w 0000 #in00289256. · interview with client d on 4/4/19 at 11:43 am indicated residential...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

05/31/2019PRINTED:

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

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DEFICIENCY)

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COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

EVANSVILLE, IN 47725

15G098 04/05/2019

COMMUNITY ALTERNATIVES SW IN

10707 BERNADETTE DR

00

W 0000

Bldg. 00

This visit was for an investigation of Complaint

#IN00289256.

Complaint #IN00289256: Substantiated.

Federal/state deficiencies related to the

allegation(s) are cited at W104 and W186.

Dates of Survey: April 3, 4 and 5, 2019.

Facility Number: 000637

Provider Number: 15G098

AIMS Number: 100234000

These deficiencies reflect findings in accordance

with 460 IAC 9.

Quality Review of this report completed by #15068

on 4/17/19.

W 0000

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, record review and

interview for 4 of 4 clients living in the facility,

(clients A, B, C and D), the facility's governing

body failed to exercise operating direction over

the facility to ensure sufficient staff was available

to address clients' health, programming and

behavioral needs.

Findings include:

Observations were conducted at the facility where

clients A, B, C and D resided on 4/03/19 from 8:16

PM until 8:32 PM. Staff #1 was working at the

facility. Client C was in the bathroom bathing.

W 0104 W104 - The governing body must

exercise general policy, budget

and operating direction over the

facility.

To correct the deficiency with

W104:

- The facility will ensure that the

group home is adequately staffed

to meet all client’s needs.

-Human Resources will consult

with PM weekly to determine

needs of homes as far as staffing.

- Staff will be retrained on

notifying Residential Manager if

05/28/2019 12:00:00AM

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

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

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

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

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

continued program participation.

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

_____________________________________________________________________________________________________Event ID: 1JEH11 Facility ID: 000637

TITLE

If continuation sheet of 25

(X6) DATE




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Clients A, B and D were in their rooms in bed.

Staff #1 was interviewed on 4/3/19 at 8:20 PM.

Staff #1 indicated she worked alone with clients

A, B, C and D during the staff shift of 2:00 PM

until 10:00 PM. The 2:00 PM to 10:00 PM staff

(staff #1 on 4/3/19) came to the facility at 2:00 PM,

and provided transportation for the clients from

their day programs back to the facility. The staff

was responsible to coordinate/monitor the

evening routine of medication administrations at

4:00 PM and 8:00 PM, oversee mealtime activities

(preparation and consumption), implement client

programming and manage behaviors if any

occurred alone. Staff was responsible to

assist/monitor clients with all activities of daily

living (bathing, oral

hygiene, dressing, toileting).

Interview with client D on 4/4/19 at 11:43 AM

indicated Residential Manager/RM #1 was the

only staff on duty that morning at the facility.

The interview indicated DSP #1 was the only staff

working the afternoon/evening of 4/3/19 at the

facility.

Program Manager/PM #1 was asked about

staffing level at the facility where clients A, B, C

and D lived on 4/4/19 at 1:17 PM. PM #1 stated it

was her understanding, according to the

BDDS/Bureau of Developmental Disabilities

Services guidelines, it was a "1 to 4 ratio (1 staff to

4 clients)." PM #1 gathered more information and

the interview continued at 1:30 PM on 4/4/19. The

interview indicated the facility, according to

BDDS guidelines, was an "8.00" home with a 1:4

ratio for staffing. PM #1 indicated the facility was

staffed with one staff per shift due to there being

4 vacant beds at the facility. The interview

indicated the facility was also short of staff and

the group home does not have

adequate staff assigned to a shift

- Residential Manager will make

weekly schedules being careful

that the group home is adequately

staffed to meet all client’s needs.

-Residential Manager will ensure

through daily observation that

there is adequate staff in the home

to meet all client needs.

- QIDP will make weekly checks

to ensure that there is adequate

staff assigned to and working

shifts to meet all client’s needs.

- Area Supervisor will review staff

schedules weekly and make

weekly home checks to ensure

the there is adequate staff

assigned to and working shifts to

meet all clients’ needs.

- Program Manager will make

monthly checks to ensure the

there is adequate staff assigned to

and working shifts.

Persons Responsible: Staff,

Residential Manager, QIDP, Area

Supervisor, Program Manager, HR

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1JEH11 Facility ID: 000637 If continuation sheet of 25




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staff from other facilities and the Residential

Manager/RM were helping cover shifts. The PM

was asked how one staff would be able to deal

with an emergency or a behavioral incident, PM

#1 indicated the staff would call the Residential

Manager for assistance. The Facility's Area

Director or the Program Manager may also be

summoned to lend help. The interview indicated

the time for response was unknown.

