherr identify other
residents having the potential
to be affected by the same
07/23/2020 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 9 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
On 6/22/20 at 2:00 PM, client #3's record was
reviewed. There was no documentation in the
record indicating HRC approval had been
obtained for locking the hygiene products and
laundry detergent in the hall closet.
On 6/22/20 at 2:45 PM, a focused review of client
#4's record was conducted. There was no
documentation in the record indicating HRC
approval had been obtained for locking the
hygiene products and laundry detergent in the
hall closet.
On 6/22/20 at 2:50 PM, a focused review of client
#5's record was conducted. There was no
documentation in the record indicating HRC
approval had been obtained for locking the
hygiene products and laundry detergent in the
hall closet.
On 6/22/20 at 2:55 PM, a focused review of client
#6's record was conducted. There was no
documentation in the record indicating HRC
approval had been obtained for locking the
hygiene products and laundry detergent in the
hall closet.
On 6/22/20 at 3:05 PM, a focused review of client
#8's record was conducted. There was no
documentation in the record indicating HRC
approval had been obtained for locking the
hygiene products and laundry detergent in the
hall closet.
On 6/17/20 at 9:00 AM, the RM (Residential
Manager) was interviewed. The RM stated the
closet was locked due to client #7 "licking his
deodorant and eating toothpaste multiple times
several years ago". The RM indicated the laundry
products and the hygiene baskets were locked in
deficient practice and what
corrective action will be taken?
All South B clients have the
potential to be affected.
·McSherr has obtained HRC
approval for the restrictive practice
of locking laundry supplies and
hygiene items in the hall closet.
·McSherr has obtained guardian
approval for the restrictive practice
of locking laundry supplies and
hygiene items in the hall closet.
·Team will review client
restrictive practices through
monthly IDT
What measures will be put into
place or what systemic
changes you will make to
ensure that the deficient
practice does not recur?
·McSherr has obtained HRC
approval for the restrictive practice
of locking laundry supplies and
hygiene items in the hall closet.
·McSherr has obtained guardian
approval for the restrictive practice
of locking laundry supplies and
hygiene items in the hall closet.
·Team will review client
restrictive practices through
monthly IDT
How will the corrective
action(s) be monitored to
ensure that the deficient
practice will not recur (quality
assurance program, etc.) and
how will it be put into place?
·McSherr has obtained HRC
approval for the restrictive practice
of locking laundry supplies and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 10 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
the closet to prevent client #7 from ingesting
non-food items. The RM indicated the cleaning
supplies were not locked and client #7 hasn't
attempted to do anything since those items were
locked. The RM stated, "We probably need to
look at that again".
On 6/22/20 at 4:00 PM, the CEO (Chief Executive
Officer), QIDP (Qualified Intellectual Disabilities
Professional), RN (Registered Nurse) and the SSC
(Social Services Coordinator) were interviewed.
The QIDP stated the closet was locked due to
client #7 ingesting toothpaste and licking his
deodorant "several years ago". The QIDP
indicated the HRC was meeting this week and
they were going to recommend to discontinue the
restriction.
9-3-4(a)
hygiene items in the hall closet.
·McSherr has obtained guardian
approval for the restrictive practice
of locking laundry supplies and
hygiene items in the hall closet.
·Team will review client
restrictive practices through
monthly IDT
What is the date by which the
systemic changes will be
implemented?
·7/23/2020
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.
W 0327
Bldg. 00
Based on record review and interview for 1 of 3
sampled clients (#3), the facility failed to ensure
client #3 had an annual TB (tuberculosis)
screening completed.
Findings include:
On 6/22/20 at 2:00 PM, client #3's record was
reviewed. The record did not include
documentation of a TB screening being completed
W 0327 Name and Address of Provider: McSherr, Inc., 4412 S
B St, Richmond
Date Survey Complete:
06/23/2020
Provider Identification Number:
15G457
Survey Event ID: O9MO11
Finding: W 327 The facility
07/23/2020 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 11 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
since 2/1/19.
