printed: 01/04/2018 department of health and human … · 2018. 1. 4. · left front wheel won't...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

01/04/2018PRINTED:

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)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

INDIANAPOLIS, IN 46241

15G435 10/26/2017

TRANSITIONAL SERVICES SUB LLC

4155 RAY ST

00

W 0000

Bldg. 00

This visit was for a PCR (Post Certification

Revisit) to a full annual recertification and

state licensure survey completed on

8/22/17. This visit included the PCR to the

investigation of complaint #IN00235174

which resulted in an Immediate Jeopardy on

8/22/17.

This visit was done in conjunction with the

PCR to the PCR completed on 8/22/17 to

the investigation of complaint #IN00230402

completed on 6/9/17.

Complaint #IN00235174: Not Corrected.

Dates of Survey: 10/19/17, 10/20/17,

10/23/17 and 10/26/17.

Facility Number: 000949

Provider Number: 15G435

AIMS Number: 100244680

These deficiencies reflect state findings in

accordance with 460 IAC 9.

Quality Review of this report completed by

#15068 on 11/16/17.

W 0000

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: LUEH13 Facility ID: 000949

TITLE

If continuation sheet Page 1 of 32

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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

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Based on observation, record review and

interview for 1 additional client (E), the

facility failed to implement its written policy

and procedures to thoroughly investigate

client E's fall with injury to determine

contributing factors to the fall regarding the

condition of his manual wheelchair and to

develop and implement corrective measures

to prevent recurrence.

Findings include:

Observations were conducted at the group

home on 10/20/17 from 7:00 AM through

8:20 AM. Client E utilized a manual

wheelchair for his ambulation needs. At 8:23

AM, staff #4 pushed client E in his

wheelchair from the home's side door, down

a wheelchair ramp and to the home's van for

transport. The front left wheel on client E's

wheelchair did not swivel properly as staff

pushed the wheelchair.

The facility's BDDS (Bureau of

Developmental Disabilities Services) reports

W 0149 The facility has policies and procedures in place that prohibit

abuse, neglect, mistreatment, or

exploitation of the clients served.

The Regional Director will retrain

the Quality Improvement

Specialist (QIS) on the

components of a thorough

investigation, including the need to

review any and all factors that

could contribute to a client’s fall

such as the client’s health status

prior to a fall, interviewing

additional staff that could have

insight into the clients health

status, an environmental

assessment, and an adaptive

equipment assessment to

determine functionality/condition of

wheelchair.

The Quality Improvement Manager

will review all investigations at this

location for the next month to

ensure thoroughness of

investigations. The Quality

Improvement Manager will

continue to review investigations

as needed ongoing after that time.

11/25/2017 12:00:00AM

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and investigations were reviewed on

10/19/17 at 1:33 PM. The review indicated

the following:

-BDDS report dated 10/7/17 indicated,

"Staff (unspecified) was assisting all

consumers off (of) the van (on 10/6/17) and

into the house after the van run. Staff went

to check on [client E] and saw his

wheelchair by the entrance to the bathroom

door. Staff went in (to) the restroom and

saw [client E] on the floor and his head was

bleeding. Staff assisted [client E] back onto

the toilet and assess (sic) his head. He had a

few small cuts on his forehead. When staff

asked if he fell, he said 'yes'. Staff tried to

stop the bleeding and assisted him back to

his wheelchair. Staff notified [RN

(Registered Nurse) #1] and [PC (Program

Coordinator) #1]. Staff were directed to

take [client E] to (the) ER (Emergency

Room) for evaluation since he hit his head.

At the ER, [client E] was assessed and no

additional injuries were indicated. They

cleaned the cuts on his head-no stitches

were required but glue was applied to cut to

seal it. [Client E] was released to come

back home."

-Internal Investigation dated 10/13/17

indicated QIS (Quality Improvement

Specialist) #1 completed an investigation

Client E had a wheelchair

assessment and the front left

wheel has been repaired. The

Area Director will retrain the

Program Supervisor to ensure

prompt response to any adaptive

equipment needs or assessments.

