W 0000 - In · 2019. 4. 1. · He usually come(s) when I'm asleep already and he comes in my room while I'm sleeping. It's been plenty of times I roll over and he sitting on my couch

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

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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

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

FORT WAYNE, IN 46815

15G658 02/25/2019

VOCA CORPORATION OF INDIANA

3335 SANIBEL DR

00

W 0000

Bldg. 00

This visit was for the investigation of complaint

#IN00285653.

Complaint #IN00285653: Substantiated, federal

and state deficiencies related to the allegation are

cited at W149, W153, W154, W156, and W157.

Survey Dates: 2/21, 2/22, and 2/25/19.

Facility number: 001195

Provider number: 15G658

AIM number: 100474580

These deficiencies also reflect state findings in

accordance with 460 IAC 9.

Quality Review of this report completed by #15068

on 3/14/19.

W 0000

483.420(d)(1)

STAFF TREATMENT OF CLIENTS

The facility must develop and implement

written policies and procedures that prohibit

mistreatment, neglect or abuse of the client.

W 0149

Bldg. 00

Based on record review and interview for 1 of 3

sampled clients (A), plus 2 additional clients (E

and H), the facility failed to ensure implementation

of the agency's abuse, neglect, and/or

mistreatment policy and procedure to ensure

clients A and E were protected from personal

property being stolen/misplaced and client H from

verbal abuse by staff.

Findings include:

The facility's Bureau of Developmental Disabilities

W 0149 W149: The facility must develop

and implement written policies and

procedures that prohibit

mistreatment, neglect or abuse of

the client. All consumer property

will be entered on the inventory list

upon purchase. Large or

expensive items (TVs, tablets,

computers, etc) will be inventoried

2 times weekly by the Site

Supervisor using the Habilitation

Observation form. The QIDP will

inventory those items 1 time per

03/27/2019 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: THOB11 Facility ID: 001195

TITLE

If continuation sheet Page 1 of 22

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Services (BDDS) reports were reviewed on 2/21/19

at 1:59 PM and indicated the following:

1. A 1/9/2019 BDDS report indicated on 1/8/19 "

...it was discovered that an electronic tablet

belonging to [client A] was unable to be located.

[Client A] asked staff for it but it was no longer in

the area it was being stored ...Rescare has initiated

an internal investigation. Rescare will purchase

and replace the electronic tablet if not found ...".

A 1/9/19 IS (Investigative Summary) indicated

"On 1/8/19, at approximately 7:54AM, it was

discovered that an electronic tablet belonging to

[client A] was unable to be located. The tablet is

kept in the med room when not in use."

The 1/9/19 IS's Factual Findings indicated "It was

determined that [client A] had a black [name]

tablet that was last seen on Monday morning

1/7/19. Everyone had access to the tablet as it was

last seen on the kitchen table."

The 1/9/19 IS's Conclusion indicated "After

thorough review of documentary evidence, the

peer review committee was not able to

substantiate ANE (Abuse, Neglect, and

Exploitation). Rescare has replaced the tablet. The

tablet will be locked at night. Staff will sign off on

each shift that the tablet is present."

2. An 10/21/18 BDDS report indicated on 10/20/18

" ...It was discovered that a television belonging

to [client A] was unable to be located. [Client A]'s

father came to the home to pick it up but it was no

longer in the area it was being stored ...Rescare

has initiated an internal investigation ...".


" ...it was reported to Rescare QIDP (Qualified

week via the Habilitation

Observation form. Staff will be

retrained on our abuse neglect

policy with attention to the

reporting policy. QIDP will include

asking staff when they are to

report abuse/neglect when she is

completing her weekly observation

form. A member of the

Management team (Executive

Director, Program Manager, Nurse

Manager and/or Quality Manger)

will complete a site review monthly

that will include questions about

abuse/neglect.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: THOB11 Facility ID: 001195 If continuation sheet Page 2 of 22




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Intellectual Disability Professional) that [client E]'s

laptop is missing. It was also stated that [client E]

informed staff of the situation on 10/12/18

...Rescare has initiated an internal investigation

...".

A 10/23/18-10/26/18 Investigative Summary (IS)

introduction indicated "On 10/20/18, at

approximately 11:30 AM, it was discovered that a

television belonging to [client A] was unable to

be located. [Client A]'s father came to the home to

pick it up but (it) was no longer in the area it was

being stored. On 10/15/18, at approximately

12:00PM, it was reported to Rescare QIDP

(Qualified Intellectual Disability Professional) that

[client E]'s laptop is missing. It was also stated

that [client E] informed staff of the situation on

10/12/18."

