printed: 01/31/2017 department of health and …(x1) provider/supplier/clia department of health and...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIES

(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

COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

W 0000

Bldg. 00

This visit was for a full recertification

and state licensure survey.

Survey Dates: October 24, 25, 26, 27 and

28, 2016

Facility Number: 001115

Provider Number: 15G665

AIM Number: 100235410

These deficiencies also reflect state

findings in accordance with 460 IAC 9.

Quality Review of this report completed

by #15068 on 11/4/16.

W 0000

483.410

GOVERNING BODY AND MANAGEMENT

The facility must ensure that specific

governing body and management

requirements are met.

W 0102

Bldg. 00

Based on observation, record review and

interview for 7 of 7 clients living in the

group home (#1, #2, #3, #4, #5, #6 and

#7), the facility's governing body failed to

meet the Condition of Participation:

Governing Body. The facility's

governing body failed to exercise

operating direction over the facility by

failing to ensure the group home staff

supervised client #5 to ensure she did not

W 0102 104 To correct the deficient

practice and prevent recurrence,

an investigation was completed

for the incident that occurred on

6/23/16, and client #5’s nursing

care plan and fall risk plan was

updated. A rail has been installed

at the sidewalk near the driveway

to prevent people from walking off

the side, and the group home

parking pattern has been

changed so customers don’t have

11/27/2016 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: R7XG11 Facility ID: 001115

TITLE

If continuation sheet of 79

(X6) DATE




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COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

fall off a ledge at the group home, a

window in the office had a screen to keep

out insects, the floors were free of dirt,

debris and dust, client #6's mattress was

cleaned or replaced, and the laminate

flooring in client #4 and #6's bedroom

did not have gaps in between the planks.

Findings include:

1) Please refer to W104. For 7 of 7

clients living in the group home (#1, #2,

#3, #4, #5, #6 and #7), the facility's

governing body failed to exercise

operating direction over the facility by

failing to ensure: 1) the group home staff

supervised client #5 to ensure she did not

fall off a ledge at the group home, 2) a

window in the office had a screen to keep

out insects, 3) the floors were free of dirt,

debris and dust, 4) client #6's mattress

was cleaned or replaced, and 5) the

laminate flooring in client #4 and #6's

bedroom did not have gaps in between

the planks.


incident/investigative reports reviewed

affecting clients #1, #3, #4, #5, #6 and

#7, the facility's governing body

neglected to implement its policies and

procedures to thoroughly investigate

client #5 and #7's falls, prevent client to

client abuse and conduct investigations of

to cross over to the next door

parking lot. The screen has been

replaced in the office. The

flooring in the office area is

scheduled to be replaced, as well

as repairs made to the flooring in

client #4 and #6’s bedrooms, and

flooring throughout the home has

been cleaned thoroughly. Client

#6’s mattress has been replaced.

The Team Manager and Network

Director/ QIDP (ND/QIDP) will be

re-trained on their responsibilities

around ensuring all areas of the

home are clean and well

maintained, and the process for

communicating repair needs to

maintenance staff when

necessary. Ongoing monitoring

will be accomplished by the Team

Manager, who is scheduled to

work in the home full time, and

completes a monthly Health and

Safety Checklist. The Team

Manager also completes a weekly

Team Manager (TM) Report, that

includes any new or ongoing

maintenance needs and status of

previous requests. The TM

Weekly Report is forwarded to

the ND/QIDP, Director of

Residential Services (DRS) And

Chief Services Officer (CSO) for

review.

Investigations have been

completed for all incidents.

Recommended corrective actions

will be reviewed with all staff at

the next staff meeting to ensure

implementation. All services

supervisors, including the Chief

Services Officer, Directors of

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R7XG11 Facility ID: 001115 If continuation sheet of 79




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(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

client to client abuse. The facility's

governing body neglected to ensure staff

provided oversight and supervision of

client #5 to ensure she did not fall while

going out to the group home van while

the Home Manager provided supervision

to a client receiving waiver services. The

facility's governing body neglected to

ensure appropriate corrective actions

were implemented to address client #5

and #7's falls. The facility's governing

body neglected to ensure staff

implemented client #7's plan for

supervision while using the stairs at the

group home.

9-3-1(a)

Services and ND/QIDPs, will be

retrained on the criteria for

completion of investigations.

Ongoing monitoring will be

accomplished through the daily

review of BDDS Incident Reports

by the Directors of Services to

ensure investigations are

completed when appropriate.

Additionally, the Services

Leadership Team, including all

Directors of Services, the CSO

and CEO, meet at least twice

monthly and review the status of

all investigations. To ensure

investigation recommendations

are implemented as plans are

followed as written, the TM is

scheduled to work full time

alongside direct support staff to

provide ongoing support and

supervision. The ND/Q is in the

home no less than weekly, and

the DRS in the home monthly.

483.410(a)(1)

GOVERNING BODY

The governing body must exercise general

policy, budget, and operating direction over

the facility.

W 0104

Bldg. 00

Based on observation, interview and

record review for 7 of 7 clients living in

the group home (#1, #2, #3, #4, #5, #6

and #7), the facility's governing body

failed to exercise operating direction over

the facility by failing to ensure: 1) the

group home staff supervised client #5 to

ensure she did not fall off a ledge at the

group home, 2) a window in the office

had a screen to keep out insects, 3) the

W 0104 To correct the deficient practice

and prevent recurrence, an

investigation was completed for

the incident that occurred on

6/23/16, and client #5’s nursing

care plan and fall risk plan was

updated. A rail has been installed

at the sidewalk near the driveway

to prevent people from walking off

the side, and the group home

parking pattern has been

changed so customers don’t have

11/27/2016 12:00:00AM





01/31/2017PRINTED:

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OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

floors were free of dirt, debris and dust,

4) client #6's mattress was cleaned or

replaced, and 5) the laminate flooring in

client #4 and #6's bedroom did not have

gaps in between the planks.

Findings include:

1) On 10/24/16 at 11:16 AM, a review of

the facility's incident/investigative reports

was conducted and indicated the

following: A 7/7/16 Bureau of

Developmental Disabilities Services

(BDDS) incident report indicated, in part,

"On June 23 [client #5] fell off the ledge

(approximately 18 inches) out by the

driveway at her home and dislocated her

elbow. She went to the ER (emergency

room) and they put her arm in a sling.

We made her an appointment with [name

of orthopedic] for as soon as possible.

She went to [orthopedic] on 6-29-16

where they tried to put her elbow in

socket, they was (sic) unable to do this

due to her behaviors and it would keep

popping out of place. They scheduled

her for emergency surgery for 7/1/16.

She went in for out patient surgery on

July 1st. They put her under and still

experienced the same trouble, every time

they put her elbow in place it popped

back out. They set it as best as they

could and put it in a brace and splint.

Scheduled her to see a (sic) orthopedic

to cross over to the next door

parking lot. The screen has been

replaced in the office. The

flooring in the office area is

scheduled to be replaced, as well

as repairs made to the flooring in

client #4 and #6’s bedrooms, and

flooring throughout the home has

been cleaned thoroughly. Client

#6’s mattress has been replaced.

The Team Manager and Network

Director/ QIDP (ND/QIDP) will be

re-trained on their responsibilities

around ensuring all areas of the

home are clean and well

maintained, and the process for

communicating repair needs to

maintenance staff when

necessary. Ongoing monitoring

will be accomplished by the Team

Manager, who is scheduled to

work in the home full time, and

completes a monthly Health and

Safety Checklist. The Team

Manager also completes a weekly

Team Manager (TM) Report, that

includes any new or ongoing

maintenance needs and status of

previous requests. The TM

Weekly Report is forwarded to

the ND/QIDP, Director of

Residential Services (DRS) And

Chief Services Officer (CSO) for

review. Additionally, the ND/QIDP

is in the home no less than

weekly to provide ongoing

monitoring of the home, and the

DRS is in the home at least

monthly.





