DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 03/121~014FORM APPROVED

OMB NO 0938-0391STATEMENT Of DEfiCIENCIESAND PLAN OF CORReOTION

(Xl) PROVlDER[SUPPlIERICLIAIDENTIFICATION NUMBER:

NAME OF PROVIDER OR SUPPLIER09G162

METRO HOMES

02/28/2014B.WlNG

(X2) MULTIPLE CONSTRUCTIONA. BUILDING _

(X4) IDPREFIX

TAG

SUMW\RY. STATEMENT OF DEFICIENCIES(EACH D.EFICIENCY MUST BE PRECEDED BY FULL

REGUlATORY OR LSC IOENTIFYlNG INFORMATION)

10PREFIX

TAG

(X3) DATE SURVEYCOMPLETED

STREET ADDRESS, CITY, STATE, ZIP CODE

4424 20TH STREET, NEWASHINGTON, DC 20019

PROVIDER'S PLAN OF COMeCTION(EACH CORRECTIVEAOTION SHOULD BE

CROSS·REFERENCED TO THE APPROPRIATEDEFICIENCy)

(X6)COMPLETION

·DATE

W 000 INITIAL COMMENTS

A recertification survey was conducted fromFebruary 24,2014 through February 26,2014. Asample of three clients was s.elected from apopulation of five men and women with varyingdegrees of Intellectual disabllltl~s. This surveywas conducted utilizing the fundamental surveyprocess. .

The findings of the survey were based onobservations, interviews and review of client andadministrative records.

Note: the below are abbreviations that mayappear throughout the body of this report.

Group Home for Individuals with IntellectualDisabilities - GHIIDIntermediate Care Facility -ICFMilligrams - MGPhysical Therapy - PTPrimary Care Physician - PCPQualified Intellectual Disabilities Professlonal-QIDPRegistered Nurse - RNTrained Medication Employee - TMEUrinary Tract Infection - UTIDay Program Staff-DPSDirect Support Professlonal-DSPIndividual Support Plan-ISP

W 120 483.41 O(d)(3) SERVICES PROVIDED WITHOUTSIDE SOURCES

The facility must assure that outside servicesmeet the needs of each client.

This STANDARD Is not met as evidenced by:

W120

wooo

~80Rl\TOAY OIREF~R'S '?l.FfOVIOERlS~PllER ~$ENTATrrS ~IGNAT~.. .[ TITLE r71. (X6)OATE

. .Ji...ll\L... \. \ ~ O)\} t:::(~(\~IJ(J" k:AM<~r ~'LLl(t-\Any deficiency s\atemelit\ending .wi!h an asterisk (.) denotes a deficiency which the institution may be excu$~d from C;orreclll'igproviding it Is determined thatother safeguards provide sufficient protection (0 the patients. (See Instrucllons.) Except for nursing homes e . the findings stated above are dlsclosable. 90 daysfollowing the date of survey whether or not a plan of correction Is proVIded. For nursing homes, the above flndil'!gs and plans of correcilon are d/s.closable 14days following the dale these documents are made available 10 the facility. If deficIencIes are cited, an approved plan of correction is requisite to continuedprogram partlclpallon.---_._-----_.---_ ....._-

FORM CMS-2687{OZ.99) Previous VersionS Obsolete Event lO;EMLT11 Facility 10: 09G162 If continuation Sheet Page 1 of 3

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 03112/2014FORMAPPROVED

OMB NO: 0938-0391STATEMENT OF DEFICIENCIESAND PlAN OF CORRECTioN

090162 B.WING 02126/2014

(X1) PROVlOERISUPPLIERIClIAIDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTIONA. BUlLOiNG _

(X3) DATE .SURVEYCOMPLEtED

NAME Of PROVIDER OR SUPP.UER

METRO HOMES

SUMMARY STATEMENT OF OEFI~IENCIES(EACH DEFICIENCY MUST PI: PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

(X4)IDPREFIX

TAG

W 120 Continued From page 1Based on observation, interview and recordreview, the faoility failed to ensure that staffemployed by outside services utilized each iclient's adaptive equipment effeotively duringambulatlon, for one of three clients In the sample.(Cflent#3)

The finding includes:

On February 24, 2014, at 6:21 p.m., DSP #1 inthe home was observed escorting Client #3 fromthe clienfs bedroom to the dining room table. Theclient walked Independently lIslng a roiling walker.The client also wore a gait belt, which DSP #1held loosely as she walked behind the client.Client #3 was again observed ambulatingindependently in the home the next morning(February 26, 2014) at 7:22 a.m. DSP #2 wasobserved using the same technique (looselyholding the client's gait belt) durIng ambulatlon,On occasions, the gait belt was placed aroundClient #3's waist.