Interview with QIDP/Qualified Intellectual

Disabilities Professional #1 on 4/4/19 at 1:50 PM

indicated she wrote the ISPs and BSPs for clients

A, B, C and D. The interview indicated clients A,

B, C and D had training goals to be implemented

by DSPs (Direct Support Professionals). The

clients all had BSPs which contained strategies to

deal with their challenging behaviors. The

interview indicated some of the behavioral

strategies required implementation by 2 staff

members. The interview indicated the RM

(Residential Managers), AS (Area Supervisors)

and the PM (Program Manager) were in charge of

staffing the agency's facilities.

Please see W186 for the governing body's failure

to exercise operating direction over the facility to

provide sufficient staff to manage clients'

behaviors and monitor clients A, B, C, and D

during their activities of daily living.

This federal tag relates to Complaint #IN00289256.

9-3-1(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

W 0186

Bldg. 00





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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.

Based on observation, record review and

interview for 4 of 4 clients living in the facility (A,

B, C and D), the facility failed to provide sufficient

staff to implement client programming and

monitoring according to established guidelines.

Findings include:

Observations were conducted at the facility where

clients A, B, C and D resided on 4/03/19 from 8:16

PM until 8:32 PM. Staff #1 was working at the

facility. Client C was in the bathroom bathing.

Clients A, B and D were in their rooms in bed.

Staff #1 was interviewed on 4/3/19 at 8:20 PM.

Staff #1 indicated she worked alone with clients

A, B, C and D during the staff shift of 2:00 PM

until 10:00 PM. The 2:00 PM to 10:00 PM staff

(staff #1 on 4/3/19) came to the facility at 2:00 PM,

and provided transportation for the clients from

their day programs back to the facility. The staff

was responsible to coordinate/monitor the

evening routine of medication administrations at

4:00 PM and 8:00 PM, oversee mealtime activities

(preparation and consumption), implement client

programming and manage behaviors if any

occurred alone. Staff was responsible to

assist/monitor clients with all activities of daily

living (bathing, oral hygiene, dressing, toileting).

1. Client A's record was reviewed on 4/4/19 at 2:00

PM, 3:45 PM and on 4/5/19 at 9:30 AM. The

reviews indicated client A's diagnoses included,

but were not limited to, PTSD (post traumatic

W 0186

W186- The facility must provide

enough direct care staff to manage

and supervise clients in

accordance with their individual

program plans.

-The facility has a policy regarding

recruitment, retention, and hiring

practices which has been reviewed

and remains appropriate.

To correct the deficiency with

W186:

-The current schedule in place

has been revised to address the

needed staffing changes to assure

enough staff within the Bernadette

home.

-Human Resources will consult

with PM weekly to determine

needs of homes as far as staffing

-The Area Supervisor will

complete a review of all schedules

at each group home to ensure

enough staff are at each home is

present per current licensure

levels.

- Residential Manager shall assure

proper implementation of schedule

through weekly review of schedule

for the upcoming week to assure

proper staffing.

-Residential Manager will ensure

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stress disorder), Personality Disorder - NOS (not

otherwise specified) with Borderline Traits,

Schizoaffective D/O, Mild Intellectual Disability,

Acne, Enuresis (incontinence), IBS (irritable bowel

syndrome, HTN (hypertension), Constipation,

Irregular Menses, Allergic Rhinitis, Melanosis

Coli (pigmentation of the colon wall),

Avitaminosis (vitamin deficiency), potential for

EPS (extra pyramidal side effects from

medications), Sleep Apnea, Insomnia, Mild

Leukocytosis (increase of white blood cells),

Severe Gingivitis, Above Ideal Body Weight, HX

(history) of Mild Scoliosis, HX of Seizures. Client

A's 4/2019 physician's order's (reviewed on 4/4/19

at 2:12 PM) indicated the diagnosis of IDDM

(Insulin Dependent Diabetes Mellitus) and she

received metformin 1000 mg/milligrams twice daily

for IDDM, and she received an injection via

insulin pen of Lantus (slow acting insulin) 70 unit

subcutaneously at bedtime for IDDM. Interview

with Nurse #1 on 4/4/19 at 3:55 PM indicated

client A self injected her insulin under staff

supervision.