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COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

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specialist in [name of city]. She went

and seen (sic) [name of doctor] in [name

of city] on July 5th for 1st initial visit.

They then scheduled her for outpatient

surgery for July 7th. They put her under

and got her elbow in place and put a

straight arm cast on her. She is in

recovery at this time... Where she

walked off the ledge at home, the

maintenance man came over June 24th

and they put up a fence surrounding the

ledge to make sure she or anybody else

falls off there. When [client #5] goes out

to the van we will make sure someone is

walking with her at all times."

On 10/26/16 at 4:57 PM, the Qualified

Intellectual Disabilities Professional

(QIDP) sent the following 6/23/16 BDDS

report: "[Client #5] was walking out to

the church parking lot to get in the van to

go to (sic) workshop. [Name of former

staff] and myself (Home Manager) was

(sic) loading [name of waiver client] in

van, when we heard [client #5] scream,

turned around and [client #5] was laying

(sic) on the ground. She had walked off

the ledge instead of going down the stairs

as she usually does. I went over and

picked her up and noticed that her elbow

was out of place. I had [name of former

staff] run in the house and get the MC

(medical coordinator) so she could take

her to the emergency room (ER). [Name





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COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

of former staff] also called [QIDP] while

getting [client #5] in to vehicle to go to

ER. They took xray of her left arm at the

ER and said elbow had popped out of

place. They popped (sic) left elbow back

in place and took another xray to make

sure it was in (sic) correct place. They

then placed her left arm in a splint and

put on a sling. They said to make an

appointment with a (sic) orthopedic

specialist for 1 week. Talked to

maintenance about putting a fence around

the area where she walked off ledge so

she knows that (sic) is not a safe place to

walk around. Parking the van in the

group home parking lot for easier access

for her to get into it."

There was no documentation the facility

conducted an investigation. There was

no documentation client #5's 9/27/16 Fall

Risk Plan and 1/19/16 Nursing Care Plan

included written instructions for staff to

walk with client #5 to the van at all

times. There was no documentation

indicating why the Home Manager was in

the church parking lot assisting a client

receiving waiver services (not a group

home client).

On 10/24/16 at 11:50 AM, the Director

of Residential Services (DRS) indicated

on 6/23/16, client #5 had a fall off of the

curb at the group home causing her to





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COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

dislocate her elbow. The DRS indicated

client #5 needed to have surgery to install

pins since her elbow kept popping out of

place. The DRS indicated client #5's IDT

(interdisciplinary team) conducted an

investigation. The DRS indicated the

investigation would be spread out

throughout client #5's record. The DRS

stated there would not be a "fancy

investigation form." The DRS indicated

the nurse updated client #5's Nursing

Care Plan to address falls.

On 10/25/16 at 9:57 AM, a review of

client #5's record was conducted. There

was no documentation of an investigation

of client #5's 6/23/16 fall. There was no

documentation client #5's 1/19/16

Nursing Care Plan was updated since the

6/23/16 fall. A Fall Risk Plan was added

to client #5's plans on 9/27/16. The plan

indicated, in part, "Due to [client #5]

experiencing two falls within the past 3

months the following precautions should

be followed: 1) Ensure [client #5] has

well fitting shoes and that they are

laced/fastened properly. 2. Monitor

house for any tripping hazards such as

rugs, spills, furniture in the path and

correct if noted. 3. Encourage [client #5]

to pay attention while walking. 4.

Encourage [client #5] to walk at a safe

pace. 5. Staff should stabilize/guide

[client #5] at the elbow especially when





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COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

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walking in the community as she tends to

rush in these settings. 6. [Client #5]

currently has a stable gait, but staff

should note any changes in gait and

report to nurse. 7. If [client #5] should

experience any falls, staff should seek

prompt medical attention."

On 10/25/16 at 6:35 AM, the Home

Manager (HM) indicated on 6/23/16,

client #5 walked off the ledge from the

group home yard to the next door church

parking lot. The HM indicated she did

not witness client #5's fall due to

assisting a waiver client get onto the

group home van. The HM indicated she

heard client #5 start screaming and could

immediately tell her arm was dislocated.

The HM indicated the next day when

volunteers were at the group home a

fence was installed so the clients could

not walk off the ledge again. The HM

indicated staff escort client #5 out of the

group home and into the van. The HM

indicated she walked in front of client #5

to slow her down since client #5 was

always in a hurry and client #5 does not

like to be touched. The HM indicated

she discussed the incident with the

Qualified Intellectual Disabilities

Professional (QIDP) and the nurse. The

HM indicated the corrective action part

was discussed at a team meeting.





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15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

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On 10/25/16 at 11:09 AM, the QIDP

indicated the result of the fall was the

facility installed a fence. The QIDP

indicated the facility was going to put a

handrail along the stairs to the parking lot

but the handrail had not been installed.

The QIDP stated, regarding the handrail,

the facility, "lagged behind on it." The

QIDP indicated he spoke to the HM and

the waiver staff who were present at the

time but did not document his interviews

with the staff. The QIDP indicated there

was no documentation the facility

conducted an investigation.

On 10/25/16 at 2:13 PM, the Chief

Services Officer (CSO) indicated the

facility had all the medical appointment

form documentation. The CSO indicated

a fence was installed within 24 hours of

the incident. The CSO stated, "We didn't

do the full write up thing." The CSO

indicated the HRC reviewed the surgeries

and approved the medications. The CSO

indicated staff was outside with client #5

at the time of the fall. The CSO

indicated client #5 got too close to the

edge of the wall and went down. The

CSO stated, "No one thought there

needed to be an investigation." She

indicated she did not recall doing a

full-on investigation. The CSO stated,

"Didn't do the piece of paper." The CSO

indicated at the time of client #5's fall,





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2701 FAIRLAWN AVE

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there were volunteers at the home helping

clean up the outside of the home. The

CSO indicated client #5 was outside

walking around at the time and there was

no reason for staff to be with her since

she was not one on one at the time. The

CSO indicated it was a nice day and

everyone was outside at the time client #5

fell. The CSO stated, "Staff there

witnessed the fall. Staff explained what

happened." The CSO indicated a formal

write up was not completed.

On 10/25/16 at 2:28 PM, the Home

Manager (HM) indicated she was present

at the time client #5 fell off the wall and

into the parking lot. The HM indicated

the incident occurred on 6/23/16 at 7:30

AM. The HM indicated the volunteers

were at the group home the next day

(6/24/16) and were not present at the time

client #5 fell. The HM indicated she was

outside in the parking lot next to the

group home when client #5 came out.

The HM indicated she was assisting a

Supported Living (waiver) client transfer

from the Supported Living van to the

group home van with a Supported Living

staff who was no longer employed by the

agency. The HM indicated as she was

assisting with the waiver client, she heard

client #5 screaming. The HM indicated

she did not witness the incident. The HM

indicated client #5 was walking from the





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group home to the parking lot due to the

group home van being in the parking lot.

The HM indicated the group home van

was in the parking lot due to the waiver

client. The HM indicated the waiver

client had difficulty walking up the

driveway to the group home due to his

ambulation issues so the staff at the

group home parked the group home van

in the church parking lot next door in

order to make it easier on the waiver

client. The HM indicated the group

home staff transported the waiver client

from the group home to the day program

for months prior to the incident.

On 10/25/16 at 3:15 PM, the CSO

indicated in an email, in part, "...As we

discussed, we did not complete an ANE

(abuse/neglect/exploitation) investigation

into her fall as this was not an injury of

unknown origin and staff was present

when she fell. [Client #5] did not have

any protocol in place that required 1-on-1

assistance while walking. While

participating in the 'Day of Caring'

activities with the group home staff and

volunteers she got too close to the edge

of the drive/green area and stumbled into

the neighboring church parking lot,

hurting her elbow. Staff immediately

assisted her and got her medical

treatment and attended to her follow up

medical needs. The agency HRC





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(Human Rights Committee) committee

was involved through review of the use

of anesthesia for her emergency medical

procedures. The fall was reported to

BDDS and APS (Adult Protective

Services) as required and follow up was

provided to BDDS...."