Addendum:

The Lead Area Director will provide

ongoing oversight of all incidents

for the next two month and ensure

those that require investigations to

be completed are done so

following the facilities policies.

The Lead Area Director will

monitor the next five investigations

to ensure they are thorough and

the completed investigation and

results are shared with the

administrator within five working

days, and will continue routine

monitoring ongoing thereafter.

Any investigations regarding any

abuse, neglect and/or exploitation

will receive a final review by the

Regional Quality Improvement

Manager over the Redwood

operating group (this position is


Managers Supervisor.) This will

ensure a minimum of three people

are reviewing each investigation for

thoroughness.





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regarding client E's 10/6/17 fall with injury.

The Internal Investigation dated 10/13/17

did not indicate documentation of a review

of factors contributing to client E's 10/6/17

fall. The investigation did not review client

E's status prior to the fall to determine if

there had been any changes in his health

status. The review did not identify or review

issues or concerns regarding the

functionality/condition of client E's

wheelchair as a potential contributing factor

to his fall.

QIS #1 was interviewed on 10/19/17 at

2:39 PM. QIS #1 indicated she had

completed the 10/13/17 Internal

Investigation regarding client E's 10/6/17 fall

with injury. QIS #1 indicated she had not

interviewed staff who had worked with

client E prior to the fall to determine if client

E had signs or symptoms of a change in

health status. QIS #1 indicated client E did

not have a history of falls and transferred

independently. QIS #1 indicated all

allegations should be thoroughly

investigated.

Staff #1 was interviewed on 10/19/17 at

6:07 PM. Staff #1 indicated the front left

wheel on client E's wheelchair was not

functioning properly. Staff #1 indicated client

E's wheelchair was difficult to maneuver with





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the front left wheel not turning and moving

properly. Staff #1 stated the front left wheel

on client E's wheelchair had not worked for

"a few weeks". Staff #1 indicated client E's

wheelchair had not been repaired and

continued to be difficult to maneuver.


5:35 PM. Staff #2 indicated client E did not

have a history of falls and was able to

transfer from his wheelchair independently

prior to the 10/6/17 fall. Staff #2 stated,

"[Client E's] wheelchair is not too good. The

left front wheel won't roll straight. I noticed it

last week. Told [PC #1] about it."


5:49 PM. Staff #3 indicated he was not

working in the home at the time of client E's

fall on 10/6/17 but came in for his shift after

the fall and transported client E to the ER.

Staff #3 indicated client E did not have a

history of falls prior to 10/6/17. Staff #3

indicated the front left wheel on client E's

wheelchair was not functioning. Staff #3

indicated client E had been able to self

propel/maneuver his wheelchair.

Client E's record was reviewed on 10/23/17

at 1:00 PM. Client E's Risk Assessment

form dated 8/13/17 indicated client E used a

manual wheelchair or crawled to





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move/ambulate and could independently

transfer from his wheelchair. Client E's

record did not indicate documentation of a

wheelchair repair/assessment since client E's

10/6/17 fall to determine if client E's

wheelchair was a contributing factor to the

10/6/17 fall.


8:23 AM. Staff #4 indicated the front left


working correctly.

The facility's policy and procedures were

reviewed on 10/26/17 at 9:00 AM. The

facility's Quality and Risk Management

Policy dated September 2017 indicated the

following:

-"Indiana Mentor promotes a high quality of

service and seeks to protect individuals

receiving Indiana Mentor services through

oversight of management procedures and

company operations, close monitoring of

service delivery and through a process of

identifying, evaluating and reducing risk to

which individuals are exposed.

-"Indiana Mentor is committed to

completing a thorough investigation for any

event out of the ordinary which jeopardizes

the health and safety of any individual served





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or other employee."

-"Investigation summary report will minimally

include: (a) Immediate safety measures put

into place following event/alleged event; (b)

Nature of the event/allegation; (c)... (d)

Review of all information reviewed (daily

support records, staff notes, medication

administration records, behavior tracking or

any other evidence reviewed."