On 6/22/20 at 4:00 PM, the CEO (Chief Executive
Officer), QIDP (Qualified Intellectual Disabilities
Professional), RN (Registered Nurse) and then
SSC (Social Services Coordinator) were
interviewed. The RN indicated TB tests should be
completed on an annual basis. The RN indicated
the RM (Residential Manager) was responsible for
scheduling medical appointments and she had not
scheduled the screening.
9-3-6(a)
failed to ensure client had an
annual TB screening
What corrective action(s) will
be accomplished for these
residents found to have been
affected by the deficient
practice?
·HSC/Nurse will be retrained on
maintaining all client TBs
·McSherr nurse will ensure all
clients receive annual TB
screening.
·HSC/nurse will monitor through
tracking.
How will McSherr identify other
residents having the potential
to be affected by the same
deficient practice and what
corrective action will be taken?
All South B clients have the
potential to be affected.
·HSC/Nurse will be retrained on
maintaining all client TBs
·McSherr nurse will ensure all
clients receive annual TB
screening.
·HSC/nurse will monitor through
tracking.
What measures will be put into
place or what systemic
changes you will make to
ensure that the deficient
practice does not recur?
·HSC/Nurse will be retrained on
maintaining all client TBs
·McSherr nurse will ensure all
clients receive annual TB
screening.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 12 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
·HSC/nurse will monitor through
tracking.
How will the corrective
action(s) be monitored to
ensure that the deficient
practice will not recur (quality
assurance program, etc.) and
how will it be put into place?
·HSC/Nurse will be retrained on
maintaining all client TBs
·McSherr nurse will ensure all
clients receive annual TB
screening.
·HSC/nurse will monitor through
tracking.
What is the date by which the
systemic changes will be
implemented?
7/23/2020
483.460(k)(2)
DRUG ADMINISTRATION
The system for drug administration must
assure that all drugs, including those that are
self-administered, are administered without
error.
W 0369
Bldg. 00
Based on observation, record review and
interview for 1 of 3 sampled clients (#3), the
facility failed to ensure staff administered client
#3's medications as ordered by the physician.
Findings include:
1. On 6/17/20 from 5:55 AM to 7:55 AM an
observation was conducted at the group home.
At 6:15 AM, client #3's 6:00 AM medication was
administered. Staff #1 administered client #3's
W 0369 Name and Address of Provider: McSherr, Inc., 4412 S
B St, Richmond
Date Survey Complete:
06/23/2020
Provider Identification Number:
15G457
Survey Event ID: O9MO11
Finding: W 369 The facility
failed to ensure staff
07/23/2020 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 13 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
Levothyroxine (for hypothyroidism/low thyroid
hormone) 75 mcg (micrograms) tab (tablet). After
client #3's medication was administered client #3
went to the dining room and sat down at the table
for breakfast. Client #3 started eating a breakfast
burrito at 6:25 AM.
On 6/22/20 at 2:00 PM, client #3's record was
reviewed. Client #3's 2/5/20 PO (Physician's
Order) signed by the physician indicated client #3
was prescribed Levothyroxine 75 mcg tab, take
one tablet by mouth daily at 5:00 AM. The June
2020 MAR (Medication Administration Record)
indicated client #3 was prescribed Levothyroxine
75 mcg tab, take one tablet by mouth daily at 5:00
AM.
On 6/22/20 at 4:00 PM, the CEO (Chief Executive
Officer), QIDP (Qualified Intellectual Disabilities
Professional), RN (Registered Nurse) and the SSC
(Social Services Coordinator) were interviewed.
The RN indicated the Levothyroxine should be
administered at 5:00 AM because it was ordered
to be taken on an empty stomach. The RN
indicated client #3 should not eat for 30 minutes
to one hour after the medication is administered.
2. On 6/17/20 at 7:10 AM an observation of client
#3's 7:00 AM medication was conducted. Staff #1
did not administer client #3's Miralax (for
constipation) and Debrox (for ear wax buildup) ear
drops.
On 6/22/20 at 2:00 PM, client #3's record was
reviewed. Client #3's 2/5/20 PO (Physician's
Order) signed by the physician indicated client #3
was prescribed Miralax 17 G (grams) daily at 8:00
AM and Debrox 6.5% OT (otic/ear) SOL (solution)
in both ears daily at 8:00 AM.
administered client
medications as ordered by the
physician.