On 10/25/16 at 11:09 AM, the nurse

indicated she developed and implemented

a fall risk plan on 9/27/16. The nurse

indicated there was no fall risk plan prior

to 9/27/16. The nurse indicated client #5

hurried and did not pay attention while

she walked which contributed to her falls.

On 10/27/16 at 11:09 AM, the QIDP

indicated the group home transported the

waiver client to the same day program as

client #5. The QIDP indicated the waiver

client's staff dropped him off at the group

home and picked up clients #2, #3 and #5

to take them to the LifeDesigns day

program. The QIDP indicated this

occurred for approximately 3-4 months.

On 10/27/16 at 11:09 AM, the DRS

stated client #5's fall was a "freak

accident" and client #5 had not had any

issues with falls prior to this fall.

On 10/27/16 at 11:09 AM, the CSO

indicated she discussed the incident with

the Chief Executive Officer. She





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indicated neither thought an investigation

needed to be conducted.

2) On 10/24/16 from 3:19 PM to 5:13

PM, an observation was conducted at the

group home. During the observation, one

of two windows in the group home home

area where medications were

administered was open. The window did

not have a screen in it to keep out insects

and rodents. This affected clients #1, #2,

#3, #4, #5, #6 and #7.

On 10/27/16 at 11:09 AM, the QIDP

indicated the window should have a

screen.

On 10/27/16 at 11:09 AM, the DRS


screen.

On 10/27/16 at 11:09 AM, the CSO


screen if it was open.

3) On 10/24/16 from 3:19 PM to 5:13

PM and 10/25/16 from 6:04 AM to 7:40

AM, an observation was conducted at the

group home. During the observation, the

floors throughout the group home had

dirt, dust, and debris on them. This

affected clients #1, #2, #3, #4, #5, #6 and

#7.





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On 10/27/16 at 11:09 AM, the DRS

indicated the floors should be clean.

4) On 10/25/16 from 6:04 AM to 7:40


group home. During the observation,

client #6's mattress had three areas with a

brown substance in a line toward the

edge of the mattress.

On 10/27/16 at 11:09 AM, the QIDP

indicated client #6 does not wipe after

using the restroom and will not allow

staff to wipe his buttocks. The QIDP

indicated client #6 used the restroom, did

not wipe his bottom thoroughly and sat

on his mattress. The QIDP indicated

client #6's mattress had been cleaned 3-4

times in the past year. The QIDP

indicated client #6's mattress needed to

be cleaned.

On 10/27/16 at 11:09 AM, the CSO

indicated client #6 would not keep a bed

protector on it and would not leave his

sheets on his bed. The CSO indicated

client #6 used the restroom without

informing staff so they could assist him

clean up. The CSO indicated the staff

needed to spot check client #6's mattress

and clean it as needed.

5) On 10/25/16 from 6:04 AM to 7:40






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there were several areas with gaps in

between the planks of the laminate

flooring in client #4 and #6's bedroom.

There were 4 gaps ranging from 1/4 inch

to 3 inches on client #4's side of the

bedroom. There were smaller gaps in the

planks near the entrance to their

bedroom.

On 10/27/16 at 11:09 AM, the QIDP

indicated the maintenance staff had the

room measured recently for new laminate

flooring. The QIDP indicated the

flooring was being replaced in client #4

and #6's bedroom.

On 10/27/16 at 11:09 AM, the DRS

indicated the flooring in client #4 and

#6's bedroom was being replaced.

9-3-1(a)

483.410(d)(3)

SERVICES PROVIDED WITH OUTSIDE

SOURCES

The facility must assure that outside

services meet the needs of each client.

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record review for 3 of 3 clients in the

sample (#2, #4 and #5) who attended

outside services workshops, the facility

failed to ensure the outside services met


and ensure it does not continue,

the ND/QIDP will meet with day

programs for each individual to

discuss the appropriateness of

placement, and to develop plans

that are meaningful for each

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the needs of the clients.

Findings include:

1) On 10/24/16 from 2:13 PM to 2:52

PM, an observation was conducted at

client #2 and #5's workshop. During the

observation, clients #2 and #5 were not

engaged in meaningful activities. Client

#2 sat at a table with his head down for a

majority of the observation. Client #5

walked around the workshop. Clients #2

and #5 were not prompted by staff to

engage in work or any other activities.

On 10/24/16 at 2:17 PM, the Industry

Manager (IM) indicated the workshop

had concerns with client #2. The IM

indicated client #2 had been running back

and forth between his workstation and the

medication room. The IM indicated

client #2 would stand at the medication

room waiting for medications. The IM

indicated client #2 needed one on one

staffing to learn a job. The IM indicated

the workshop was willing to provide

client #2 one on one staffing if

LifeDesigns paid for the increased

staffing. The IM indicated it was

acceptable to the workshop for

LifeDesigns to provide client #2

increased support in order for him to

learn a job. The IM indicated client #2

did not work and did not engage in

individual served. Day program

staff will be trained on individual

plans and told of the expectation

that all individuals are to be

encouraged to be engaged in

meaningful activities while at day

program. The ND/QIDP will be

re-trained on his responsibility to

monitor day program activities.

The ND/QIDP will complete

weekly day program observations

for a period of at least 6 weeks to

ensure day program staff are

providing adequate support, and

address any noted issues

immediately. The ND/QIDP will

do day program observations no

less than monthly on an ongoing

basis. Day program observations

are documented as part of the

TM Weekly Checklist, which is

shared with the ND/QIDP, DRS

and CSO for ongoing

communication and monitoring.





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activities at the workshop.

On 10/24/16 at 2:28 PM, client #2 and

#5's Workshop Supervisor (WS)

indicated neither client participated in the

work. The WS indicated she was unsure

why the clients were in the workshop.

The WS indicated client #2 would string

beads and client #5 would stack rings, but

neither completed any work. The WS

stated the workshop was "not the place

for them." The WS indicated client #2

was agitated by the noises in the

workshop.

On 10/24/16 at 2:34 PM, the Day

Program Manager (DPM) stated, when

asked why the clients were in the

workshop, "I have no idea." The DPM

indicated when the workshop staff

attempted to teach client #2 how to

complete a job, he scratched the staff.

The DPM indicated when she spoke to

the group home Qualified Intellectual

Disabilities Professional (QIDP), the

QIDP indicated client #2's father wanted

client #2 to be in a workshop. The DPM

indicated she thought clients #2 and #5

would do well in the day program instead

of the workshop since neither

participated in the work. The DPM

indicated the clients' teams needed to

convene to discuss how to proceed.





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On 10/27/16 at 11:09 AM, the QIDP

indicated client #5, in the past, attempted

the day program however she would not

stay in the day program. The QIDP

indicated client #5 wanted to do puzzles

and act like a supervisor in the workshop.

The QIDP indicated he had three

behavior consultants assess client #2 at

the workshop.



client #2 needed a community job. The

DRS indicated it was the group home's

responsibility to ensure the outside

services met the needs of the clients.

On 10/27/16 at 11:09 AM, the Chief

Services Officer (CSO) indicated client

#2 was in LifeDesigns' day program for

awhile however his family wanted him in

a workshop. The CSO indicated client

#2 was more engaged in activities at the

LifeDesigns' day program than his

current workshop. The CSO stated client

#2 was "not involved in anything."