This deficiency was cited on 8/22/17. The

facility failed to implement a systemic plan of

correction to prevent recurrence.

This federal tag relates to complaint

#IN00235174.

9-3-2(a)

483.420(d)(3)


The facility must have evidence that all

alleged violations are thoroughly investigated.

W 0154

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interview for 1 of 1 fall with injury reviewed,

the facility failed to thoroughly investigate

client E's fall with injury to determine

W 0154 The Lead Area Director will retrain the Area Director and QIDP on the

facility’s investigation policy and

procedures to confirm all

investigations are thorough and

11/25/2017 12:00:00AM





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contributing factors to the fall regarding the

condition of his manual wheelchair.

Findings include:





the following:






















the completed investigation and

results are shared with the

administrator within five working

days.

The Lead Area Director will

provide ongoing oversight of all

incidents for the next two month

and ensure those that require

investigations to be completed are

done so following the facilities

policies. The Lead Area Director

will monitor the next five

investigations to ensure they are

thorough and the completed

investigation and results are

shared with the administrator

within five working days, and will

continue routine monitoring

ongoing thereafter.

The Lead Area Director will retrain


Specialist (QIS) on the

components of a thorough

investigation, including ensuring

that all parties related to the

incident are interviewed so that a

thorough investigation can be

completed.

The Quality Improvement Manager

will review all investigations at this

location for the next month to

ensure thoroughness of

investigations. The Quality





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back home."








fall. The investigation did not review client

E's status prior to the fall to determine if

there had been any changes in his health

status. The review did not identify or review




to his fall.












Improvement Manager will

continue to review investigations

as needed ongoing after that time.





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health status. QIS #1 indicated client E did

not have a history of falls and transferred

independently. QIS #1 indicated all

allegations should be thoroughly

investigated.























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10/6/17 fall.




working correctly.






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#IN00235174.

9-3-2(a)

483.420(d)(4)


If the alleged violation is verified, appropriate

corrective action must be taken.

W 0157

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interview for 1 of 1 fall with injury reviewed

regarding client E, the facility failed to

develop and implement corrective measures

to prevent recurrence.

Findings include:





the following:





W 0157 A Lead Area Director

has been designated

to provide oversight

for all survey

corrections. Lead

Area Director will

provide training to all

staff, including

Program Coordinator

to ensure that

ongoing all adaptive

equipment needs are

assessed and

addressed. Ongoing,

Program Nurse, QIDP

11/25/2017 12:00:00AM





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back home."








fall. The review did not identify or review




and/or Program

Coordinator will

complete inspections

of all adaptive

equipment a minimum

of weekly to ensure

equipment is in good

working order. If any

repairs are assessed

to be needed, Lead

Area Director will be

notified to ensure

repair or replacement

is completed as soon

as possible.





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to his fall.



















health status or other contributing factors to

client E's 10/6/17 fall. QIS #1 indicated

client E did not have a history of falls and

transferred independently. QIS #1 indicated

all allegations should be thoroughly

investigated.









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10/6/17 fall.




working correctly.




9-3-2(a)

483.430(a)

QUALIFIED MENTAL RETARDATION

PROFESSIONAL

Each client's active treatment program must

be integrated, coordinated and monitored by

a qualified mental retardation professional.

W 0159

Bldg. 00


interview for 4 of 4 sampled clients (A, B, C

and D), plus 1 additional client (E), the

QIDP (Qualified Intellectual Disabilities

W 0159 1. Program Nurse will receive complete retraining with all staff on

ensuring that all medications are

available in the home and are able

to be administered as directed.

11/25/2017 12:00:00AM





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Professional) failed to integrate, coordinate

and monitor clients A, B, C, D and E's

active treatment programs by failing to

ensure staff working with clients C and H

were competent regarding medication

administration, to ensure clients' formal

training objective trials were documented

and to ensure client E's wheelchair was in

good repair.