The IS indicated client E was interviewed on

10/23/18. The interview indicated " ...[Client E]

was asked if he noticed anyone take his laptop.

[Client E] stated it was stolen and does not know

by who or when. [Client E] was asked if he noticed

anyone take [client A]'s TV (television). [Client E]

stated no ...[Client E] was asked how long has it

been missing. [Client E] stated 3 weeks ...[Client E]

was asked who did you notify. [Client E] stated

my med (medication) coach 3 weeks ago ...she

wrote an incident report. [Client E] was asked if he

reported it to [QIDP name] too. [Client E] stated

yes a week ago. [Client E] was asked who he

thinks took it. [Client E] stated I have no idea. It

was took when in my room sleep (sic) ...[Client E]

was asked if he thinks [friend's name] took his

laptop. [Client E] stated I don't know but I was

thinking and suspecting because no one else in

the house would take it. Plus they checked all the

rooms and it was not there. [Client E] was asked if

[friend's name] knows where he keeps his laptop.





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[Client E] stated yeah, he's always in my room.

[Client E] was asked if [friend's name] was at his

home the day the laptop came up missing. [Client

E] stated I think he was. He usually come(s) when

I'm asleep already and he comes in my room while

I'm sleeping. It's been plenty of times I roll over

and he sitting on my couch listening to music

waiting for me to wake up."

The IS indicated client I was interviewed on

10/23/18. The interview indicated " ...[Client I] was

asked if he noticed anyone take [client E]'s laptop.

[Client I] stated no. [Client I] was asked if he

noticed anyone take [client A]'s TV. [Client I]

stated no, I thought he got rid of that TYV (sic) a

long times (sic) ...".

The IS indicated client G was interviewed on

10/23/18. The interview indicated " ...[Client G]

was asked if he noticed anyone take [client E]'s

laptop. [Client G] stated no. [Client G] was asked if

he noticed anyone take [client A]'s TV. [Client G]

stated no, I didn't know it was gone ...".

The IS indicated staff #6 was interviewed on

10/23/18. The interview indicated " ...[Staff #6]

was asked what type of (sic) TV does [client A]

have. [Staff #6] stated I don't know. I wasn't aware

he had a TV until staff mentioned it ... ...[Staff #6]

was asked when was the last time she seen (sic)

[client E]'s laptop. [Staff #6] stated the weekend

before I came back, maybe 2 weeks ago...".

The IS indicated the medication coach (MC) was

interviewed on 10/23/18. The interview indicated "

...[The MC] was asked what kind of TV does

[client A] have. [The MC] stated I don't know the

brand, I just know it was a 32" (inch) ...[The MC]

was asked when was the last time she seen (sic)

[client E]'s laptop. [The MC] stated umm, that





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Thursday before it came up missing. Him (sic) and

his housemates were watching it outside about 3

weeks ago ...[The MC] was asked if she seen (sic)

any staff take the laptop. [The MC] stated no ....

[The MC] was asked who did she report the

missing items to. [The MC] stated [the residential

manager], [the area supervisor], and [the QIDP]

that was three weeks ago. [The MC] was asked

what was their response. [The medication coach]

stated no one responded ...".

The IS indicated the Residential Manager #1 (RM

#1) was interviewed on 10/23/18. The interview

indicated " ...[RM #1] was asked what kind of

laptop does [client E] have. [RM #1] stated I don't

know. [RM #1] was asked when was the last time

she seen (sic) [client E]'s laptop. [RM #1] stated it

has been missing for a few weeks. [RM #1] was

asked when was the last time she seen (sic) [client

A]'s TV. [RM #1] stated it was under his bed

when I first started, haven't seen (sic) it since then

...[RM #1] was asked if she seen (sic) any staff

take the laptop. [RM #1] stated no ...[RM #1] was

asked who did she report the missing items to.

[RM #1] stated no, [staff #6] was. [RM #1] was

asked when was it reported. [RM #1] stated not

sure. [RM #1] was asked what was their response.

[RM #1] responded not sure ...".


unknown date and time. The interview indicated "

...[Staff #1] was asked what kind of laptop does

[client E] have. [Staff #1] stated I wasn't aware

[client E] had a laptop ...". The IS indicated staff

#8 was interviewed on 10/24/18 and indicated " ...