2) On 10/25/16 from 8:03 AM to 8:57

AM, an observation was conducted at

client #4's day program. During the

observations, client #4 was not engaged

in meaningful activities. Client #4 was

not engaged and was not prompted to

engage in activities. Client #4 walked





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around the program area.

On 10/27/16 at 11:09 AM, the QIDP

indicated client #4 just walked around at

the day program. The QIDP stated he

was "discouraged" the staff did not ask

him to participate in any activities. The

QIDP indicated it was discussed moving

client #4 to another program however

client #4 would have a difficult time

being away from client #6 (his buddy).

On 10/27/16 at 11:09 AM, the CSO

indicated the group home discussed client

#4's program with the day program staff.

The CSO indicated the day program staff

told the group home staff that the

program was the program and nothing

was going to be changed.

On 10/27/16 at 11:09 AM, the DRS

stated the group home staff "can't be

there the whole time." The DRS

indicated the group home was

responsible for ensuring outside services

met the needs of the client.

9-3-1(a)

483.420

CLIENT PROTECTIONS

The facility must ensure that specific client

protections requirements are met.

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interview for clients #1, #3, #4, #5, #6

and #7, the facility failed to meet the

Condition of Participation: Client

Protections. The facility failed to

implement its policies and procedures to

thoroughly investigate client #5 and #7's

falls, prevent client to client abuse and

conduct investigations of client to client

abuse. The facility failed to ensure staff






facility failed to ensure appropriate

corrective actions were implemented to

address client #5 and #7's falls. The

facility failed to ensure staff implemented

client #7's plan for supervision while

using the stairs at the group home.

Findings include:




#7, the facility neglected to implement its

policies and procedures to thoroughly

investigate client #5 and #7's falls,

prevent client to client abuse and conduct

investigations of client to client abuse.

The facility neglected to ensure staff



investigations have been
































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facility neglected to ensure appropriate



facility neglected to ensure staff



group home.




#7, the facility failed to conduct thorough

investigations.



affecting clients #5 and #7, the facility

failed to implement appropriate

corrective actions to address client #5 and

#7's falls.

9-3-2(a)

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.

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interview for 7 of 13



#7, the facility neglected to implement its

policies and procedures to thoroughly

investigate client #5 and #7's falls,

prevent client to client abuse and conduct

investigations of client to client abuse.

The facility neglected to ensure staff






facility neglected to ensure appropriate



facility neglected to ensure staff



group home.

Findings include:




following:

1) A 7/7/16 Bureau of Developmental

Disabilities Services (BDDS) incident

report indicated, in part, "On June 23

[client #5] fell off the ledge







































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times.














investigation form." The DRS indicated

the nurse updated client #5's Nursing

Care Plan to address falls.




of client #5's 6/23/16 fall. There was no

documentation client #5's 1/19/16







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like to be touched. The HM indicated

she discussed the incident with the

Qualified Intellectual Disabilities

Professional (QIDP) and the nurse. The

HM indicated the corrective action part

was discussed at a team meeting.

On 10/25/16 at 11:09 AM, the QIDP

indicated the result of the fall was the

facility installed a fence. The QIDP





the facility, "lagged behind on it." The

QIDP indicated he spoke to the HM and

the waiver staff who were present at the

time but did not document his interviews

with the staff. The QIDP indicated there

was no documentation the facility




facility had all the medical appointment

form documentation. The CSO indicated

a fence was installed within 24 hours of





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the incident. The CSO stated, "We didn't


indicated the HRC reviewed the surgeries

and approved the medications. The CSO

indicated staff was outside with client #5

at the time of the fall. The CSO

indicated client #5 got too close to the

edge of the wall and went down. The

CSO stated, "No one thought there

needed to be an investigation." She

indicated she did not recall doing a

full-on investigation. The CSO stated,

"Didn't do the piece of paper." The CSO


















the incident occurred on 6/23/16 at 7:30

AM. The HM indicated the volunteers

were at the group home the next day





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(6/24/16) and were not present at the time

client #5 fell. The HM indicated she was

outside in the parking lot next to the

group home when client #5 came out.


























On 10/25/16 at 3:15 PM, the CSO








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2) On 9/20/16 at 2:30 PM at an outside

services workshop, client #5 was going to

her table when she tripped and fell. The

9/21/16 BDDS report indicated, "...she





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tripped landing on her left arm which is

in a sling from a previous injury...."



On 10/24/16 at 2:28 PM, client #5's

outside services supervisor indicated

client #5 was on break. The supervisor

indicated client #5 pushed through others,

tripped and fell.

On 10/25/16 at 11:09 AM, the QIDP

indicated client #5's falls at the workshop

were related to her not having her shoes

tightened. The QIDP indicated there was

no documentation of an investigation

being conducted to review the fall.


services workshop, client #5 was leaving

the breakroom when she fell on her left

arm. The 9/22/16 BDDS report

indicated, "...she was walking from the

breakroom and fell on her left arm which

is in a splint from a previous injury...."



On 10/25/16 at 11:09 AM, the QIDP

indicated client #5's falls at the workshop

were related to her not having her shoes

tightened. The QIDP indicated there was





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no documentation of an investigation

being conducted to review the fall.

4) On 7/27/16 at 8:00 AM, client #7

attempted to ascend the stairs at the

group home when her foot slipped on the

first step and she fell. Client #7 hit her

right arm and shoulder on the stairwell.

She was taken to a walk-in clinic where

they x-rayed her arm and shoulder.

Client #7 had a hairline fracture up

toward her shoulder.



On 10/24/16 at 11:50 AM, the DRS

stated client #7's interdisciplinary team

"looked into the fall." The DRS

indicated he did not have documentation

an investigation was conducted.

Observations were conducted at the

group home on 10/24/16 from 3:19 PM

to 5:13 PM and 10/25/16 from 6:04 AM

to 7:40 AM. During the observations,

client #7 ascended and descended the

stairs numerous times to go outside to

smoke (the group home's main level

where the kitchen, dining room and client

#7's bedroom was located on the second

floor requiring the use of stairs to access

the main level). Client #7 did not receive

stand-by assistance from staff while using





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the stairs. During the observations, client

#7 was not observed to use a walker at

any point.




of her fall. There was no documentation

the interdisciplinary team discussed the

fall. There was no documentation of

corrective action following the fall.

Client #7's 9/27/16 Nursing Care Plan

(NCP) indicated, in part, "At risk for falls

related to weakness following surgery...

Always use stand-by assistance on stairs.

Guide at elbow as needed. [Client #7]

should use her rolling walker once

upstairs and whenever on flat surfaces.

Staff should carry the walker to the

desired floor. Ensure surfaces are clear

of tripping hazards such as rugs, spills,

furniture. If a fall should occur, seek

prompt medical attention paying close

attention to venous cath site (A central

venous catheter, also called a central line,

is a long, thin, flexible tube used to give

medicines, fluids, nutrients, or blood

products over a long period of time,

usually several weeks or more) and

surgical site." A 10/18/16 Medical

Appointment Record indicated, in part,

by the Physical Therapist (PT), "...May

go without walker at this time." The

nurse failed to update client #7's NCP





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after the PT discontinued the use of the

walker.

On 10/25/16 at 11:04 AM, the QIDP

indicated although he interviewed the

staff present at the time of client #7's fall,

he did not have documentation of his

interviews. The QIDP indicated there

should be documentation of an

investigation. The QIDP indicated the

team discussed having a staff go up and

down the stairs with client #7. The QIDP

stated, "We still try to implement as

much as possible." The QIDP indicated

staff should implement assisting client #7

up and down the stairs.


indicated client #7 should be assisted up

and down the stairs using stand-by assist.

The nurse indicated this was part of her

Nursing Care Plan.

5) On 8/10/16 at 2:45 PM while at the

facility-operated day program, client #3's

neck and shirt were grabbed by a peer.

Client #3's shirt was ripped off.