The record reviews indicated client A has allergies

to Ham, Barbiturates, Benzodiazepines,

Carbamazepine, and

Sensitivity to Hydrocortisone.

The record reviews indicated client A had an

ISP/Individual Support Plan dated 2/1/19 which

included, in part, the following information:

"[Client A] is a [age/race] female. [Client A] is

ambulatory and has effective use of all limbs.

[Client A] is verbal and able to make her wants

and needs known. [Client A] wears glasses to

correct her vision. [Client A]'s hearing is within

normal limits. [Client A] is over her ideal body

weight. [Client A] likes one on one attention.

through daily observation that

there is adequate staff in the home

to meet all client needs.

-QIDP shall monitor through

weekly observation within the

home to ensure that there is

adequate staffing to meet all client

needs.

-Area Supervisor shall monitor

through weekly observation within

the home to ensure that there is


needs.

-Program Manager shall monitor

through monthly observations in

the home to ensure that there is


needs.

Persons Responsible: Residential

Manager, QIDP, Area Supervisor,

Program Manager, , Human

Resources Director

Area Supervisor, Program

Manager, , Human Resources

Director





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[Client A] is very attention seeking when she

doesn't get her way. [Client A] gets upset when

she doesn't get her way. [Client A] gets upset

when she thinks other people are getting more

attention than she is. [Client A] has family but

seldom has contact with them."

The 2/1/19 ISP contained the following needs list:

Needs to learn to make change correctly, has a

goal to make change for $20.00.

Needs to take care of personal belongings

Needs to follow prescribed diet

Needs to wash hands at appropriate times, has

training object for washing hands prior to meds.

Needs to keep room clean

Needs to put clothes away when finished washing

Needs to make bed daily, has a training objective

for bed making.

Needs to learn proper hygiene, has objective for

stating the reason for supervision during

showers/bathing (seizure precaution).

"CHALLENGING BEHAVIORS

Hits

Pulls hair

Bites / attempts to bite

Throws things at people

Slams doors

Yells

Cusses

Follows staff - attention seeking

Steals

Makes untrue statements about self, situations

and others

Refuses medications

Refuses to do chores

Is demanding

Gets upset when redirected

Gets upset when doesn't get her own way





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Tattles on others

Pretends to be ill

Has gone AWOL (leaving assigned area) in the

past

Paces

Attempts to harm herself

Threatens others

Wants to hug / hang on to staff."

The record reviews indicated client A had a

BSP/Behavior Support Plan dated 2/1/19 which

included, in part, the following information

regarding the behaviors she exhibited:

"1. Maladaptive behavior associated with her

Diagnoses of PTSD, Personality d/o NOS

w/Borderline Traits, Schizoaffective d/o." The

"maladaptive behavior" was not defined in the

BSP

"2. Verbal Disruption defined as threatening to

have a behavior, crying and screaming, makes fun

of others, pouts, cusses, etc.

3. Physical Aggression- hangs on others, hugs

too tightly, hitting, slapping, pulling hair,

throwing items at others, etc. Excessive sleeping

as defined as during normal waking hours,

refusing programming by sleeping during work,

active treatment, and/or outings.

4. Refusals- refusing treatment plan, workshop

activities, riding in the van, refusing to take

prescribed medications, etc.

5. Stealing- Taking items that do not belong to

her.

6. Fabricating Stories Regarding Others- Stating

others said or done (sic) things to gain attention.

7. Fabricating Symptoms and Illnesses Mimicking

psych and physical symptoms to gain attention of

nurse and QIDP.

8. SIB (self injurious behavior)- picking and

biting nails, picking skin off of fingertips, picking





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at existing sores, picking at skin causing sores,

sticking finger down throat, etc.

9. Elopement is defined as; Going outside of the

home without staff's knowledge or leaving the

group while in a public place. Leaving the

workshop without staff."

"PROACTIVE STRATEGIES:

" [Client A] will receive 10 minutes of 1 on 1

from direct care staff in the morning before going

to work and 10 minutes in the evening with (sic)

she returns from work to discuss any issues that

may be bothering her, upcoming appointments,

upcoming trips, holidays etc.

" [Client A] will be offered activities that she

enjoys participating in - going for a walk, playing

bingo, playing cards, listening to music.

" Staff will always use a respectful and polite

tone with [Client A].

" When redirecting [Client A] talk to her in a

quiet area - DO NOT REDIRECT HER IN FRONT

OF OTHERS.