[Staff #8] was asked when was the last time she

seen (sic) [client E]'s laptop. [Staff #8] stated day

before he said it was missing ...".






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10/24/18 and indicated " ...[Staff #2] was asked

when was the last time she seen (sic) [client E]'s

laptop. [Staff #2] stated it's been about 3-4 weeks

...".

The IS indicated the QIDP was interviewed on

10/23/18 and indicated "[The QIDP] was asked

who reported the missing TV (television) and

laptop to you. [The QIDP] stated TV [staff #6].

laptop [the medication coach]. [The QIDP] was

asked how long did they say the items were

missing. [The QIDP] stated TV no idea, just

discovered that day, and laptop not sure. [The

QIDP] was asked if this was the first time these

items were reported missing. [The QIDP] stated

TV yes, laptop no [the medication coach] text (sic)

me about a week ago."

The IS Factual Findings indicated "It was

determined that the TV was 32 inch brand name of

television] and unknown when it went missing. It

was determined the laptop may have been taking

(sic) out of [client E] (sic) bottom dresser drawer

located in his bedroom. All the rooms were

searched and it was not found in the possession

of any house mate. The laptop is [brand name of

laptop] and only 1 friend who does not live in the

home but visits frequently had access to take the

laptop." The IS conclusion indicated "After



substantiate how the items came up missing.

Rescare will replace all items missing to the

consumers involved."

4. A 1/30/19 BDDS report indicated on 1/29/19

"[client H]'s mother expressed concerns to

ResCare QAC (Quality Assurance Coordinator)

that during a phone call with her son, she

overheard staff cursing and being inappropriate





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...Rescare has initiated an internal investigation.

Staff, [staff #9], has been suspended pending the

outcome ...".

A 1/29/19 IS introduction indicated "On 1/29/19,

[client H's guardian], expressed concerns to

Rescare QAC (Quality Assurance Coordinator)

that during a phone call with her son, she

overheard staff cursing and being inappropriate.

After speaking with [client H]'s mom she reported

that she heard staff [staff #9] yelling at [client H]

saying he had her f***** up, [client H] was

stupid, and childish. [Client H]'s mom also

reported that [staff #9] told [client H] she had 'gas'

marijuana and [staff #9] was smoking marijuana in

the car on 1/24/19."

The IS indicated client H's guardian was

interviewed on 1/29/19. The interview indicated

"[Client H's guardian] was asked what happen

(sic) between [client H] and [staff #9]. [Client H's

guardian] replied [client H] called her, she missed

[client H]'s call and then called [client H] back.

[Client H's guardian] states she could hear [client

H] and staff arguing while on the phone. [Client

H's guardian] states that [staff #9] told [client H]

he had her f***** up. [Client H's guardian] states

that [client H] had a discussion about [staff #9]

not braiding his housemates hair ...[Client H's

guardian] states that [client H] was told by [staff

#9], what the f*** did you tell him? [Client H's

guardian] states that staff didn't start acting that

way until she went outside to smoke weed in the

car. [Client H's guardian] states that she called the

supervisor of the home and let her know what was

going on ...[Client H's guardian] stated that she

was on the phone with [client H] and could hear

[staff #9] in the background saying [client H] had

her f***** up. [Client H's guardian] states [staff

#9] was calling [client H] names. [Client H's





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guardian] states that [staff #9] was muffing his

head with her finger ...[Client H's guardian] was

asked what names did you hear [staff #9] call

[client H]. [Client H's guardian] replied I'm not sure

of what all she was saying. [Client H's guardian]

states they were both hollering. [Client H's

guardian] replied she hear (sic) [staff #9] call

[client H] stupid, childish, and a little boy. [Client

H's guardian] was asked did staff tell [client H]

they were smoking. [Client H's guardian] replied

yes, [staff #9] said she had gas or marijuana ...

[Client H's guardian] was asked did [staff #9] yell

at [client H]. [Client H's guardian] replied yes,

most definitely. [Client H's guardian] states that

[client H] went to his room and [staff #9] followed

[client H] yelling at him. [Client H's guardian] was

asked would [client H] change his story. [Client

H's guardian] replied yes, because [client H] and

[staff #9] made up. [Client H's guardian] states

[client H] kept telling [staff #9] to leave him

alone."

