E 0000Facility Number: 000669 Provider Number: 15G132 AIM Number: 100234280 At this Emergency...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

02/25/2020PRINTED:

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

PREFIX

SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

PREFIX

IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

BERNE, IN 46711

15G132 01/21/2020

BI-COUNTY SERVICES INC

423 WIND RIDGE TR

E 0000

Bldg. --

An Emergency Preparedness Survey was

conducted by the Indiana State Department of

Health in accordance with 42 CFR 483.475.

Survey Date: 01/21/20

Facility Number: 000669

Provider Number: 15G132

AIM Number: 100234280

At this Emergency Preparedness survey,

Bi-County Services Inc was found not in

compliance with Emergency Preparedness

Requirements for Medicare and Medicaid

Participating Providers and Suppliers, 42 CFR

483.475

The facility has 8 certified beds. All 8 beds are

certified for Medicaid. At the time of the survey,

the census was 7.

Quality Review completed on 01/29/20

E 0000

403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)

(1)-(2), 441.184(a)(1)-(2), 482.15(a)(1)-(2),

483.475(a)(1)-(2), 483.73(a)(1)-(2), 484.102(a)

(1)-(2), 485.625(a)(1)-(2), 485.68(a)(1)-(2),

485.727(a)(1)-(2), 485.920(a)(1)-(2),

486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)

(1)-(2)

Plan Based on All Hazards Risk Assessment

[(a) Emergency Plan. The [facility] must

develop and maintain an emergency

preparedness plan that must be reviewed,

and updated at least every 2 years. The plan

must do the following:]

E 0006

Bldg. --

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: 9VZ321 Facility ID: 000669

If continuation sheet Page 1 of 22

(X6) DATE

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

(1) Be based on and include a documented,

facility-based and community-based risk

assessment, utilizing an all-hazards

approach.*

(2) Include strategies for addressing

emergency events identified by the risk

assessment.

*[For LTC facilities at §483.73(a)(1):]

Emergency Plan. The LTC facility must

develop and maintain an emergency

preparedness plan that must be reviewed,

and updated at least annually. The plan must

do the following:

approach, including missing residents.

assessment.

*[For ICF/IIDs at §483.475(a)(1):] Emergency

Plan. The ICF/IID must develop and maintain

an emergency preparedness plan that must

be reviewed, and updated at least every 2

years. The plan must do the following:

approach, including missing clients.

assessment.

* [For Hospices at §418.113(a)(2):]

Emergency Plan. The Hospice must develop

and maintain an emergency preparedness

plan that must be reviewed, and updated at

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 2 of 22

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

least every 2 years. The plan must do the

following:

approach.

assessment, including the management of

the consequences of power failures, natural

disasters, and other emergencies that would

affect the hospice's ability to provide care.

Based on record review and interview, the facility

failed to maintain an emergency preparedness

plan that was (1) based on and includes a

documented, facility-based and community-based

risk assessment, utilizing an all-hazards approach,

including missing clients and (2) included

strategies for addressing emergency events

identified by the risk assessment in accordance

with 42 CFR 483.475(a) (1) and 42 CFR 483.475(a)

(2). This deficient practice could affect all

occupants.

Findings include:

Based on review of the facility's Emergency

Preparedness Plan with the Training Coordinator,

House Manager and Maintenance Supervisor on

01/21/20 at 3:47 p.m., the facility had a few

(tornado, fire, etc.) facility-based and

community-based risk hazards that were

addressed in the plan, however, there was no

documentation of an actual facility-based and

community-based risk assessment based on an

all-hazard approach specific to the geographic

location of the facility that encompassed potential

hazards available for review. Based on interview

at the time of record review, the Training

Coordinator said there was no all hazards risk

E 0006 Wind Ridge Life Safety Code

and Emergency Preparedness

Plan of Correction

Survey Event ID 9VZ321

February 2020

E006-Plan Based on

All-Hazards Risk Assessment

At the time of the EPP survey for

the Wind Ridge (WR) basic

development Supervised Group

Living (SGL) home, BCS had an

Emergency Preparedness Plan

(EPP) in place using an

All-Hazards Risk Assessment,

provided to us in 2018 by ISDH

surveyor, for the group home that

was acceptable during the 2019

survey process and as such no

changes/revisions were made to

our All-Hazards Risk Assessment

since that time. We have reached

out to another provider to assist us

in better understanding the check

list that the surveyor was looking

for at the time of this survey. The

focus of this plan of correction

(POC) is the development of the

02/20/2020 12:00:00AM

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

assessment available for the facility. facility based and community

based assessment specifically for

the WR home.