What corrective action(s) will
be accomplished for these
residents found to have been
affected by the deficient
practice?
·Staff will be retrained on correct
times to administer medications
per the MAR
·All medications will be
administered as ordered by the
prescribing physician
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
How will McSherr identify other
residents having the potential
to be affected by the same
deficient practice and what
corrective action will be taken?
All South B clients have the
potential to be affected.
·Staff will be retrained on correct
times to administer medications
per the MAR
·All medications will be
administered as ordered by the
prescribing physician
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 14 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
On 6/22/20 at 4:00 PM, the CEO, QIDP, RN and the
SSC were interviewed. The RN indicated
medications should be administered as prescribed
by the physician.
9-3-6(a)
What measures will be put into
place or what systemic
changes you will make to
ensure that the deficient
practice does not recur?
·Staff will be retrained on correct
times to administer medications
per the MAR
·All medications will be
administered as ordered by the
prescribing physician
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
How will the corrective
action(s) be monitored to
ensure that the deficient
practice will not recur (quality
assurance program, etc.) and
how will it be put into place?
·Staff will be retrained on correct
times to administer medications
per the MAR
·All medications will be
administered as ordered by the
prescribing physician
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
What is the date by which the
systemic changes will be
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 15 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
implemented?
7/23/2020
483.470(l)(1)
INFECTION CONTROL
There must be an active program for the
prevention, control, and investigation of
infection and communicable diseases.
W 0455
Bldg. 00
Based on observation, record review and
interview for 3 of 3 sampled clients (#1, #2 and #3)
and 5 additional clients (#4, #5, #6, #7 and #8), the
facility failed to complete a health screening prior
to the surveyor entering the group home to assist
with preventing the spread of Covid-19
(Coronavirus Disease/respiratory illness) during a
pandemic.
Findings include:
On 6/16/20 from 4:00 PM to 6:15 PM and on
6/17/20 from 5:55 AM to 7:55 AM, observations
were conducted at the group home. The surveyor
was not screened (temperature and symptoms
checklist) for Covid-19 upon entry to the group
home during the observations. This affected
clients #1, #2, #3, #4, #5, #6, #7 and #8.
On 6/23/20 at 9:00 AM, the undated article
"Guidance for Group Homes for Individuals with
Disabilities" was reviewed from the website
www.cdc.gov. The article indicated: "...Screen
and advise residents, staff, and essential
volunteers. GH (group home)administrators may
want to consider screening residents, workers,
and essential volunteers for signs and symptoms
of COVID-19.
Screening includes actively taking each person's
temperature using a no-touch thermometer, and
asking whether or not the person is experiencing
W 0455 Name and Address of Provider: McSherr, Inc., 4412 S
B St, Richmond
Date Survey Complete:
06/23/2020
Provider Identification Number:
15G457
Survey Event ID: O9MO11
Finding: W 455 The facility
failed to complete a health
screening prior to the surveyor
entering the group home to
assist with preventing the
spread of COVID-19.
What corrective action(s) will
be accomplished for these
residents found to have been
affected by the deficient
practice?
·A health screening sheet has
been put into place and all visitors
are screened upon arrival at the
group home.
·Staff have been trained on
implementation of the screening
process.
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
07/23/2020 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 16 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
symptoms such as shortness of breath or has a
cough...."
On 6/17/20 at 9:00 AM, the RM (Residential
Manager) was interviewed. The RM indicated
visitation at the group home was suspended and
they haven't had a visitor since the beginning of
March 2020. The RM indicated staff are required
to take their temperature prior to clocking in for
their shift. The RM indicated visitors should be
screened prior to entering the group home.
On 6/22/20 at 4:00 PM, the CEO (Chief Executive
Officer), QIDP (Qualified Intellectual Disabilities
Professional), RN (Registered Nurse) and the SSC
(Social Services Coordinator) were interviewed.
The CEO indicated the group home stopped all
visitation the middle of March 2020 so they didn't
have a screening process for visitors in place.
The CEO indicated visitors should be screened
prior to entering the group home to assist with
preventing the spread of Covid-19. The CEO
stated she would have a process in place
"immediately".