The IS indicated client H was interviewed on

1/29/19. The interview indicated "[Client H] was

ask (sic) what happened between you and [staff

#9]. [Client H] states that he was texting this girl

and she was p****** [client H] off ...[Client H]

states that then him (sic) and [client E] went

outside to smoke and talk. [Client H] states that

then [client E] came in the home and told [staff #9]

she didn't have to do his hair. [Client H] then

states that [staff #9] asked him what did you tell

[client E] ... [Client H] states that no one cursed at

him, he was in the wrong ...[Client H] was asked

was anyone else present when the incident

occurred. [Client H] replied my housemates, [staff

#9], [staff #10], and [staff #11] ... [Client H] was

asked did [staff #9] tell you she was going outside

to smoke gas or marijuana. [Client H] replied no ...

[Client H] was asked have (sic) [staff #9] cursed at





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you before and [Client H] replied no ...[Client H]

was asked did [staff #9] call you stupid, little boy,

or childish. [Client H] replied no, [staff #9] was

trying to calm me down. [Client H] was asked did

[staff #9] ever put her hand or finger in your face

and push your head. [Client H] replied no. [Client

H] was asked did [staff #9] tell you that you had

her f***** up at any point of the argument.

[Client H] replied no."

The IS indicated client F was interviewed on

1/29/19. The interview indicated "[Client F] was

asked have you ever heard [staff #9] curse at your

housemates. [Client F] replied yes, [staff #9] said

every name in the book to [client H]. [Client F]

was asked do you know the day the incident

occurred and [client F] replied no. [Client F] was

asked what did [staff #9] say to [client H]. [Client

F] replied [staff #9] kept telling [client H] to get

the f*** out of [staff #9]'s business. [Client F]

states that [client H] stated he was going to report

[staff #9] and [staff #9] then put her hand in

[client H]'s face ...[Client F] states that [client H]

told [staff #9] to leave him alone. [Client F] states

that [staff #9] said she was going to her car to

calm down. [Client F] states that [staff #9] told

[client H] to get the f*** away from her car.

[Client F] states that [staff #9] stated she was

going to whoop [client H]'s a**. [Client F] states

that [staff #9] then called [client H] a little n****.

[Client F] was asked did [staff #9] say she was

going outside to smoke marijuana and calm down.

[Client F] replied yes, to chill her nerves from

[client H] talking s***. [Client F] was asked did

you see [staff #9] smoke marijuana and [client F]

replied no ...[Client F] was asked did [staff #9] call

client H] stupid. [Client F] replied [staff #9] called

[client H] a stupid a** n**** ...".

The IS indicated client E was interviewed on





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1/29/19. The interview indicated "[Client E] was

asked how do you get along with [staff #9]. Client

E] replied staff #9] is cool, I never had any issues

with her. [Client E] was asked have you witnessed

[staff #9] use her hand or fingers to push [client

H]'s head. [Client E] replied no ...[Client E] as

asked did you hear arguing and [client E] replied

no ...[Client E] was asked do you know if [staff #9]

went out to her car to smoke marijuana and [client

E] replied no ...[Client E] was asked have you ever

heard staff call [client H] out of his name and

[client E] replied no ...".

The IS indicated RM #2 was interviewed on

1/29/19. The interview indicated "[RM #2] was

asked what happen (sic) between [staff #9] and

[client H]. [RM #2] replied I got a call last

Thursday from [client H]'s mom saying that I

needed to call [group home name]. [RM#2] states

that client H]'s mom was on the phone with him

and heard [staff #9] go off. [RM #2] states that

she then called [staff #9] and [staff #9] stated that

[client H] was snapping on her. [RM #2] states

that [staff #9] was trying to calm [client H] down

and [staff #9] told [client H] not to disrespect her.

[RM #2] states she then called [group home name]

and spoke with [client H] to figure out his side of

the story. [RM #2] stated that [client H] reported

to her he and [staff #9] had a disagreement ...[RM

#2] stated that [staff #9]'s questions turned [client

H] into a behavior ...[RM #2] states that staff

should not argue back and forth or raise their

voices ...[RM #2] stated she reported the incident

to her supervisor..[RM #2] was asked did [staff

#9] yell at [RM #2] ([client H]) and [RM #2] replied

yes, that's what [client H]'s mom reported to me.