" Consistent and positive staff interaction

" Consistent staff redirection

" Meds as ordered

" Quarterly psych appointments

" Individual therapy monthly

ENVIRONMENTAL STRATEGIES:

" Quiet areas work best for [Client A]

" Staff need to know [Client A]'s likes/dislikes,

BSP, Behavioral Contract and Token Plan.

" [Client A] will be encouraged to talk to staff

about problems instead of reacting

inappropriately.

" Staff will not share information in front of or

to [Client A] regarding other client's SIB or

illnesses.

" Staff will not discuss in front of or to [Client

A] their personal illnesses or issues.





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" [Client A] is not allowed to get the mail due to

past incidents of stealing other client's

birthday/graduation cards with money in them.

REACTIVE STRATEGIES:

VERBAL DISRUPTION

" Staff will prompt [Client A] to stop the

behavior

" Staff will prompt [Client A] to go to her

bedroom or somewhere quiet, listen to music, calm

down.

" After 10 to 15 minutes staff will attempt to talk

with [Client A] to determine what is upsetting her.

" Discuss with [Client A] better ways to deal

with her frustrations.

PHYSICAL AGGRESSION

" If [Client A] is hanging on clients or staff or

hugging too tightly then staff are to immediately

prompt [Client A] to stop and let go.

" Remind [Client A] of personal space in a

polite and respectful tone.

" When [Client A] begins getting upset staff

are to immediately stop what they are doing and

ask [Client A] if she wants to talk about what is

upsetting her.

If [Client A] does not calm down after talking with

staff, staff need to be aware of where [Client A] is

and keep her within eyesight to ensure that she

does not become physically aggressive.

" If [Client A] does become physically

aggressive staff are to use YSIS (You're Safe, I'm

Safe/behavior management techniques) per

ResCare policy to ensure the safety of all

involved.

" [Client A] will be placed on 15-minute checks

for the next 24 hours after being physically

aggressive.

" Staff will attempt to stay between [Client A]





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and the other individuals in the house to attempt

to prevent her from harming them if she becomes

physically aggressive.

" Discuss with [Client A] better ways to deal

with her frustrations, the consequences of being

physically aggressive (no community access for

48 to 72 hours after physical aggression per

behavioral contract)

" NOTE: IT WILL REQUIRE TWO PEOPLE TO

USE THE YSIS- DO NOT ATTEMPT TO USE

YSIS IF YOU ARE BY YOURSELF.

" IF YOU ARE THE ONLY STAFF WORKING

YOUR PRIORITY IS TO GET THE OTHER

INDIVIDUALS TO THEIR ROOMS OR TO THE

VAN. DO NOT TRY TO PREVENT HER FROM

TEARING UP ITEMS IN THE HOUSE.

REFUSALS

" Staff will provide [Client A] with three verbal

prompts to complete a task in a firm but respectful

manner.

" Staff will allow [Client A] 15 minutes between

each verbal prompt.

" Staff will not repeatedly give [Client A] verbal

prompts or make threats to call QIDP or Nurse.

" If [Client A] continues to disregard staff's

prompts, then staff will document refusal on her

behavior data record and make note on her

behavioral incentive chart.

" If [Client A] is refusing to take medications,

staff will wait until 3 verbal prompts have been

given then go to a private area away from [Client

A] to contact the Nurse and QIDP. (Staff are not

to call nurse or QIDP in front of [Client A], staff

are not to discuss calling the nurse or QIDP with

[Client A])

STEALING

" Staff will not confront [Client A] about

stealing





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" Staff will document the incident on [Client

A]'s behavioral data record and notify QIDP

privately. (Not in front of [Client A]. Do not

discuss notifying QIDP with [Client A])

" QIDP will then investigate the incident and

meet with [Client A] within 24 hours of

investigation.

FABRICATING STORIES regarding others

" Staff will talk with [Client A] in a quiet area

alone

" Staff will explain the importance of telling the

truth.

" Staff will ask [Client A] why she is fabricating

stories about individuals. (by history [Client A]

fabricates stories about other individuals to get

them into fights)

" Staff will discuss with [Client A] proper ways

of making friends and handling frustrations.

" If [Client A] has made an accusation towards

staff, staff are to say 'ok thank you' to [Client A]

and redirect her to an activity she enjoys.

" Staff will then notify QIDP (not in front of or

around [Client A])

" Staff will not discuss the accusation with

[Client A].

" OM and QIDP will investigate the accusation

without asking leading questions and report

allegation to appropriate individuals.

FABRICATING SYMPTOMS AND ILLNESSES

" Staff is to show as little outward emotional

response as possible.