Corrective Action:

1. Development of a more

comprehensive All-Hazards Risk

Assessment with focus on

specific community and WR SGL

based risk hazards and

vulnerabilities. This process was

started on 1/30/20 with the

Program Director (PD), Residential

Administrator (RA) and the

Administrative Assistant (AA)

involved in the assessment

process as well as reaching out to

another provider for a clearer

understanding of a comprehensive

format. The All Hazards Risk

Assessment and EPP will be

completed and ready for staff

training by 2/20/20. Competency

testing will be completed following

the EPP training.

2. The EPP Risk Assessment

checklist and EPP now includes

missing consumer(s)/elopement

as a community and facility based

hazard addressed in the EPP.

Person’s Responsible: Program

Director (PD); Residential

Administrator (RA); Administrative

Assistant; Residential

Management Team (RMT) and

Training Coordinator.

Target Completion Date:

2/20/20

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

403.748(c)(2), 416.54(c)(2), 418.113(c)(2),

441.184(c)(2), 482.15(c)(2), 483.475(c)(2),

483.73(c)(2), 484.102(c)(2), 485.625(c)(2),

485.68(c)(2), 485.727(c)(2), 485.920(c)(2),

486.360(c)(2), 491.12(c)(2), 494.62(c)(2)

Emergency Officials Contact Information

[(c) The [facility] must develop and maintain

an emergency preparedness communication

plan that complies with Federal, State and

local laws and must be reviewed and updated

at least every 2 years (annually for LTC).] The

communication plan must include all of the

following:

(2) Contact information for the following:

(i) Federal, State, tribal, regional, and

local emergency preparedness staff.

(ii) Other sources of assistance.

*[For LTC Facilities at §483.73(c):] (2)

Contact information for the following:

(ii) The State Licensing and Certification

Agency.

(iii) The Office of the State Long-Term

Care Ombudsman.

(iv) Other sources of assistance.

*[For ICF/IIDs at §483.475(c):] (2) Contact

information for the following:

(ii) Other sources of assistance.

(iii) The State Licensing and Certification

Agency.

E 0031

Bldg. --

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

(iv) The State Protection and Advocacy

Agency.

failed to ensure the emergency preparedness

communication plan includes (2) Contact

information for the following: (i) Federal, State,

tribal, regional, or local emergency preparedness

staff (ii) The State Licensing and Certification

Agency (iii) The Office of the State Long-Term

Care Ombudsman (iv) Other sources of assistance

in accordance with 42 CFR 483.475(c)(2). This

deficient practice could affect all occupants.

Findings include:

01/21/20 at 3:48 p.m., emergency plan did not

include contacting the Indiana State Department

of Health (ISDH) by telephone at 317-460-7287 for

emergency incidents that require a full or partial

evacuation. Based on interview at the time of

record review, the Training Coordinator said the

plan did not include the contact information for

the aforementioned emergency preparedness

staff.

E 0031 E031

Emergency Officials Contact

Information

The EPP had the Indiana State

Department of Health (ISDH)

contact information related to

using the ISDH Gateway link, but

the telephone contact number was

not included.

Corrective Action:

1. The EPP was revised to

include the ISDH telephone

contact number 317-460-7287 for

emergency incidents requiring a

full or partial evacuation on

1/30/20. This revised information is

located with the ISDH Gateway

link method of contact.

2. Staff and management

training on revised EPP

information, including the addition

of the ISDH telephone number will

be completed by 2/20/20.

Persons responsible: Program

Director; Residential

Administrator; Administrative

Assistant; Training Coordinator

and Residential Management.

Target Completion Date: 1/30/20

01/30/2020 12:00:00AM

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

403.748(c)(4)-(6), 416.54(c)(4)-(6), 418.113(c)

(4)-(6), 441.184(c)(4)-(6), 482.15(c)(4)-(6),

483.475(c)(4)-(6), 483.73(c)(4)-(6), 484.102(c)

(4)-(5), 485.625(c)(4)-(6), 485.68(c)(4),

485.727(c)(4), 485.920(c)(4)-(6), 491.12(c)(4),

494.62(c)(4)-(6)

Methods for Sharing Information

[(c) The [facility] must develop and maintain

an emergency preparedness communication

plan that complies with Federal, State and

local laws and must be reviewed and updated

at least every 2 years (annually for LTC).]

The communication plan must include all of

the following:

(4) A method for sharing information and

medical documentation for patients under the

[facility's] care, as necessary, with other

health providers to maintain the continuity of

(5) A means, in the event of an evacuation, to

release patient information as permitted

under 45 CFR 164.510(b)(1)(ii). [This

provision is not required for HHAs under

§484.102(c), CORFs under §485.68(c)]

(6) [(4) or (5)]A means of providing information

about the general condition and location of

patients under the [facility's] care as

permitted under 45 CFR 164.510(b)(4).