[RM #2] was asked did [client H] report to you

that [staff #9] cursed him out. [RM#2] replied

[client H] reported to her [staff #9] told [client H]

to sit his little a** down and calm down ...[RM #2]





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was asked what type of tone does [staff #9] take

with [client H]. [RM #2] replied [staff #9] may get

sassy but [staff #9] has a regular tone with the

guys for the most part ...[RM #2] was asked did

[client H] report to you that [staff #9] stated

[client H] had her f***** up and [RM#2] replied

yes."

The IS indicated client C was interviewed on

1/29/19. The interview indicated " ...[Client C] was

asked did you hear any arguing between them

(staff #9 and client H) and [client C] replied yes ...

[Client C] was asked did you hear [staff #9] yell at

[client H] and [client C] replied yes ...".

The IS indicated client B was interviewed on

1/30/19. The interview indicated " ...[Client B] was

asked did you hear arguing and [client B] replied

yes ...[Client B] was asked was [staff #9] cursing

and [client B] replied yes, I can't remember what

she said ...[Client B] was asked does [staff #9]

ever yell at you and [client B] replied yes. [Client

B] was asked what did [staff #9] say and [client B]

replied [staff #9] stated if I had a problem with

[staff #9] to tell her instead of other staff ...".


1/30/19. The interview indicated "[Staff #11] was

asked did [staff #9] call [client H] childish or a

little boy and [staff #11] replied [staff #9] stated

[client H] was acting like a little boy ...[Staff #11]

was asked was [staff #9] yelling at [client H] and

[staff #11] stated to calm [client H] down [staff #9]

was yelling over him ....[Staff #11] was asked what

type of tone does [staff #9] take with the

consumers and [staff #11] replied [staff #9] talks

loud but is never intimidating ...".


1/30/19. The interview indicated "[Staff #9] was





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asked what happened between you and [client H].

[Staff #9] replied I don't remember the day we had

to come to the home and [staff #9] asked [client E]

is (sic) he had shampoo so that [staff #9] could do

[client E]'s hair. [Staff #9] states that [client H]

stated they were going to call the police. [Staff #9]

states she had no idea what [client H] was talking

about. [Staff #9] then stated [client H] asked

[client E] to come outside with him. [Staff #9]

stated that [client E] then came in the home and

stated that [staff #9] didn't have to do his hair.

[Staff #9] stated that she asked [client H] what did

you tell [client E]. [Staff #9] states that [client H]

was asking (sic) upset like he was going to fight

[staff #9]. [Staff #9] states that [client H] got on

the telephone with his mom. [Staff #9] states that

she went outside to call [RM #2] but [RM #2]

ended up calling her first. [Staff #9] states that

[RM #2] told her [client H]'s mom called and they

were upset.. [Staff #9] states that [RM #2] told

[client H]'s mom [RM #2] was going to handle it.

[Staff #9] states that when she came in the house

from outside [client H] apologized to her. [Staff

#9] states that she told [client H] if he feels as if

[staff #9] accused him of something she's sorry ...

[Staff #9] was asked what type of tone do you

take with [client H]. [Staff #9] replied when [client

H] jumped in my face I wasn't screaming, [client H]

was yelling at me and I was talking over him ...

[Staff #9] was asked was there anytime (sic) where

you had to raise your voice. [Staff #9] replied

when I told [client H] to be quiet and stop yelling

over me ...[Staff #9] was asked was there anytime

(sic) you had to put your hand in [client H]'s face

or push his head. [Staff #9] replied no. [Staff #9]

was asked did you call [client H] names like

stupid, childish, little n*****, or say [client H]

had you f***** up. [Staff #9] replied no ...[Staff

#9] was asked did you tell anyone in the home

that you were going outside to smoke marijuana.





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[Staff #9] was asked did any staff have to tell you

to stop outside and [staff #9] replied no. [Staff #9]

was asked did you tell [client H] to sit his little a**

down and [staff #9] replied no ...[Staff #9] was

asked did you tell [RM #2] that you were going to

beat [client H]'s a** and [staff #9] replied no ...".

The IS's conclusion indicated "After thorough

review of documentary evidence, it was

determined by the peer review committee that

staff, [staff #9], employment will be separated for

7.1A1, power struggle with consumer, cursing,

and verbal abuse. All staff in the home will be

retrained on the social media policy and reporting

suspected ANE (Abuse, Neglect, and

Exploitation)."