On 10/25/16 at 11:03 AM, the QIDP

indicated there was no investigation. The

QIDP indicated an investigation should





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have been conducted. The QIDP

indicated client to client aggression was

abuse and the facility should prevent

abuse of the clients. The QIDP indicated

the facility had a policy and procedure

prohibiting abuse of the clients.

6) On 8/23/16 at 2:00 PM, client #6

pushed client #4 on the back with both

hands.



On 10/25/16 at 11:03 AM, the QIDP









7) On 9/25/16 at 3:30 PM, client #4

grabbed client #1 around the neck and

left a few scratches (no description of

size or location).



On 10/25/16 at 11:03 AM, the QIDP






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On 10/24/16 at 11:52 AM, the facility's

policy, Individual Rights and Protections,

dated May 2014, indicated, in part,

"Customers have the right: To be free

from all forms of discrimination,

harassment, humiliation and cruel or

unusual punishment, including forced

physical activity and practices that deny

an individual of sleep, shelter, physical

movement for extended periods of time

and/or use of bathroom facilities. To be

treated with consideration and respect

with recognition of his/her dignity and

individuality. To be free from emotional,

verbal, and physical

abuse/neglect/exploitation including but

not limited to hitting, pinching and

application of painful or noxious

stimuli." The 2014-2015 Violation of

Rights policy indicated, in part,

"...Neglect: Placing a customer in a

situation that may endanger his or her life

or health; abandoning or cruelly

confining a customer, including seclusion

alone in an area from which exit is

prohibited; depriving a customer of





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necessary support including food, shelter,

medical care, or technology...." The

2014-2015 Reporting

Abuse/Neglect/Exploitation policy

indicated, in part, "...Any injury of an

unknown origin or death will be reported

as a possible violation of rights...."

9-3-2(a)

483.420(d)(3)


The facility must have evidence that all

alleged violations are thoroughly

investigated.

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#7, the facility failed to conduct thorough

investigations.

Findings include:




following:














Services Officer (CSO), Directors

of Services and ND/QIDPs, will

be retrained on the criteria for











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A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00









times.














investigation form."




of client #5's 6/23/16 fall.

On 10/25/16 at 11:09 AM, the QIDP

indicated indicated he spoke to the HM

and the waiver staff who were present at





01/31/2017PRINTED:

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OMB NO. 0938-0391




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(X4) ID

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(X5)

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COLUMBUS, IN 47203

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2701 FAIRLAWN AVE

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the time but did not document his

interviews with the staff. The QIDP

indicated there was no documentation the

facility conducted an investigation.


Services Officer (CSO) stated, "We didn't


stated, "No one thought there needed to

be an investigation." She indicated she

did not recall doing a full-on

investigation. The CSO stated, "Didn't

do the piece of paper." The CSO














On 10/25/16 at 3:15 PM, the CSO











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(X5)

COMPLETION


COLUMBUS, IN 47203

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LIFE DESIGNS INC

2701 FAIRLAWN AVE

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services workshop, client #5 was going to

her table when she tripped and fell. The

9/21/16 BDDS report indicated, "...she

tripped landing on her left arm which is

in a sling from a previous injury...."



On 10/24/16 at 2:28 PM, client #5's

outside services supervisor indicated

client #5 was on break. The supervisor

indicated client #5 pushed through others,

tripped and fell.





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

On 10/25/16 at 11:09 AM, the QIDP

indicated there was no documentation of

an investigation being conducted to

review the fall.


services workshop, client #5 was leaving

the breakroom when she fell on her left

arm. The 9/22/16 BDDS report

indicated, "...she was walking from the

breakroom and fell on her left arm which

is in a splint from a previous injury...."



On 10/25/16 at 11:09 AM, the QIDP

there was no documentation of an

investigation being conducted to review

the fall.

4) On 7/27/16 at 8:00 AM, client #7















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2701 FAIRLAWN AVE

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On 10/24/16 at 11:50 AM, the DRS

stated client #7's interdisciplinary team

"looked into the fall." The DRS

indicated he did not have documentation

an investigation was conducted.




of her fall. There was no documentation

the interdisciplinary team discussed the

fall.

On 10/25/16 at 11:04 AM, the QIDP

indicated although he interviewed the

staff present at the time of client #7's fall,

he did not have documentation of his

interviews. The QIDP indicated there

should be documentation of an

investigation.

5) On 8/10/16 at 2:45 PM while at the

facility-operated day program, client #3's

neck and shirt were grabbed by a peer.

Client #3's shirt was ripped off.



On 10/25/16 at 11:03 AM, the QIDP



have been conducted.





01/31/2017PRINTED:

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OMB NO. 0938-0391




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(X4) ID

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DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

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2701 FAIRLAWN AVE

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6) On 8/23/16 at 2:00 PM, client #6

pushed client #4 on the back with both

hands.



On 10/25/16 at 11:03 AM, the QIDP




7) On 9/25/16 at 3:30 PM, client #4

grabbed client #1 around the neck and

left a few scratches (no description of

size or location).



On 10/25/16 at 11:03 AM, the QIDP




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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OMB NO. 0938-0391




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(X5)

COMPLETION


COLUMBUS, IN 47203

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2701 FAIRLAWN AVE

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affecting clients #5 and #7, the facility

failed to implement appropriate

corrective actions to address client #5 and

#7's falls.

Findings include:




following:




























supervisors, including the CSO,

Directors of Services and

ND/QIDPs, will be retrained on

the criteria for completion of

investigations. Ongoing

monitoring will be accomplished

through the daily review of BDDS

Incident Reports by the Directors

of Services to ensure

investigations are completed

when appropriate. Additionally,

the Services Leadership Team,

including all Directors of Services,

the CSO and CEO, meet at least

twice monthly and review the

status of all investigations. To

ensure investigation

recommendations are

implemented as plans are








11/27/2016 12:00:00AM





01/31/2017PRINTED:

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OMB NO. 0938-0391




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(X4) ID

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COMPLETION


COLUMBUS, IN 47203

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2701 FAIRLAWN AVE

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01/31/2017PRINTED:

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OMB NO. 0938-0391




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DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

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There was no documentation client #5's

9/27/16 Fall Risk Plan and 1/19/16

Nursing Care Plan included written

instructions for staff to walk with client

#5 to the van at all times.











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(X5)

COMPLETION


COLUMBUS, IN 47203

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2701 FAIRLAWN AVE

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place. The DRS indicated the nurse

updated client #5's Nursing Care Plan to

address falls.



was no documentation client #5's 1/19/16






























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(X5)

COMPLETION


COLUMBUS, IN 47203

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2701 FAIRLAWN AVE

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like to be touched. The HM indicated the

corrective action part was discussed at a

team meeting.

On 10/25/16 at 11:09 AM, the QIDP





the facility, "lagged behind on it."











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OMB NO. 0938-0391




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(X5)

COMPLETION


COLUMBUS, IN 47203

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2701 FAIRLAWN AVE

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2) On 7/27/16 at 8:00 AM, client #7











to 5:13 PM and 10/25/16 from 6:04 AM












any point.



was no documentation of corrective

action following the fall. Client #7's

9/27/16 Nursing Care Plan (NCP)

indicated, in part, "At risk for falls related





01/31/2017PRINTED:

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COLUMBUS, IN 47203

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2701 FAIRLAWN AVE

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to weakness following surgery... Always

use stand-by assistance on stairs. Guide

at elbow as needed. [Client #7] should

use her rolling walker once upstairs and

whenever on flat surfaces. Staff should

carry the walker to the desired floor.

Ensure surfaces are clear of tripping

hazards such as rugs, spills, furniture. If

a fall should occur, seek prompt medical

attention paying close attention to venous

cath site (A central venous catheter, also

called a central line, is a long, thin,

flexible tube used to give medicines,

fluids, nutrients, or blood products over a

long period of time, usually several

weeks or more) and surgical site." A

10/18/16 Medical Appointment Record

indicated, in part, by the Physical

Therapist (PT), "...May go without

walker at this time." The nurse failed to

update client #7's NCP after the PT

discontinued the use of the walker.