*[For RNHCIs at §403.748(c):] (4) A method

for sharing information and care

documentation for patients under the RNHCI's

care, as necessary, with care providers to

maintain the continuity of care, based on the

written election statement made by the

patient or his or her legal representative.

E 0033

Bldg. --

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

*[For RHCs/FQHCs at §491.12(c):] (4) A

means of providing information about the

general condition and location of patients

under the facility's care as permitted under 45

CFR 164.510(b)(4).

failed to ensure the emergency preparedness

communication plan includes (4) A method for

sharing information and medical documentation

for clients under the ICF/IID facility's care, as

necessary, with other health care providers to

maintain the continuity of care; (5) A means, in

the event of an evacuation, to release client

information as permitted under 45 CFR 164.510(b)

(1)(ii); (6) A means of providing information about

the general condition and location of clients under

the facility's care as permitted under 45 CFR

164.510(b)(4) in accordance with 42 CFR 483.475(c)

occupants.

Findings include:

Based on record review of the facility Emergency

Preparedness Plan and interview on 01/21/20 at

3:49 p.m., the Training Coordinator confirmed the

communication plan did not include a policy and

procedure for sharing information and medical

documentation for each client with other health

care providers.

E 0033 E033

Methods of Sharing Information

The EPP Communication plan did

not include a procedure/process

for sharing pertinent information

and medical documentation for

each consumer with other health

care providers.

Corrective Action:

1. Consent to Share Pertinent

Information and Medical

Documentation in Case of

Emergency has been submitted to

consumers, their guardians and/or

Health Care Representatives for

signatures and these consents will

be included in the EPP book(s) for

2. The WR EPP Communication

Plan was revised to include the

addition of information sharing

related to the health/safety of the

consumer(s).

Person’s responsible: Program

Director; Residential

Administrator; Residential

Management Team (RMT);

Administrative Assistant and

Training Coordinator (TC).

02/20/2020 12:00:00AM

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

403.748(d)(1), 416.54(d)(1), 418.113(d)(1),

441.184(d)(1), 482.15(d)(1), 483.475(d)(1),

483.73(d)(1), 484.102(d)(1), 485.625(d)(1),

485.68(d)(1), 485.727(d)(1), 485.920(d)(1),

486.360(d)(1), 491.12(d)(1)

EP Training Program

*[For RNCHIs at §403.748, ASCs at §416.54,

Hospitals at §482.15, ICF/IIDs at §483.475,

HHAs at §484.102, "Organizations" under

§485.727, OPOs at §486.360, RHC/FQHCs

at §491.12:] (1) Training program. The

[facility] must do all of the following:

(i) Initial training in emergency

preparedness policies and procedures to all

new and existing staff, individuals providing

services under arrangement, and

volunteers, consistent with their expected

roles.

(ii) Provide emergency preparedness

training at least every 2 years.

(iii) Maintain documentation of all

emergency preparedness training.

(iv) Demonstrate staff knowledge of

emergency procedures.

(v) If the emergency preparedness

policies and procedures are significantly

updated, the [facility] must conduct training

on the updated policies and procedures.

*[For Hospices at §418.113(d):] (1) Training.

The hospice must do all of the following:

new and existing hospice employees, and

individuals providing services under

arrangement, consistent with their expected

E 0037

Bldg. --

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

roles.

(ii) Demonstrate staff knowledge of

(iii) Provide emergency preparedness

(iv) Periodically review and rehearse its

emergency preparedness plan with hospice

employees (including nonemployee staff),

with special emphasis placed on carrying out

the procedures necessary to protect patients

and others.

(v) Maintain documentation of all

(vi) If the emergency preparedness

updated, the hospice must conduct training

on the updated policies and procedures.

*[For PRTFs at §441.184(d):] (1) Training

program. The PRTF must do all of the

following:

roles.

(ii) After initial training, provide

emergency preparedness training every 2

years.

(iii) Demonstrate staff knowledge of

(iv) Maintain documentation of all

updated, the PRTF must conduct training on

the updated policies and procedures.

*[For LTC Facilities at §483.73(d):] (1)

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

Training Program. The LTC facility must do all

of the following:

training at least annually.

(iii) Maintain documentation of all

*[For CORFs at §485.68(d):](1) Training. The

CORF must do all of the following:

(i) Provide initial training in emergency

new and existing staff, individuals

providing services under arrangement,

and volunteers, consistent with their

expected roles.

(iii) Maintain documentation of the

training.

emergency procedures. All new personnel

must be oriented and assigned specific

responsibilities regarding the CORF's

emergency plan within 2 weeks of their first

workday. The training program must include

instruction in the location and use of alarm

systems and signals and firefighting

equipment.

updated, the CORF must conduct training on

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

*[For CAHs at §485.625(d):] (1) Training

program. The CAH must do all of the

following:

preparedness policies and procedures,

including prompt reporting and extinguishing

of fires, protection, and where necessary,

evacuation of patients, personnel, and

guests, fire prevention, and cooperation with

firefighting and disaster authorities, to all

roles.