Findings include:

1. The QIDP failed to integrate, coordinate

and monitor clients C and H's active

treatment programs by failing to ensure staff

working with clients C and H were

competent regarding medication

administration. Please see W189.


and monitor clients A, B, C and D's active

treatment programs by failing to ensure

clients A, B, C and D's formal training

objective trials were documented. Please

see W252.


and monitor clients E's active treatment

program by failing to ensure client E's

wheelchair was in good repair. Please see

W436.

Program Coordinator and Program

Nurse will complete a review of

MAR and all medications a

minimum of three times weekly for

6 weeks to ensure that all

medications are present in the

home and if needed to be refilled

that they are ordered and refilled

when there is only a 7 day supply

left. Since staff have been trained

on this multiple times, if a pattern

is seen with a particular staff not

ordering medications or notifying

the Program coordinator or

program nurse that medications

need to be ordered, they will be

given corrective action as needed.

Ongoing, Program Coordinator and

Program Nurse will complete a

review of MAR and all medications

a minimum of twice weekly to

ensure that all medications are

present in the home and if needed

to be refilled that they are ordered

and refilled when there is only a 7

day supply left. Since staff have

been trained on this multiple

times, if a pattern is seen with a

particular staff not ordering

medications or notifying the

Program coordinator or program

nurse that medications need to be

ordered, they will be given

corrective action as needed.

2.

All direct care staff have received

additional training on ensuring that





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9-3-3(a)

all consumers goals are

documented prior to the end of the

staff scheduled shift.

Program Coordinator will complete

a review of goal tracking

documentation a minimum of daily

for 4 weeks to ensure all

consumers goal are being

documented as directed.

After the initial 4 weeks, Program

Coordinator will complete a review

of goal tracking documentation a

minimum of every other day for an

additional 4 weeks to ensure all



Ongoing, the Program Coordinator

will complete a review of goal

tracking documentation a

minimum of three times weekly to

ensure all consumers goal are

being documented as directed.

Since staff have been trained on

this multiple times, if a pattern is

seen with a particular staff not

documenting goals as directed

they will be given corrective action

as needed.

3. Program Nurse will receive

complete retraining with all staff on









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483.430(e)(1)

STAFF TRAINING PROGRAM

The facility must provide each employee with

W 0189

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initial and continuing training that enables the

employee to perform his or her duties

effectively, efficiently, and competently.

Based on record review and interview for 1

of 4 sampled clients (C), plus 1 additional

client (H), the facility failed to ensure staff

working with clients C and H were

competent regarding medication

administration.

Findings include:





the following:

1. BDDS report dated 9/25/17 indicated,

"[Client C] is prescribed Aviane (birth

control) to be given daily. Directive is not to

give bottom (placebo tablets) to suppress

her menstrual cycle. New cycle of tablets

was not ordered timely and tablets were not

available for [client C] to take on (the)

evening of 9/24/17. [PC (Program

Coordinator) #1], [AD (Area Director) #1]

and [RN (Registered Nurse) #1] were

notified and medication was ordered. [Client

C] resumed medications as directed on

9/25/17. Staff (unspecified) and [PC #1]

will receive retraining on ensuring that all

non-cycle fill meds are ordered in advance

W 0189 Program Nurse will receive complete retraining with all staff on

































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so medications are available and there is no

delay in consumers receiving medications as

directed."

Client C's record was reviewed on

10/23/17 at 10:50 AM. Client C's

Physician's Orders dated 10/13/17

indicated, "Aviane 28 Tablet/Lutera 28

tablet. Take 1 tablet by mouth daily at 8 PM

for hormones. Skip placebo tablets. Take

continuously to suppress menstrual cycle."


"[Client H] is prescribed Ketoconazole

cream (anti-fungal) daily. After a review of

the MAR (Medication Administration

Record), it was noted that it was written on

the back of the MAR that the cream was

unavailable on the 6th, 7th (and) 8th of

September 2017. It was in fact in the house

and was delivered on 8/17/17. It was not

administered for sure on those 3 days."