" If symptom/illness is not a new one staff will

actively ignore it for approximately 5 minutes.

(limping, foot pain, ankle pain, diarrhea or

vomiting without staff seeing, drowsiness,

attempts to raise body temp., coughing, spitting

up meds or food and saying threw up, confusion,

dizziness)





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" If symptoms continue then staff will provide

one additional verbally prompt for [Client A] to

complete routine.

" If symptoms continue then staff will offer

[Client A] choices of a preferred activity to be

done following the completion of routine task.

Such as taking a walk with staff, listening to

music, playing cards etc.

" Staff, in a location where [Client A] cannot

hear, will report symptom to the nurse.

" Staff will not discuss with [Client A] if nurse

or QIDP were notified.

" If it is determined that symptom/illness was

fabricated, then track on behavior tracking sheet

and behavior incentive plan.

Minor SIB

" Staff will show as little outward emotional

response as possible

" Staff will keep [Client A] within eyesight

during waking hours and door will be prompt

open at night time.

" Notify Nurse, PM and QIDP of any injuries

(not in front of or around [Client A]), document

and provide appropriate first aid.

" Appointment will be made with therapist.

" Document on tracking sheet and complete all

other necessary documentation.

Elopement:

" In the group home: If [Client A] walks out of

the house without asking, staff will ask [Client A]

to come back into the home.

" In the community: If [Client A] walks away

from the group without asking, staff will ask

[Client A] to return to the group.

" While at the workshop: If [Client A] walks

out of the workshop without asking, staff will ask

[Client A] to come back inside the workshop.

" If [Client A] refuses to return, staff will stay





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with [Client A], encouraging her to return.

" 5. If [Client A] refuses to respond to staff and

appears that she is putting herself at risk with

poor pedestrian skills/poor interactions with

bystanders- law enforcement will be contacted to

assist in bringing [Client A] back to the

home/workshop.

" 6. If staff is unsure where [Client A] is staff

will walk around the block and surroundings of

the area to see if a visual can be obtained.

" 7. If staff cannot locate [Client A] then they

are to contact law enforcement and provide a

physical description along with request to bring

her back to the home/workshop."

Review of behavior incident reports/BIRs,

provided by the facility on 4/4/19 at 2:45 PM,

indicated the following made by the day program

staff for client A:

3/8/19 at 1:15 PM, client A went AWOL (left the

day program building) with staff following behind

her.

3/12/19 at 12:40 PM, client A "got upset and

walked out with staff following."

3/14/19 at 1:30 PM, client A "eloped."

4/4/19 at 10:10 AM, client A "got upset at staff

because she asked her to give her a second

because she was in the middle of doing

something. Client got upset and walked out of day

program, W/staff (with) following."

Interview with the Residential Manager/RM on

4/4/19 at 2:45 PM indicated on two occasions the

police had been called and responded to the day

services building. The police being called was not

noted on the BIRS. They had been called to the

day program on 3 of the 4 occasions noted above.

Interview with the QAM/Quality Assurance

Manager on 4/4/19 at 2:45 PM, indicated day





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program staff should have filled out the proper

paperwork and notified the day program

supervisors and QA staff.

Additional review of client A's Behavior Reports

on 4/4/19 at 4:00 PM indicated she had behaviors

at the living facility on 2/28/19 at 9:05 AM and

5:00 PM of refusing requests which were

addressed with verbal redirection. On 3/5/19 at

5:00 PM and 5:30 PM, client A was verbally and

physically aggressive toward staff when she was

asked to take a shower when the water was warm;

other clients' showers had depleted the hot water

available. Client A "screamed" an obscenity to

staff #3 (only staff on duty) opened a door, "and

attacked staff reaching for neck and face of staffs

(sic). Staff used behavior management technique

to control client A's physical aggression and

client A "spit in staff's face."

On 3/25/19 (time illegible) client A was refusing

her medications. the Behavior Report did not

indicated if she took the medications or not.

2. Client B's record was reviewed on 4/4/19 at 3:45

PM and on 4/5/19 at 10:00 AM. The reviews

indicated client B's diagnoses included, but were

not limited to, Anxiety, Major Disruptive Mood

Dysregulation D/O Moderate Intellectual

Disability, Seizures, Risk of Falls, RT (due to)

Right Arm and Leg weakness/Vertigo, Potential

for Interruption of skin integrity RT (due to)

Urinary incontinence, Dependent edema bilateral

lower extremities, Dependent lower leg edema,

Allergic Rhinitis, and Constipation. The 7/10/18

ISP indicated client B used eyeglasses, a gait belt

and a walker. The ISP indicated the following

areas had been prioritized as training needs:

"Improve money skills

Improve oral care





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Improve domestic skills

Improve leisure skills

Improve eating skills

Improve toileting skills

Improve bathing skills

Improve socialization skills

Improve self-med skills

Improve first aid skills

Improve Table manners

Improve coping skills."