The facility's Policy/Procedure for Reporting and

Investigating Abuse, Neglect, Exploitation, and

Mistreatment of clients dated 6/2011 was reviewed

on 2/22/19 at 1:28 PM and indicated "All

allegations or occurrences of

abuse/neglect/exploitation/mistreatment shall be

reported to the appropriate authorities through

the appropriate supervisory channels and will be

thoroughly investigated under the policies of

ResCare Northern Region Indiana, local, state and

federal guidelines...Procedures: 1. Any ResCare

staff person who suspects an individual is the

victim of abuse/neglect/exploitation should

immediately notify the Director of Supported

Group Living (group homes), then complete an

Incident Report. The Director of Supported Group

Living/Supported Living will then notify the

Executive Director. This step should be done

within 24 hours. The Director of the program (SGL

or SL) or designee will report the suspected

abuse, neglect or exploitation within 24 hours of

the initial report to the appropriate contacts,

which may include:...Bureau of Developmental





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Disabilities Service Coordinator...The Director of

the Program (SGL or SL) will assign an

investigative team. A full investigation will be

conducted by investigators who have received

training from Labor Relations Association and

ResCare's internal procedures or

investigations...One of the investigators will

complete a detailed investigative case summary

based on witness statements and other evidence

collected...An investigative peer review committee

chosen by the Executive Director will meet to

discuss the outcome of the investigation and to

ensure that a thorough investigation has been

completed. Members of the committee must

include at least one of the investigators, the

Executive Director or designee, Director of

Supported Living or SGL, and a Human Resources

representative."

The Area Supervisor (AS) and the Program

Manager (PM) were interviewed on 2/22/19 at

10:50 AM. The PM indicated clients should not be

subjected to verbal abuse by staff. The PM

indicated the agency at the time when the

property came up missing did not have a

procedure in place to keep track of large expensive

items and should have. The PM indicated clients

should not have their items misplaced or taken by

staff or other consumers. The PM indicated staff

should have implemented the facility's Policy and

Procedure for reporting and investigating

suspected Abuse, Neglect, Exploitation, and

Mistreatment.

This federal tag relates to complaint #IN00285653.

9-3-2(a)

483.420(d)(2)


W 0153





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The facility must ensure that all allegations of

mistreatment, neglect or abuse, as well as

injuries of unknown source, are reported

immediately to the administrator or to other

officials in accordance with State law through

established procedures.

Bldg. 00


sampled clients (A) plus 1 additional client (E), the

facility failed to ensure immediate reporting of

missing personal property to an administrator and

BDDS (Bureau of Developmental Disabilities

Services) in accordance with state law.

Findings include:
















...".






W 0153 W153: The facility must ensure

that all allegations of

mistreatment, neglect or abuse,

as well as injuries of unknown

source, are reported immediately

to the administrator or to other

officials in accordance with State

law through established

procedures. Staff will be retrained

on our abuse neglect policy with

attention to the reporting policy.

QIDP will receive training on

reporting any allegation of

abuse/neglect exploitation

immediately to the Program

Manager. The QIDP will include

asking staff when they are to

report abuse/neglect when she is

completing her weekly observation

form. A member of the

Management team (Executive

Director, Program Manager, Nurse

Manager and/or Quality Manger)

will complete a site review monthly

that will include questions about

abuse/neglect.

03/27/2019 12:00:00AM





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pick it up but was no longer in the area it was






10/12/18."



10:50 AM. The PM and AS indicated staff should

have reported immediately to an administrator

when the items were discovered missing. The PM

indicated the Qualified Intellectual Disability

Professional should have reported immediately to

an administrator when it was reported to her by

staff.


9-3-2(a)

483.420(d)(3)


The facility must have evidence that all

alleged violations are thoroughly investigated.

W 0154

Bldg. 00

Based on record review and interview 1 of 3

sampled clients (A), plus 1 additional client (E),

the facility failed to complete thorough

investigations regarding clients A and E's missing

personal property by not including

recommendations.

Findings include:




W 0154 W154: The facility must have

evidence that all alleged violations

are thoroughly investigated. The

Quality team will be trained that

there must be recommendations

to prevent further occurrence

included on investigations. The

Executive Director will review the

summary of investigations to

assure that there are

recommendations to prevent

further occurrence. All consumer

property will be entered on the

inventory list upon purchase.