Client H's record was reviewed on

10/23/17 at 6:23 PM. Client H's Physician's

Orders dated 10/1/17 indicated,

"Ketoconazole 2% Cream/Nizoral 2%

Cream. Apply Topically to feet daily for foot

fungus."

The home's In-Services and Training Binder

was reviewed on 10/23/17 at 10:00 AM.






Responsible Party: QIDP,

Program Nurse, Program

Coordinator





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The review indicated RN #1 completed an

In-Service/Training with all staff working in

the home on 10/12/17. The 10/12/17

In-Service indicated, "If you are passing

medication and you see that a cream, drops

or medication is only 7 days worth, then

reorder the medication, if it is urgent than

(sic) we must write urgent and follow up

with a call to the pharmacy."


4:50 PM. Staff #6 indicated medications

should be reordered when 4 pills were left.

Staff #6 indicated she would notify the

home's PC (Program Coordinator) to

reorder medications.


7:40 AM. Staff #5 indicated the she had

been trained to re-order and administer

medications by RN #1. Staff #5 stated she

would "call the nurse to reorder

medications" and medications should be

reordered "when the medicine is all gone".

RN #1 was interviewed on 10/23/17 at 1:35

PM. RN #1 indicated medications should be

re-ordered when supply is at 7 days. RN #1

indicated staff had been re-trained regarding

medication ordering timeframes to ensure

adequate supply. RN #1 indicated

medications should be administered as





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ordered.




9-3-3(a)

483.440(e)(1)

PROGRAM DOCUMENTATION

Data relative to accomplishment of the

criteria specified in client individual program

plan objectives must be documented in

measurable terms.

W 0252

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of 4 sampled clients (A, B, C and D), the

facility failed to ensure clients' formal training

objective trials were documented.

Findings include:

1. Client A's record was reviewed on

10/23/17 at 12:07 PM. Client A's Action

Plan Summary (APS) form dated from

9/1/17 through 10/23/17 indicated client A

had daily formal training objectives to

increase her independence regarding

medication administration, bathing her body,

feeding herself and clothing care. The review

indicated staff had documented 1 trial

through the 9/1/17 through 10/23/17 review

period.

W 0252 All direct care staff have received additional training on ensuring that

all consumers goals are

documented prior to the end of the

staff scheduled shift.

Program Coordinator will complete

a review of goal tracking

documentation a minimum of daily

for 4 weeks to ensure all



After the initial 4 weeks, Program

Coordinator will complete a review

of goal tracking documentation a

minimum of every other day for an

additional 4 weeks to ensure all



Ongoing, the Program Coordinator

will complete a review of goal

11/25/2017 12:00:00AM





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2. Client B's record was reviewed on

10/23/17 at 12:27 PM. Client D's APS

form dated 9/1/17 through 10/23/17

indicated client D had daily formal training

objectives to increase her independence

regarding medication administration, bathing,

chore completion, leisure time activity and

oral hygiene. The review indicated staff had

not documented any trials through the

9/1/17 through 10/23/17 review period.

3. Client C's record was reviewed on

10/23/17 at 10:50 AM. Client C's APS


indicated client C had daily formal training



chore completion, money management and

oral hygiene. The review indicated staff had

not documented any trials through the

9/1/17 through 10/23/17 review period.

4. Client D's record was reviewed on

10/23/17 at 11:46 AM. Client D's APS


indicated client D had daily formal training



chore completion, leisure time activity and

oral hygiene. The review indicated staff

documented 1 trial through the 9/1/17

tracking documentation a

minimum of three times weekly to

ensure all consumers goal are

being documented as directed.

Since staff have been trained on

this multiple times, if a pattern is

seen with a particular staff not

documenting goals as directed

they will be given corrective action

as needed.





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through 10/23/17 review period.

RD (Regional Director) #1 was interviewed

on 10/23/17 at 1:08 PM. RD #1 indicated

the home's QIDP (Qualified Intellectual

Disabilities Professional) was on vacation

and not available for interview. RD #1

indicated he was QIDP #1's supervisor. RD

#1 indicated he expected formal training

objective trials to be documented daily or as

indicated by the objectives criteria. RD #1

indicated there was not additional

documentation available for review

regarding training attempts for clients A, B,

C or D.