On 10/25/16 at 11:04 AM, the QIDP

indicated indicated the team discussed

having a staff go up and down the stairs

with client #7. The QIDP stated, "We

still try to implement as much as

possible." The QIDP stated staff should

implement assisting client #7 up and

down the stairs.


indicated client #7 should be assisted up





01/31/2017PRINTED:

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OMB NO. 0938-0391




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(X5)

COMPLETION


COLUMBUS, IN 47203

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2701 FAIRLAWN AVE

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and down the stairs using stand-by assist.

The nurse indicated this was part of her

Nursing Care Plan.

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 clients in the sample

(#2, #4, #5, and #7) and one additional

client (#6), the Qualified Intellectual

Disabilities Professional (QIDP) failed to

integrate, coordinate and monitor the

clients' program plans. The QIDP failed

to ensure the clients' monthly summaries

indicated whether or not the clients' goals

and objectives were revised, discontinued

or continued from month to month. The

QIDP failed to ensure an accurate

assessment was completed within 30

days after admission for client #7. The

QIDP failed to ensure client #5 had a

plan for staff to assist her to the van

following a fall with injury while walking

out to the van. The QIDP failed to ensure

staff implemented: 1) client #7's Nursing

Care Plan for the use of a walker and

W 0159 W210 & W259 To correct the

deficient practice, a CFA has

been completed or will be revised

for all individuals living in the

home. To prevent the deficient

practice from recurrence, the

DRS will re-train all ND/QIDPs on

the requirement to complete a

CFA for individuals within 30 days

after admission, and annually

thereafter. Ongoing monitoring

will be accomplished through the

ND/QIDP Monthly Report, which

includes the date of the most

recent CFA. The Monthly Reports

are forwarded to the DRS,

Director of Support Services and

CSO for review.

W240 To correct the deficient

practice and ensure it does not

continue, client #5’s NCP and Fall

Risk Plan have been revised, and

all staff have been re-trained on

the revised plans. Ongoing


11/27/2016 12:00:00AM





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B. WING

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DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

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2701 FAIRLAWN AVE

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stand-by assistance from staff when using

the stairs and 2) client #6's program plan

for wiping after toileting. The QIDP

failed to implement an active treatment

(AT) schedule for client #7. The QIDP

failed to ensure the client #2, #4 and #5's

comprehensive functional assessments

(CFA) were reviewed annually for

relevancy and updated as needed.

Findings include:

1) On 10/25/16 at 9:06 AM, a review of

client #2's record was conducted.

Although the QIDP compiled the client's

goal tracking data on a monthly basis

from October 2015 to September 2016,

there was no documentation on the

Residential Monthly Summary indicating

whether or not the client's goals and

objectives were revised, discontinued or

continued from month to month. The

client's monthly summaries indicated the

percentage the client met (or did not

meet) the goals and objectives each

month but did not compare the

percentage to the previous month to

indicate whether or not progress was

achieved or not. There was no

documentation in the client's record of

quarterly reviews being conducted and

whether or not the client progressed on

the goals.

through observations no less than

3 times per week by the TM or

ND/QIDP for at least 6 weeks. If

no issues are noted related to

implementation of plans, ongoing


by the TM, who is scheduled full

time in the home to work

alongside staff to provide ongoing

support and supervision. The

ND/Q is in the home at least

weekly, and DRS monthly to

provide regular observation of

staff as well.

W249 To correct the deficient

practice and ensure it does not

continue, the nurse updated client

#7s nursing care plan, and the

ND/QIDP developed a program

plan for client #6 for wiping after

toileting. To ensure no others

were affected by the deficient

practice, the ND/QIDP will review

all plans for the other individuals

living in the home to ensure they

are current, and make revisions

as necessary. All staff will be

re-trained by the ND/Q on the

revised plans and expectations

for implementation. Ongoing

















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COLUMBUS, IN 47203

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the goals.















staff as well.

W250 The ND/QIDP will work

with the IDT to develop an active

treatment schedule for client #7,

and all staff will be trained on

implementation of the plan. To

ensure no others were affected

by the deficient practice, the

ND/QIDP will review active

treatment schedules for all others

living in the home and make

revisions as necessary. Ongoing















staff as well.





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COLUMBUS, IN 47203

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the goals.





from May 2016 to September 2016, there

was no documentation on the Residential

Monthly Summary indicating whether or

not the client's goals and objectives were

revised, discontinued or continued from

month to month. The client's monthly

summaries indicated the percentage the

client met (or did not meet) the goals and

objectives each month but did not

compare the percentage to the previous

month to indicate whether or not progress

was achieved or not. There was no




the goals.

On 10/27/16 at 11:09 AM, the QIDP

indicated the clients' monthlies and

quarterlies needed to be more thorough.





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the information regarding whether or not

the clients made progress on their goals

needed to be indicated on the quarterly

reviews.



clients' monthlies needed to be more

thorough.


client (#7) in the sample who was

admitted to the group home since

10/24/15, the QIDP failed to ensure an

accurate assessment was completed

within 30 days after admission.


clients in the sample (#5), the QIDP

failed to ensure client #5 had a plan for

staff to assist her to the van following a

fall with injury while walking out to the

van.


clients in the sample (#7) and one

additional client (#6), the QIDP failed to

ensure staff implemented: 1) client #7's

Nursing Care Plan for the use of a walker

and stand-by assistance from staff when

using the stairs and 2) client #6's program





01/31/2017PRINTED:

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COMPLETION


COLUMBUS, IN 47203

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2701 FAIRLAWN AVE

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plan for wiping after toileting.


clients in the sample (#7), the QIDP

failed to implement an active treatment

(AT) schedule for client #7.


clients in the sample (#2, #4 and #5), the

QIDP failed to ensure the clients'

comprehensive functional assessments

(CFA) were reviewed annually for


9-3-3(a)

483.430(d)(1-2)

DIRECT CARE STAFF

The facility must provide sufficient direct

care staff to manage and supervise clients in

accordance with their individual program

plans.

Direct care staff are defined as the present

on-duty staff calculated over all shifts in a

24-hour period for each defined residential

living unit.

W 0186

Bldg. 00

Based on record review and interview for

1 of 4 clients in the sample (#5), the

facility failed to deploy staff in a manner

to manage and supervise client #5 in

accordance with her program plan.

Findings include:



the staffing schedule has been

revised, in coordination with

individual support plans, to

ensure staff are deployed in

sufficient number to implement

plans as written. Ongoing


11/27/2016 12:00:00AM





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following:

A 7/7/16 Bureau of Developmental




























through weekly meetings

between the TM and ND/QIDP to

ensure staff are scheduled as

planned, and problem solve any

staffing issues. Additionally, the

DRS and ND/QIDP meet no less

than monthly to discuss all issues

pertinent to the setting, including

staffing issues.





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she knows that (it) is not a safe place to























like to be touched.





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Services Officer (CSO) indicated at the

time of her fall, client #5 was outside






fell.





staff #2 was in the group home at the

time of the incident. The HM indicated

she was outside in the parking lot next to

the group home when client #5 came out.





















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9-3-3(a)

483.440(c)(3)

INDIVIDUAL PROGRAM PLAN

Within 30 days after admission, the

interdisciplinary team must perform accurate

assessments or reassessments as needed

to supplement the preliminary evaluation

conducted prior to admission.

W 0210

Bldg. 00


1 of 1 client (#7) in the sample who was

admitted to the group home since

10/24/15, the facility failed to ensure an

accurate assessment was completed

within 30 days after admission.