03/27/2019 12:00:00AM





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A 1/9/19- 1/16/19 IS (Investigative Summary)

indicated "On 1/8/19, at approximately 7:54AM, it

was discovered that an electronic tablet belonging

to [client A] was unable to be located. The tablet

is kept in the med room when not in use."













The 1/9-1/16/19 investigation did not recommend

staff do an inventory check to make sure clients

had all personal belongings accounted for.








Large or expensive items (TVs,

tablets, computers, etc.) will be

inventoried 2 times weekly by the

Site Supervisor using the

Habilitation Observation form. The

QIDP will inventory those items 1

time per week via the Habilitation

Observation form.





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...".

A 10/23-10/26/18 investigation did not indicate

any recommendations to take an inventory of

items of significant value when they are brought

in after admittance to the facility.



10:50 AM. The PM and AS indicated an

inventory is done upon admittance into the

facility and each year after. The PM and AS

indicated if this had been done staff would have

know client A had a television under his bed and

client E had a personal laptop. The PM and AS

indicated staff should have put the television and

laptop on an inventory sheet when they were

purchased. The AS and PM indicated the

investigations did not give any recommendations

on how to prevent client's personal items coming

up missing and it should have.


9-3-2(a)

483.420(d)(4)


The results of all investigations must be

reported to the administrator or designated

representative or to other officials in

accordance with State law within five working

days of the incident.

W 0156

Bldg. 00

Based on record review and interview for 1 of 3 W 0156 W156: The results of all

investigations must be reported to 03/27/2019 12:00:00AM





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facility failed to report the results of an

investigation of clients A and E's missing

property to the administrator within 5 business

days of the alleged events.

Findings include:











A 1/9-1/16/19 Investigative Summary indicated

results of the investigation were completed on

1/16/19 which was after 5 business days after the

alleged event.







...".

A 10/23-10/26/18 Investigative Summary indicated

results of the investigation were completed on

10/26/18 which was 10 business days after the

alleged event.



the administrator or designated

representative or to other officials

in accordance with State law

within five working days of the

incident. The Quality team will be

trained that all investigations are

to be completed within 5 business

days of the incident. The Quality

team will keep a record of when an

investigation begins and when it

ends to assure that they are

completing the investigations

within the 5 business days. The

Executive Director will

monitor/review the record weekly

to assure that the investigations

are being completed within the five

business days.





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10:50 AM. The PM and AS indicated the results

of an investigation should be available 5 days

after alleged event, not 7 or 10.


9-3-2(a)

483.420(d)(4)


If the alleged violation is verified, appropriate

corrective action must be taken.

W 0157

Bldg. 00



facility failed to ensure effective corrective

measures were in place to prevent the potential for

future personal property to come up missing.

Findings include:











A 1/9/19 IS (Investigative Summary) indicated

"On 1/8/19, at approximately 7:54AM, it was

discovered that an electronic tablet belonging to

[client A] was unable to be located. The tablet is

kept in the med room when not in use."


W 0157 W157: If the alleged violation is

verified, appropriate corrective

action must be taken. Quality

team will be trained that there

must be recommendations to

prevent further occurrence

included on investigations. The

Executive Director will review the

summary of the investigations to

assure that recommendations to

prevent further occurrence are

included. All consumer property

will be entered on the inventory list

upon purchase. Large or

expensive items (TVs, tablets,

computers, etc.) will be inventoried

2 times weekly by the Site

Supervisor using the Habilitation

Observation form. The QIDP will

inventory those items 1 time per

week via the Habilitation

Observation form.

03/27/2019 12:00:00AM





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...".






pick it up but was no longer in the area it was






10/12/18."





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The 10/23/18 investigation did not give

recommendations for administrators or staff on

ways to prevent clients' personal items being

misplaced and/or stolen by staff or other clients

which enter the home.



10:50 AM. The AS and PM indicated there were

not effective corrective measures since personal

belongings came up missing on 3 separate

occasions. The AS and PM indicated client A

now has a sign in and out sheet for his tablet. The

AS and PM indicated they track inventory when a

client moves in and on an annual basis thereafter.

The PM and AS indicated they have not checked

the inventory sheets since items have come up

missing to ensure all clients in the home have

record of all personal items of value.


9-3-2(a)


Documents

W 0000 - In · 2019. 4. 1. · He usually come(s) when I'm asleep already and he comes in my room while I'm sleeping. It's been plenty of times I roll over and he sitting on my couch