The record review indicated a BSP/Behavior

Support Plan of 7/10/18 with the following

behaviors exhibited by client B:

1. Anxiety, defined as excessive sleeping, crying,

noncompliance, excessive complaining, constant

negative comments, and over exaggerating

medical concerns.

2. Making false allegations towards others

defined as making untrue statements regarding

self and others.

3. Trustworthiness as defined as saying things

knowing they are untrue.

4. Verbal Aggression defined as yelling, cursing,

or screaming.

5. Physical Aggression as defined as hitting,

punching, kicking.

6. Spitting as defined as spitting at staff and

peers.

7. Non-Compliance with Showering as defined as

refusing to complete hygiene (showering).

Client B required supervision during bathing due

to her seizure diagnosis.





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The 7/10/18 BSP indicated the following behavior

management intervention client Client B's Physical

Aggression:

"Staff will prompt [Client B] to stop being

physically aggressive

i. If [Client B] continues the behavior and staff

believe she is in danger to herself or others

implement AYSIS (Advanced YS (You're Safe) IS

(I'm Safe/behavior management) techniques.

ii. Approach individual - one person on each

side.

iii. Grab under individual's wrist with your

outside hand.

iv. Reach with other hand under individual's arm,

bending over the wrist and grab own wrist.

v. Draw person's elbow backward over your hip

using your shoulder to support as much as

possible.

vi. Move in close, hugging individual's arm.

vii. Use your body to hold individual snug at

hips.

viii. Position leg closest to individual behind

individual's leg - may need to bump kick.

ix. Lower individual to ground if needed.

x. Prompt [Client B] again in a firm voice to

"Stop".

Once [Client B] is calm, re-engage in

activities.

Staff will do a body assessment and

document any reddened areas or marks.

Staff will direct [Client B] to talk to staff if

something is bothering her."

3. Client C's record was reviewed on 4/4/19 at 4:00

PM and on 4/5/19 at 10:30 AM. The review

indicated client C's diagnoses included, but were

not limited to, Mild Intellectual Disability, Down's

Syndrome, Poor Vision/Hx (history) of falls,





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History of Stroke, Hypothyroidism, History of

tinea pedis, Dandruff and Possible Rosacea,

Seasonal Rhinitis Interruption in skin integrity,

Hypertension, (and) Gastroesophageal reflux

disease (GERD).

The record review indicated an ISP dated 7/10/18.

Client C had training goals to brush her teeth and

use mouth rinse, learn her address, clip her

fingernails, assist with dinner preparation, exercise

30 minutes, state her address and phone number,

participate in a group activity for 20 minutes, make

a phone call, and complete her daily chore.

The record review indicated client C had a 7/10/18

BSP/Behavior Support Plan. The BSP indicated

interventions for the following identified

behaviors:

1. Tantrums defined as stomping feet, flailing

arms, slamming doors, crying and/or becoming

upset following redirection or directives.

2. Physical Aggression defined as hitting,

slapping, punching or striking at others with

intention to harm.

3. Verbal Aggression defined as screaming,

yelling, cursing, or using other hostile language.

4. Trustworthiness defined as lying, making false

statements, and/or blaming others.

"POSITIVE PROGRAMMING:

1. Keep [Client C]'s daily routine consistent.

2. Consistency in staff redirection.

3. When [Client C] is upset, staff will ask [Client

C] to tell them what is wrong.

ENVIRONMENTAL STRATEGIES:

1. Provide structured activities and consistency

in staff direction/response.

2. Provide [Client C] the opportunity to tell staff

what she wants/needs.





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3. Positive response and encouragement when

appropriate behavior is observed.

4. Mandt (behavior management techniques)

will be used by Day Program if necessary.

REACTIVE STRATEGIES:

Tantrums

1. When [Client C] stomps her feet, screams,

begins to flail her arms, drops to the floor, refuses

to participate during an activity etc. during a

tantrum episode.

2. Staff will reassure her that everything is ok,

ask her to stop, and then redirect [Client C] using

verbal prompts.