Findings include:


client #7's record was conducted. Client

#7 was admitted to the group home on

5/20/16 and discharged on 8/30/16 for

rehabilitation at a nursing home. Client

#7 was readmitted to the group home on

W 0210 To correct the deficient practice,

a CFA has been completed for

client #7. To ensure no others

were affected, the ND/QIDP will

review CFAs for all other

individuals living in the home, and

update as necessary. To prevent

the deficient practice from

recurrence, the DRS will re-train

all ND/QIDPs on the requirement

to complete a CFA for individuals

within 30 days after admission,

and annually thereafter. Ongoing


through the ND/QIDP Monthly

Report, which includes the date of

the most recent CFA. The

Monthly Reports are forwarded to

11/27/2016 12:00:00AM





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9/29/16. There was no documentation

the facility completed a comprehensive

functional assessment (CFA) within 30

days of admission.

On 10/25/16 at 11:02 AM, the Qualified


(QIDP) indicated he had not completed a

CFA for client #7.

9-3-4(a)

the DRS, Director of Support

Services and CSO for review.

483.440(c)(6)(i)

INDIVIDUAL PROGRAM PLAN

The individual program plan must describe

relevant interventions to support the

individual toward independence.

W 0240

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1 of 4 clients in the sample (#5), the

facility failed to ensure client #5 had a

plan for staff to assist her to the van

following a fall with injury while walking

out to the van.

Findings include:




following: A 7/7/16 Bureau of

Developmental Disabilities Services

(BDDS) incident report indicated, in part,

"On June 23 [client #5] fell off the ledge

out by the driveway at her home and



client #5’s NCP and Fall Risk

Plan have been revised, and all

staff have been re-trained on the

revised plans. Ongoing















staff as well.

11/27/2016 12:00:00AM





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dislocated her elbow. She went to the ER

(emergency room) and they put her arm

in a sling. We made her an appointment

with [name of orthopedic] for as soon as

possible. She went to [orthopedic] on

6-29-16 where they tried to put her elbow

in socket, they was (sic) unable to do this


























There was no documentation client #5's





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

9/27/16 Fall Risk Plan and 1/19/16

Nursing Care Plan included written

instructions for staff to walk with client

#5 to the van at all times.



was no documentation client #5's 1/19/16























prompt medical attention." Client #5's

NCP and Fall Risk Plan did not indicate

staff would walk with her to the van at all

times following the fall on 6/23/16.





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00


of Residential Services indicated the

information from the BDDS report

should have been included in her plan.


Services Officer indicated the

information from the BDDS report

should have been included in her plan.

9-3-4(a)

483.440(d)(1)

PROGRAM IMPLEMENTATION

As soon as the interdisciplinary team has

formulated a client's individual program plan,

each client must receive a continuous active

treatment program consisting of needed

interventions and services in sufficient

number and frequency to support the

achievement of the objectives identified in

the individual program plan.

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Bldg. 00


record review for 1 of 4 clients in the

sample (#7) and one additional client

(#6), the facility failed to ensure staff

implemented: 1) client #7's Nursing Care

Plan for the use of a walker and stand-by

assistance from staff when using the

stairs and 2) client #6's program plan for

wiping after toileting.

Findings include:



the nurse updated client #7s

nursing care plan, and the

ND/QIDP developed a program

plan for client #6 for wiping after

toileting. To ensure no others


practice, the ND/QIDP will review

all plans for the other individuals

living in the home to ensure they

are current, and make revisions

as necessary. All staff will be

re-trained by the ND/Q on the

revised plans and expectations

11/27/2016 12:00:00AM





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

1) Observations were conducted at the


to 5:13 PM and 10/25/16 from 6:04 AM












any point.



#7's 9/27/16 Nursing Care Plan (NCP)

indicated, in part, "At risk for falls related

to weakness following surgery... Always

use stand-by assistance on stairs. Guide

at elbow as needed. [Client #7] should

use her rolling walker once upstairs and

whenever on flat surfaces. Staff should

carry the walker to the desired floor.

Ensure surfaces are clear of tripping

hazards such as rugs, spills, furniture. If

a fall should occur, seek prompt medical

attention paying close attention to venous

cath site (A central venous catheter, also

called a central line, is a long, thin,

flexible tube used to give medicines,

fluids, nutrients, or blood products over a

for implementation. Ongoing















staff as well.





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

long period of time, usually several

weeks or more) and surgical site." A

10/18/16 Medical Appointment Record

indicated, in part, by the Physical

Therapist (PT), "...May go without

walker at this time." The nurse failed to

update client #7's NCP after the PT

discontinued the use of the walker.


of Residential Services indicated client

#7's plan should have been implemented

as written.



(QIDP) indicated client #7's Nursing Care

Plan should have been implemented as

written. The QIDP indicated client #7's

plan should have been updated on

10/18/16 when the PT discontinued the

walker.

2) On 10/25/16 from 6:04 AM to 7:40



client #6's mattress was not covered with

a sheet. The sheet was falling off the

mattress exposing a yellow, brown and

tan area on the mattress about 12 inches

in diameter. There was also a 4 inch by 1

inch brown substance on the mattress in a

straight line.





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

On 10/25/16 at 9:24 AM, a focused

review of client #6's record was

conducted. Client #6's 1/19/16

Individualized Support Plan indicated he

had a training objective to increase his

wiping skills after toileting. The plan

indicated in the Current Status section,

"[Client #6] does not wipe after

toileting." The Proposed Strategy section

indicated, "[Client #6] will be provided

with toilet paper when he uses the

restroom. Staff will allow [client #6] as

much privacy as possible while ensuring

that he is wiping until all feces is

removed. Initially staff will verbally cue

[client #6], '[client #6], remember to wipe

when you are finished.' Staff will wait

until [client #6] has finished having a

bowel movement, staff will then enter the

restroom to ensure that wiping is being

done. Encourage [client #6] to 'wipe

from front to back.' When [client #6] has

successfully cleaned himself staff will

praise [client #6]. This goal will be

considered met if [client #6] has

successfully cleaned his bottom after

toileting."



#6's plan should be implemented as

written.

9-3-4(a)





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

483.440(d)(2)

PROGRAM IMPLEMENTATION

The facility must develop an active treatment

schedule that outlines the current active

treatment program and that is readily

available for review by relevant staff.

W 0250

Bldg. 00


interview for 1 of 4 clients in the sample

(#7), the facility failed to implement an

active treatment (AT) schedule for client

#7.

Findings include:



to 5:13 PM, 10/25/16 from 6:04 AM to

7:40 AM and 10/25/16 from 9:03 AM to

10:30 AM. On 10/24/16 from 3:19 PM

to 4:21 PM, client #7 sat in the living

room watching television. When client

#7 was not watching television, she was

outside smoking a cigarette. On 10/25/16

at 6:30 AM, client #7 woke up to take her

medications. Client #7 got a cup of

coffee and sat in the living room

watching television. At 7:23 AM, client

#7 went outside to smoke. Client #7

came back inside and watched television.

At 9:03 AM, client #7 watched

television. At 9:35 AM, client #7 went

outside to smoke. At 9:39 AM, client #7

returned to watching television until her

W 0250 The ND/QIDP will work with the

IDT to develop an active

treatment schedule for client #7,

and all staff will be trained on

implementation of the plan. To

ensure no others were affected

by the deficient practice, the

ND/QIDP will review active

treatment schedules for all others

living in the home and make

revisions as necessary. Ongoing















staff as well.

11/27/2016 12:00:00AM





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

physical therapist arrived at 10:23 AM.



was no documentation of an active

treatment schedule in client #7's record.



(QIDP) indicated client #7 did not have

an active treatment schedule for her daily

activities. The QIDP stated, "we let her

do, for the most part, what she wants."

The QIDP indicated the Medical

Coordinator had a calendar with client

#7's medical appointments, including

physical therapy and dialysis, but nothing

for the rest of her day.