A different technique, however, was observedbeing used at Client #3's day program onFebruary 25, 2014. At 12:20 p.m., the client wasobserved ambulating In the classroom. The clientwas using the rolling walker and his/her gait beltwas observed to be placed around the upperchest and torso Instead of the waist. DPS #1 wasobserved holding a loop on the back of theclient's gait belt firmly and pulling upward on thebell. When asked, the day program supervisorycase coordinator COPS #2), who was present atthe time, stated that the physical therapist fromthe home had trained all of fhelr staff, includingDPS #1, on the proper use of the gait belt andthat it was acceptable for the belt to be securedaround the chest.

FORM CMS·2587(02·9$) Prev'.ous VetSlons Obsol~te EvenllD: EMLT11

10PREFIX

TAG

W120

STREET ADORESS. CITY. $TA'rE.ZIP CODe

4424 20tH STREET. NEWASHINGTON, DC 20019

PR.OVlDER'S PlAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCEO TO iHEAPPROPRIATEDEFICIENCy)

(X5) .COMPleTION

DAlE

3/21/14

Ongoing

W120The day program staff have beenre-inserviced on the use of the gait be t,and that the gait belt be placed arounthe waist,and not the chest area.SYSTEM: The staff at day program ar dresidentially will be observed utilizingthe gait belt.

Facility 10:09G162 If conllnllsllon sheet Page 2 of 3

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

PRINtED: 03/1212014FORMAPPROVED

OMB NO 0938-0391.STATEMENT OF DEFICIENCIES (X1) PROVlQE;RlSUPPlIERiCllA tX2) MULTIPLE CONSTRUCTION tX3) DATE SURVEYAND PlAN -OF CORRECTION IDENTIFICATION N!,IM"ER: ABUILDING COMPLETED

09G162 B.WlNG 02126/2014NAME OF PROVlDEit OR SUPPliER STREET ADDRESS, CITY. STATE. ZIP CODE

METRO HOMES4424 20TH STREET, NEWASHINGiON, DC 20019

(X4)\O I SUMMARY STATEMENT Of DEFICIENCIES [0 PROVIDER'S PLAN OF CORREOTION (lt6)

PREFIX I (EACH OEFICI/:NCY MUST BE·PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTlON SHOULD BE COMPLETIONTAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCy}

1W 120 Continued From page 2 W120

On February 26, 2014, at 2:09p.m., the QIDPwas asked about the positioning and use of Client#3's gait belt. The QIOP stated it should beplaced around the waist and staff should hold itloosely, as a precaution (If the the cllent shouldlose his/her balance). The QIDP said the gait beltshould never b.e placed around the chest, andstaff should not pull on the belt as long as theclient was ambulating Independently with his/herwalker.

IOn February 26, 2014, at 2:21 p.m., review ofClient#3's PT Evaluation dated September 18,2013, revealed the client could ambulate with useof the walker ''with contact g~ard assistance" anda ''waist gait belt. ••At 3:09 p.m., the QIDP

Ipresented documentation shoWing that thephysical therapist had provided training for dayprogram staff on March 29, 2012, almost twoyears earlier. Review of the signature sheetrevealed that both DPS #1 and DPS #2 had beenin attendance. When asked about more recenttraining, the QIDP acknowledged that there hadnot been additional PT training provided for Client#3'5 day program staff since then.

There was no evidence that the facility routinelymonitored the ambulation supports that Client #3received while at day program.

I

FORM CMS-2067(02-99) Previous Versions Obsolete Event ID:EMLT11 Facifrty II): 09G182 If conUiluation sheet Page 3 of 3

Health Reaulation & Llcenslna Administration

PRINTEO: 03/12/2014FORM APPROVED

STATEMENTOF DEFICIENCIES (Xi) PROVIOERlS.UPPlIERICLIAANO PLAN OF CORRECTION IDENTIFICATIONNUMBER:

HFD03-0149

(X2) MULTIPLE.CONSTRUCTIONA. BUILDING: _

B. WINO

(X3) DATE SURVEYCOMPLETED

02/26/2014NAME OF PROVIDER OR SUPPLIER

METRO HOMES

STREET ADDRESS, CITY,srATE, ZIP CODE

4424 20TH STREET, NEWASHINGTON, DC 20019

(X4)IDPREFIX

TAG

SUMMARY STATEMENT Of DEFICIENCIES 10(EACH DEFICIENcY MUSTBE PRECEDED BY FULL PREFIX

REGULATORYOR LSC IDENTIFYINGINFORMATION) TAG'

reoc INITIAL COMMENTS

A licensure survey was conducted from February24, 2014 through February 26, 2014. A sample ofthree residents was selected from a population offNe men and women with varying degrees ofintellectual disabilities.