3. Staff will then ask [Client C] to calm down in

her bedroom. Staff will wait 15 minutes before

prompting her to rejoin the activity.

Physical Aggression

1. Staff will assume YSIS stances to protect

[Client C] from harming staff or peers.

a. staff will initiate prepared stance

b. raise both arms in parallel position

c. intercept blows with the outside of the

forearm-moving toward the outside of the

person's "striking" arm

d. follow through with forward motion of person

attempting to deliver blow

e. step away, maintain visual contact

f. resume prepared stance

2. Staff will redirect [Client C] to a quiet area to

calm down using verbal and physical prompts.

3. Once [Client C] has calmed down, she will be

redirected to an activity.

4. [Workshop name] will use MANDT

techniques:

Mandt

One Person, Standing Side Body Hug Restraint





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a.) Staff will approach from behind and on the left

side with arms visible

b.) Staff will gently touch the individual's left

upper arm with hands ready to protect face.

c.) Staff will move left foot and left arm forward

simultaneously with his/her left hand reaching for

the individual's hip area.

d.) Staff will trap the left arm in his/her armpit area

and place his/her right hand over the left on the

hip area.

Two Person, Side Body Hug Standing Restraint

a.) First staff will follow steps listed above.

b.) Second staff will approach from behind and on

the right side with arms visible.

c.) Second staff will follow same steps as first

staff, but from the right reaching towards the left

and over the first staff's arms.

One Person, One Arm Standing Restraint

a.) Staff will place left hand slightly above

individuals left elbow with his/her thumb on the

inside and four fingers on the outside.

b.) Staff will take right hand and place on right

hip.

c.) Staff will step forward with left foot next to

individual's left foot and guide arm slightly

forward across individual's body.

d.) Right hand will hold individual's left hand

across individual's body.

e.) Staff will stand slightly to the side of the

person with chest making contact with person's

back.

f.) Staff will drop individual's left arm with his/her

left hand, place his/her left hand under the

restrained arm, and grasp the individual's left

forearm to prevent pressure on the diaphragm or





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chest.

One Person, Two Arm Standing Restraint

a.) Staff will follow steps for one person, one arm

standing restraint.

b.) Staff will grasp individual's right arm with

his/her left arm from under the individual's left

arm.

Two Person, One Arm Standing Restraint

a.) First staff will follow steps for one person, one

arm standing restraint.

b.) Second staff will approach from behind and on

the right side.

c.) Second staff will reach across the front of the

individual and place right fingers and thumb

slightly above the individual's left elbow.

d.) Second staff will place left hand across lower

back of individual and on the left hip area.

Moving Restraint for One or Two Person

a.) Staff will ask the individual to move on his/her

own.

b.) Staff will walk individual forward a few steps

and stop. Staff will ask again.

c.) Staff member on the right will use left side on

chest, left leg, and stomach to move the individual

forward.

d.) Staff member on the left side will use the

reverse.

e.) Staff will move individual a short distance.

f.) If individual will not move forward, staff may

move individual backward a short distance,

keeping the individual balanced.

Staff will keep the individual close and pay

attention to the individual's body. Staff will

remain calm and relaxed. Only one staff will talk to





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the individual. All MANDT restraints will not last

longer than 3 minutes.

Verbal Aggression

1. [Client C] will be verbally redirected to speak

in a normal tone of voice.

2. If yelling, name calling, hostile language

continues staff will prompt [Client C] to stop

using a firm voice.

3. [Client C] will be directed to an activity of her

choice.

Trustworthiness

1. Historically [Client C] has had issues with

telling stories leaving out correct /full information,

resulting in others getting into trouble

2. [Client C] will be encouraged to talk to staff

about what is wrong encouraging her to give all

the details.

3. Verbal praise will be given to [Client C] when

she tells the entire truth/story."

4. Review of client D's record on 4/4/19 at 3:30 PM

and on 4/5/19 at 11:00 AM indicated her

diagnoses included but were not limited to, Mood

Disorder NOS, Mild Intellectual Disability,

Congenital Cerebral Palsy, Hx of endometriosis,

and above ideal body weight. The record review

indicated an undated "High Risk Plan" which

addressed client D's diagnosis of Cerebral Palsy

and her history of falls. The record reviews

indicated an ISP dated 7/10/18 and an

accompanying BSP dated 7/10/18.

The BSP indicated the following challenging

behaviors exhibited by client D:

1. Verbal Aggression defined as yelling and

screaming

2. Physical Aggression defined as slapping,

hitting, others.