9-3-4(a)

483.460(k)(1)

DRUG ADMINISTRATION

The system for drug administration must

assure that all drugs are administered in

compliance with the physician's orders.

W 0368

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of 4 sampled clients (C), plus 1 additional

client (H), the facility failed to ensure clients

C and H's medications were administered as

W 0368 Program Nurse will receive complete retraining with all staff on




11/25/2017 12:00:00AM





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prescribed by their physicians.

Findings include:





the following:


"[Client C] is prescribed Aviane (birth

control) to be given daily. Directive is not to

give bottom (placebo tablets) to suppress

her menstrual cycle. New cycle of tablets

was not ordered timely and tablets were not

available for [client C] to take on (the)

evening of 9/24/17. [PC (Program

Coordinator) #1], [AD (Area Director) #1]

and [RN (Registered Nurse) #1] were

notified and medication was ordered. [Client

C] resumed medications as directed on

9/25/17. Staff (unspecified) and [PC #1]

will receive retraining on ensuring that all

non-cycle fill meds are ordered in advance

so medications are available and there is no

delay in consumers receiving medications as

directed."

Client C's record was reviewed on

10/23/17 at 10:50 AM. Client C's

Physician's Orders dated 10/13/17



































Responsible Party: QIDP,

Program Nurse, Program





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indicated, "Aviane 28 Tablet/Lutera 28

tablet. Take 1 tablet by mouth daily at 8 PM

for hormones. Skip placebo tablets. Take

continuously to suppress menstrual cycle."


"[Client H] is prescribed Ketoconazole

cream (anti-fungal) daily. After a review of

the MAR (Medication Administration

Record), it was noted that it was written on

the back of the MAR that the cream was

unavailable on the 6th, 7th (and) 8th of

September 2017. It was in fact in the house

and was delivered on 8/17/17. It was not

administered for sure on those 3 days."

Client H's record was reviewed on

10/23/17 at 6:23 PM. Client H's Physician's

Orders dated 10/1/17 indicated,

"Ketoconazole 2% Cream/Nizoral 2%

Cream. Apply Topically to feet daily for foot

fungus."

RN #1 was interviewed on 10/23/17 at 1:35

PM. RN #1 indicated medications should be

re-ordered when supply is at 7 days. RN #1

indicated staff had been re-trained regarding

medication ordering timeframes to ensure

adequate supply. RN #1 indicated

medications should be administered as

ordered.

Coordinator





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#IN00235174.

9-3-6(a)

483.470(g)(2)

SPACE AND EQUIPMENT

The facility must furnish, maintain in good

repair, and teach clients to use and to make

informed choices about the use of dentures,

eyeglasses, hearing and other

communications aids, braces, and other

devices identified by the interdisciplinary

team as needed by the client.

W 0436

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interview for 1 of 4 sampled clients who

utilized adaptive equipment, the facility failed

to ensure client E's wheelchair was in good

repair.

Findings include:





the following:

W 0436 A Lead Area Director

has been designated

to provide oversight

for all survey

corrections. Lead

Area Director will

provide training to all

staff, including

Program Coordinator

to ensure that

ongoing all adaptive

equipment needs are

11/25/2017 12:00:00AM





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asked if he fell, he said "yes". Staff tried to












back home."








assessed and

addressed. Ongoing,

Program Nurse, QIDP

and/or Program

Coordinator will

complete inspections

of all adaptive

equipment a minimum

of weekly to ensure

equipment is in good

working order. If any

repairs are assessed

to be needed, Lead

Area Director will be

notified to ensure

repair or replacement

is completed as soon

as possible.





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10/6/17 fall.




working correctly.




9-3-7(a)

W 9999

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W 9999 No documentation was indicated 11/25/2017 12:00:00AM





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printed: 01/04/2018 department of health and human … · 2018. 1. 4. · left front wheel won't...

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