9-3-7(a)
·Team will monitor through
monthly IDT
How will McSherr identify other
residents having the potential
to be affected by the same
deficient practice and what
corrective action will be taken?
All South B clients have the
potential to be affected.
·A health screening sheet has
been put into place and all visitors
are screened upon arrival at the
group home.
·Staff have been trained on
implementation of the screening
process.
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
What measures will be put into
place or what systemic
changes you will make to
ensure that the deficient
practice does not recur?
·A health screening sheet has
been put into place and all visitors
are screened upon arrival at the
group home.
·Staff have been trained on
implementation of the screening
process.
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 17 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
·Team will monitor through
monthly IDT
How will the corrective
action(s) be monitored to
ensure that the deficient
practice will not recur (quality
assurance program, etc.) and
how will it be put into place?
·A health screening sheet has
been put into place and all visitors
are screened upon arrival at the
group home.
·Staff have been trained on
implementation of the screening
process.
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
What is the date by which the
systemic changes will be
implemented?
7/23/2020
483.480(d)(4)
DINING AREAS AND SERVICE
The facility must assure that each client eats
in a manner consistent with his or her
developmental level.
W 0488
Bldg. 00
Based on observation, record review and
interview for 3 of 3 sampled clients (#1, #2 and #3)
and 5 additional clients (#4, #5, #6, #7 and #8), the
facility failed to ensure the clients were involved
in all aspects of the meal preparation based on
their skill level and to ensure the clients had
napkins while eating meals.
W 0488 Name and Address of Provider: McSherr, Inc., 4412 S
B St, Richmond
Date Survey Complete:
06/23/2020
Provider Identification Number:
15G457
07/23/2020 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 18 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
Findings include:
1. On 6/16/20 from 4:00 PM to 6:15 PM, an
observation was conducted at the group home.
At 4:45 PM, staff #4 walked to the basement to get
a box of frozen fish and a bag of broccoli to fix for
dinner. Staff #4 turned the oven on to preheat
and opened the boxes of macaroni and cheese.
Client #2 came in from the back yard and staff #4
prompted him to wash his hands to help with
dinner. Client #2 washed his hands then went to
do something else. At 5:00 PM, client #1 was
sorting coins at the kitchen table, client #5 was
working on a puzzle, client #3 was taking a
shower, client #4 was talking to the RM
(Residential Manager), client #6 was reading the
newspaper and clients #7 and #8 were sitting
outside in the swing. Staff did not prompt the
clients to assist with dinner preparation. At 5:20
PM, staff #4 poured the macaroni noodles into a
pan and stirred the noodles. Staff #4 stated to
client #6, "[Client #6], I'd let you help, but I don't
want you to get burnt". Staff #4 poured the
broccoli into the boiling water then got cans of
peaches out of the cabinets. At 5:25 PM, staff #4
stirred the broccoli and noodles then checked the
fish in the oven. At 5:50 PM, staff #3 poured the
macaroni and cheese and peaches into serving
bowls. At 5:55 PM, staff #3 and #4 carried the
food to the table and staff #4 gave everyone a
slice of cheese for their fish sandwich. The clients
served themselves their food. Staff did not
prompt or encourage clients #1, #2, #3, #4, #5, #6,
#7 and #8 to assist with meal preparation.
On 6/22/20 at 1:00 PM, client #1's record was
reviewed. Client #1's 4/2/20 ISP (Individual
Support Plan) indicated client #1 had an objective
to increase his ability to participate in meeting his
Survey Event ID: O9MO11
Finding: W 488 The facility
failed to ensure the clients
were involved in all aspects of
the meal preparation based on
their skill level and to ensure
the clients had napkins while
eating meals.
What corrective action(s) will
be accomplished for these
residents found to have been
affected by the deficient
practice?
·Staff will be retrained on client
ADLs and client involvement
during meal preparation.
·Staff will ensure clients have
napkins during each meal.
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
How will McSherr identify other
residents having the potential
to be affected by the same
deficient practice and what
corrective action will be taken?
All South B clients have the
potential to be affected.
·Staff will be retrained on client
ADLs and client involvement
during meal preparation.