9-3-4(a)

483.440(f)(2)

PROGRAM MONITORING & CHANGE

At least annually, the comprehensive

functional assessment of each client must

be reviewed by the interdisciplinary team for


W 0259

Bldg. 00


3 of 4 clients in the sample (#2, #4 and

#5), the facility failed to ensure the

clients' comprehensive functional

assessments (CFA) were reviewed

annually for relevancy and updated as


a CFA has been completed or will

be revised for all individuals living

in the home. To prevent the

deficient practice from

recurrence, the DRS will re-train

all ND/QIDPs on the requirement

to complete a CFA for individuals

11/27/2016 12:00:00AM





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

needed.

Findings include:



#2's most recent CFA was dated 9/29/15.

There was no documentation in his

record indicating the CFA was reviewed

since 9/29/15.




There was no documentation in his


since 9/29/15.




There was no documentation in her


since 9/29/15.



(QIDP) indicated there were no changes

to the clients' CFAs since 9/29/15. The

QIDP indicated the clients' CFAs were to

be updated at least annually or as things

change throughout the year.

9-3-4(a)

within 30 days after admission,

and annually thereafter. Ongoing


through the ND/QIDP Monthly

Report, which includes the date of

the most recent CFA. The

Monthly Reports are forwarded to

the DRS, Director of Support

Services and CSO for review.





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

483.440(f)(3)(i)

PROGRAM MONITORING & CHANGE

The committee should review, approve, and

monitor individual programs designed to

manage inappropriate behavior and other

programs that, in the opinion of the

committee, involve risks to client protection

and rights.

W 0262

Bldg. 00


3 of 4 clients in the sample (#2, #4 and

#5) with restrictive interventions in their

program plans, the facility's specially

constituted committee (Human Rights

Committee - HRC) failed to review,

approve and monitor the clients' plans.

Findings include:



#2's 1/19/16 Behavior Support Plan

(BSP) indicated he had the following

targeted behaviors: aggression (hitting,

biting, grabbing and head butting), rectal

digging (putting hands in pants and

placing fingers on/in anus) and

self-injurious behavior (slapping himself

on the top of his head, pinching his arms,

legs, outer thighs, stomach and nipples).

The BSP indicated client #2 was

prescribed Inderal and Depakote for

"behavior" and Haldol and Mirtazapine

for depression. The BSP indicated, in

part, "A CPI (Crisis Prevention Institute)


HRC approval will be obtained for

all restrictive measures for clients

#2, #4 and #5. To ensure no

others were affected by the

deficient practice, the ND/QIDP

will review plans for all others

living in the home and ensure

required approvals have been

obtained, and if not, will secure

them. To prevent the deficient

practice from continuing, all

ND/QIDPs have been re-trained

on the requirement to obtain

guardian and HRC approval prior

to implementation of any plan that

includes restrictive measures.

The Services Leadership will

review current HRC procedures

and develop a process for

comprehensive, centralized

ongoing monitoring to ensure the

appropriate approvals are

obtained and current. The CSO is

responsible for the coordination of

the HRC.

11/27/2016 12:00:00AM





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

approved two-man transport should only

be used as a last resort ([client #2's] life

and safety is endangered, fire, behavior in

the middle of the street, etc ...) as [client

#2] tends to become more aggressive and

extremely strong making the situation

much more intense." There was no

documentation the facility's HRC

reviewed, approved and monitored the

implementation of client #2's restrictive

BSP.



#4's 1/19/16 BSP indicated he had the

following targeted behaviors: self-injury

(hitting nose rapidly and hard biting of

knuckle of right index finger), stripping

(removing his clothing in a public place)

and wandering (walking off the group

home property or leaving staff presence

when on an outing). The BSP indicated

client #4 was prescribed Haldol for

self-injury and Eskalith for mood

stabilization. There was no




BSP.



#5's 1/19/16 BSP indicated she had the

following targeted behaviors: self-injury





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

(hard hit to the cheek with an open or

closed fist, scratching at her face or

pushing back of hands into her eyes),

tantrum (crying with no tears and

screaming), dumping (pouring drink into

plate or bowl, turning plate over, or

dumping contents of plate or bowl onto

the floor) and acquiring food (going into

the kitchen and taking food out of the

cabinets and refrigerator and consuming).


prescribed Mellaril for agitation, Trileptal

for mood stabilization, and Klonopin and

Buspar for anxiety. There was no




BSP.


Services Officer (CSO) indicated she was

unable to locate the documentation the

HRC reviewed and approved the clients'

program plans. The CSO indicated the

facility should obtain HRC consent prior

to implementing the restrictive program

plans.

9-3-4(a)

483.450(e)(2)

DRUG USAGE

W 0312





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

Drugs used for control of inappropriate

behavior must be used only as an integral

part of the client's individual program plan

that is directed specifically towards the

reduction of and eventual elimination of the

behaviors for which the drugs are employed.

Bldg. 00


1 of 3 clients in the sample with

psychotropic medications (#2), the

facility failed to ensure client #2's plan to

reduce the use of the psychotropic

medications was attainable.

Findings include:



#2's 1/19/16 Behavior Support Plan

(BSP) indicated he had the following

targeted behaviors: aggression (hitting,

biting, grabbing and head butting), rectal

digging (putting hands in pants and

placing fingers on/in anus) and

self-injurious behavior (slapping himself

on the top of his head, pinching his arms,

legs, outer thighs, stomach and nipples).


prescribed Inderal and Depakote for

"behavior" and Haldol and Mirtazapine

for depression. For each medication, the

Targeted Behavior Frequency for

Reduction section indicated, "0 incidents

of aggression for 3 consecutive months."

The Medication Reduction Plan section

indicated, "On-going monitoring by a


a plan of reduction will be revised

for client #2’s psychotropic

medications to ensure the plan is

attainable. To ensure no others


practice, the DRS will review all

other plans to ensure a current

plan of reduction is in place and

attainable, and revise as

necessary. To ensure the

deficient practice does not

continue, all ND/QIDPs have

been re-trained on plans of

reduction for psychotropic

medications. Ongoing monitoring

will be accomplished by the staff

responsible for facilitating the

Human Rights Committee, who

will review all behavior support

plan and psychotropic medication

submissions to ensure they have

all required elements.

11/27/2016 12:00:00AM





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



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(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

psychiatrist is recommended so as to

ensure the lowest possible therapeutic

doses of psychoactive medications. At

least quarterly, the Interdisciplinary Team

(IDT) will review these

medications/doses relative to the [client

#2's] current behavioral status. The

Network Director/QDDP (Qualified

Developmental Disabilities Professional)

will relay concerns relative to these

reviews to the prescribing physician, as

needed. It is the consensus of the IDT

that addressing the targeted behaviors

with medication, while replacement skills

and less restrictive reactive measures

become established and developed, that

the frequency and intensity of these

concerns will be reduced, and improve

her (sic) overall quality of life. Risks

associated with current medications have

been and will be routinely reviewed with

[client #2] along with his IDT, applicable

human rights committee, and other

relevant personnel. Consequently,

psychoactive medications will be reduced

or discontinued upon recommendation of

the prescribing physician and the IDT

according to established outcome criteria,

safety concerns, and/or less restrictive

alternatives. All other changes in

psychoactive medications will be made

upon recommendation of the prescribing

physician, and approval of the IDT, as

well as approval of the Human Rights





01/31/2017PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


COLUMBUS, IN 47203

15G665 10/28/2016

LIFE DESIGNS INC

2701 FAIRLAWN AVE

00

Committee when medication increases

beyond previously approved ranges have

been recommend and in instances, where

there is a medication within a previously

approved class."



#2's medication reduction plan for his

psychotropic medications should be

attainable.

9-3-5(a)


printed: 01/31/2017 department of health and …(x1) provider/supplier/clia department of health and...

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