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3. Elopement defined as leaving the home/day

program without permission and without

supervision

The BSP contained, in part, the following behavior

management strategies/interventions:

"Physical aggression

1. In a calm firm voice staff will prompt [Client D]

to stop the physical aggression.

2. Staff will clear the area of all other clients

3. Staff will assume the YSIS prepared stance

a. Staff will initiate prepared stance

b. Raise both arms in parallel position

c. Intercept blows with the outside of the

forearm-moving toward the outside of the

person's striking arm.

d. Follow through with forward motion of person

attempting to deliver blow

e. Step away and maintain visual contact.

f. Resume prepared stance.

4. If [Client D] is hitting another person staff will

intervene immediately using their body to block

[Client D] and use YSIS blocking techniques and

redirect her to a quiet area.

5. Staff will ask [Client D] to stop.

If [Client D] continues the behavior and staff

believe she is in danger to herself or others

implement AYSIS (Advanced You're Safe I'm Safe)

techniques."

AYSIS

"a. Approach individual - one person on each

side.

b. Grab under individual's wrist with your outside

hand.

c. Reach with other hand under individual's arm,

bending over the wrist and grab own wrist.

d. Draw person's elbow backward over your hip

using your shoulder to support as much as





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possible.

e. Move in close, hugging individuals arm.

f. Use your body to hold individual snug at

hips.

g. Position leg closest to individual behind

individual's leg - may need to bump kick.

h. Lower individual to ground if needed.

i. Prompt [Client D] again in a firm voice to

"Stop"

j. Once [Client D] is calm, re-engage in

activities.

Elopement

1. Should [Client D] leave the house,

workshop area unsupervised, staff will follow her

at a short distance until she has calmed down and

then redirect her back to the house or workshop

area.

2. Staff should then ask [Client D] what is

bothering her and try to discuss the problem with

her in a calm manner.

3. Staff should use YSIS techniques if necessary

to keep [Client D] safe (i.e. walking into traffic,

etc.) Staff will stand between [Client D] and any

dangerous situation. If [Client D] becomes

aggressive, staff will implement YSIS stance and

use blocks to avoid injury to staff and/or [Client

D]

4. If [Client D] should get out of staff's sight, 911

should be called immediately and staff should

follow missing person's procedure.

5. After [Client D] has returned to the area, staff

should explain to her why leaving unsupervised is

unsafe and engage her in an activity of (her)

choice."

Interview with client D on 4/4/19 at 11:43 AM

indicated Residential Manager/RM #1 was the

only staff on duty that morning at the facility.





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The interview indicated DSP #1 was the only staff

working the afternoon/evening of 4/3/19 at the

facility.

Program Manager/PM #1 was asked about

staffing level at the facility where clients A, B, C

and D lived on 4/4/19 at 1:17 PM. PM #1 stated it

was her understanding, according to the

BDDS/Bureau of Developmental Disabilities

Services guidelines, it was a "1 to 4 ratio (1 staff to

4 clients)." PM #1 gathered more information and

the interview continued at 1:30 PM on 4/4/19. The

interview indicated the facility, according to

BDDS guidelines, was an "8.00" home with a 1:4

ratio for staffing. PM #1 indicated the facility was

staffed with one staff per shift due to there being

4 vacant beds at the facility. The interview

indicated the facility was also short of staff and

staff from other facilities and the Residential

Manager/RM were helping cover shifts. The PM

was asked how one staff would be able to deal

with an emergency or a behavioral incident; PM

#1 indicated the staff would call the Residential

Manager for assistance. The Facility's Area

Director or the Program Manager may also be

summoned to lend help. The interview indicated

the time for response was unknown.

Interview with QIDP/Qualified Intellectual

Disabilities Professional #1 on 4/4/19 at 1:50 PM

indicated she wrote the ISPs and BSPs for clients

A, B, C and D. The interview indicated clients A,

B, C and D had training goals to be implemented

by DSPs (Direct Support Professionals). The

clients all had BSPs which contained strategies to

deal with their challenging behaviors. The

interview indicated some of the behavioral

strategies required implementation by 2 staff

members. The interview indicated the RM

(Residential Managers), AS (Area Supervisors)





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and the PM (Program Manager) were in charge of

staffing the agency's facilities.

This federal tag relates to Complaint #IN00289256.

9-3-3(a)


w 0000 #in00289256. · interview with client d on 4/4/19 at 11:43 am indicated residential...

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