·Staff will ensure clients have
napkins during each meal.
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 19 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
ADL (activities of daily living) skills.
On 6/22/20 at 12:00 PM, client #2's record was
reviewed. Client #2's 9/5/19 ISP indicated client #2
had an objective to increase his ADL skills.
On 6/22/20 at 2:00 PM, client #3's record was
reviewed. Client #3's 6/8/20 ISP indicated client #3
had an objective to increase his participation in
daily/weekly household tasks.
On 6/22/20 at 2:45 PM, a focused review of client
#4's record was conducted. Client #4's 4/2/20 ISP
indicated client #4 had an objective to increase his
ADL skills.
On 6/22/20 at 2:50 PM, a focused review of client
#5's record was conducted. Client #5's 5/1/20 ISP
indicated client #5 had an objective to increase
her participation in ADL skills.
On 6/22/20 at 2:55 PM, a focused review of client
#6's record was conducted. Client #6's 2/28/20 ISP
indicated client #6 had an objective to increase his
participation in meeting his ADL needs.
On 6/22/20 at 3:00 PM, a focused review of client
#7's record was conducted. Client #7's 2/28/20 ISP
indicated client #7 had an objective to increase his
domestic skills at the group home.
On 6/22/20 at 3:05 PM, a focused review of client
#8's record was conducted. Client #8's 5/2/20 ISP
indicated client #8 had an objective to increase his
ADL skills.
On 6/16/20 at 5:10 PM, staff #4 was interviewed.
Staff #4 stated, "The clients like to cook". Staff #4
indicated the clients should be prompted and
encouraged to help prepare the meals.
meetings, and in-house
observations
·Team will monitor through
monthly IDT
What measures will be put into
place or what systemic
changes you will make to
ensure that the deficient
practice does not recur?
·Staff will be retrained on client
ADLs and client involvement
during meal preparation.
·Staff will ensure clients have
napkins during each meal.
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
How will the corrective
action(s) be monitored to
ensure that the deficient
practice will not recur (quality
assurance program, etc.) and
how will it be put into place?
·Staff will be retrained on client
ADLs and client involvement
during meal preparation.
·Staff will ensure clients have
napkins during each meal.
·QIDP, SSC, HSC and CEO will
monitor through reporting process,
meetings, and in-house
observations
·Team will monitor through
monthly IDT
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 20 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
On 6/16/20 at 5:20 PM, client #6 was interviewed
and he indicated he liked to cook.
On 6/17/20 at 9:00 AM, the RM was interviewed.
The RM indicated the clients should be prompted
and encouraged to assist with preparing the
meals. The RM indicated all of the clients were
capable of helping.
On 6/22/20 at 4:00 PM, the CEO (Chief Executive
Officer), QIDP (Qualified Intellectual Disabilities
Professional), RN (Registered Nurse) and the SSC
(Social Services Coordinator) were interviewed.
The CEO indicated the clients should be in the
kitchen with staff helping prepare the meals. The
CEO indicated all of the clients were capable of
doing something to assist with preparing the
meals. The QIDP indicated the staff needed to be
retrained.
2. On 6/16/20 from 4:00 PM to 6:15 PM, an
observation was conducted at the group home.
Client #3 ate dinner from 5:55 PM to 6:15 PM. At
6:10 PM, client #3 had ketchup all over his fingers.
Client #3 did not have a napkin so he licked the
ketchup off of his fingers. Staff did not prompt
him to get a napkin.
On 6/17/20 at 9:00 AM, the RM was interviewed.
The RM indicated the clients should have napkins
to wipe their hands on while eating meals.
On 6/22/20 at 4:00 PM, the CEO, QIDP, RN and the
SSC were interviewed. The CEO, QIDP and the
SSC indicated staff should prompt and encourage
the clients to use napkins. The CEO indicated
staff should ensure each client has a napkin prior
to eating.
What is the date by which the
systemic changes will be
implemented?
7/23/2020
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 21 of 22
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
07/17/2020PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
RICHMOND, IN 47374
15G457 06/23/2020
MCSHERR INC - B ST
4412 S B ST
00
9-3-8(a)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 22 of 22