The findings of the survey were based onobservations, intelViews and review of residentand administrative records.

1000

I 095 3504.6 HOUSEKEEPING I 095

Health Regulation & licenSing AdmlnlslrallonLA RATORY DIRECTOR'S OR PROVIDERISUPPLIER REPRE~ENTATIVE'S SIGNATU E

Note: The below are abbreviations that mayappear throughout the body of this report.

Group Home for Individuals with IntellectualDisabilities - GHIIDIntermediate Care Facility - rCFMilligrams - MGPhysical Therapy - PTPrimary Care Physician - PCPQualified Intellectual Disabilities Professional-QIDPRegistered Nurse - RNTrained Medication Employee - TMEUrinary Tract Infection - UTIDay Program Staff-DPS

Direct Support Professional·DSPIndividual Support Plan-ISP

Each polson and caustic agent shall be stored ina locked cabinet and shall be out of direct reachof each resident.

This Statute is not met as evidenced by:Based on observation and inlelVlew, the GHIiDfailed to store poisonous agents tn a lockedcabinet and/or out of direct reach of each

IiROVIOER'S PlAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THe APPROPRIATEDEFICIENCy)

(Xl;)COWPLETE

DATE

1095The direct support professionals havebeen trained on the storage of poisono sagents being in a locked cabinet. 3/12/14SYSTEM:At least annually and as needed, staffwill be re-inserviced on storage ofpoisonous chemicals. ongoing

TITLE

If conunuaUon sheet 1 or 2

...._._ __._ _..- , --_.-.- _-.." -.,-.- -- -.--.."" - - -..- - ,~ -.- w"'f

Health Reaulatlon & l censma Administration(X2) MULTIPLE CONSTRUCTIONA. BUILDING: _

sTAtEMENT OF DEFICIENCIES (Xi) PROVIDERlSUPPlIERIClIAAND PLAN OF CORRECTION IDENTIFICATION NuMBER;

HFD03·0149

NAME Of PROVIDER OR SUPPLIER

B.WING

METRO HOMES

STREET ADDRESS, CITY, STATE, ZIP CODE

4424 20TH STREET. NEWASHINGTON, DC 20019

PRINTED: 0311212014FORM APPROVED

(X3) DATE SURVEYCOMPLETED

02/2612014

SUMMARYSTATEMENT ot DEFICIENCiES 10(EACH DEFICIENCY MUST BE PRECE.OED BY FUll PREFIX

REGULATORY OR lSC·IDENTIFYlNG INFORMATION) TAG

P(5)COMPLETEDAle

(X4)IDPREFIX

TAG

I 095 Continued From page 1 I 095

resident, for five of five residents of the facllily.(Residents #1, #2. #3, #4 and #5)

The finding includes:

During the environmental walk~thru on February26, 2014, at 3:35 p.m., a botlle of ReevaAutomatic Dlshwashlng Gel was observed In anunlocked cabinet beneath the kitchen sink.Review of the product label revealed thefollowing: "Caution: Harmful If sWallowed. Eyeand skin irritant. Keep out of reach ofchlldren ...Contains sodium silicate, sodiumhydroxide and chlorine ..• If swallowed or gets Inmouth, rinse mouth thoroughly, drink a largeglass of water or milk. After providing first aid. calla polson control center or doctor Immediately ..."

Observations during the survey had revealed allfive resldentswere ambulatory and had access tothe area.

The QIDP, who was present at the lime, removedthe bottle Immediately.

PROviDER'S PLAN Of CORRECTION(eACH CORRECTIVE ACTION SHOULD BE

CROSS·REfl:RENCEO TO 'fHeAPPROPRlATEDEFICIENCy) .

Health Regulal/on & LIcensing AdministrationSTATE FORM EMLT11 If ~un\lation sheet 2 of 2

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