(iii) Maintain documentation of the

training.

updated, the CAH must conduct training on

*[For CMHCs at §485.920(d):] (1) Training.

The CMHC must provide initial training in

emergency preparedness policies and

procedures to all new and existing staff,

individuals providing services under

arrangement, and volunteers, consistent with

their expected roles, and maintain

documentation of the training. The CMHC

must demonstrate staff knowledge of

emergency procedures. Thereafter, the

CMHC must provide emergency

preparedness training at least every 2 years.

failed to ensure the emergency preparedness E 0037 E037

EPP Training Program

02/20/2020 12:00:00AM

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

training and testing program includes a training

program. The ICF/IID facility must do all of the

following: (i) Initial training in emergency

preparedness policies and procedures to all new

and existing staff, individuals providing services

under arrangement, and volunteers, consistent

with their expected roles; (ii) Provide emergency

preparedness training at least annually; (iii)

Maintain documentation of the training; (iv)

Demonstrate staff knowledge of emergency

procedures in accordance with 42 CFR 483.475(d)

occupants.

Findings include:

01/21/20 at 3:50 p.m the facility failed to implement

an annual Emergency Preparedness training and

testing program for new and existing staff. Based

on an interview at the time of record review, the

Training Coordinator was unable to provide any

documentation to confirm the facility had an

annual training and testing program for

Emergency Preparedness.

BCS failed to implement an annual

EPP training and testing

program/procedure for new and

existing staff.

Corrective Action:

1. An Emergency Preparedness

Plan Staff Training Procedure has

been developed to meet criteria of

demonstrating

knowledge/understanding of the

EPP including roles and

responsibilities in meeting the

health, safety and security needs

of our consumers during an

emergency or disaster,

community response and

resources.

2. A copy of the EPP Staff

Training Procedure will be included

in the EPP book.

3. Training for the procedure will

be provided to residential

management teams by 2/20/20.

4. Annual Training will be

conducted during BCS annual

Mandatory Inservice Training

(MIT).

5. The orientation component of

the Staff Training Procedure will be

implemented at the next

scheduled agency orientation

effective February 2020.

6. All staff training

documentation, including

competency testing, will be kept

in the SGL homes’ EPP book for

the survey year and a copy

provided to the Administrative

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

Assistant.

Person’s responsible: PD, RA,

AA, TC and RMT’s.

K 0000

Bldg. 01

A Life Safety Code Recertification Survey was

conducted by the Indiana State Department of

Health in accordance with 42 CFR 483.470(j).

Survey Date: 01/21/20

Facility Number: 000669

Provider Number: 15G132

AIM Number: 100234280

At this Life Safety Code survey, Bi-County

Services Inc. was found not in compliance with

Requirements for Participation in Medicaid, 42

CFR Subpart 483.470(j), Life Safety from Fire and

the 2012 edition of the National Fire Protection

Association (NFPA) 101, Life Safety Code (LSC),

Chapter 33, Existing Residential Board and Care

Occupancies.

The one story facility with a basement was fully

sprinklered. The facility has a fire alarm system

with smoke detection on all levels including the

basement with hard wired smoke detectors in the

corridors, sleeping rooms and common living

areas. The alarm system through the house is

monitored by a central station service. The facility

has a capacity of 8 and had a census of 7 at the

time of this survey.

K 0000

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

Calculation of the Evacuation Difficulty Score

(E-Score) using NFPA 101A, Alternative

Approaches to Life Safety, Chapter 6, rated the

facility Slow with an E-Score of 3.6.

Quality Review completed on 01/29/20

NFPA 101

General Requirements - Other

2012 EXISTING

List in the REMARKS section any LSC

Section 33.1 or 33.2 General Requirements

that are not addressed by the provided

K-tags, but are deficient. This information,

along with the applicable Life Safety Code or

NFPA standard citation, should be included

on Form CMS-2567.

K S100

Bldg. 01

Based on record review, observation and

interview; the facility failed to ensure 1 of 2

interior emergency lights was maintained. LSC 33.

1.1.3 states the provisions of Chapter 4, General,

shall apply. LSC 4.6.12.3 states existing life safety

features obvious to the public, if not required by

the Code, shall either be maintained or removed.

This deficient practice could affect all occupants if

the facility were required to evacuate in an

emergency during a loss of normal power.

Findings include:

Based on record review with the Training

Coordinator, House Manager and the

Maintenance Supervisor on 01/21/20 between

3:08 p.m. and 4:33 p.m., there was documentation

to show battery back up lights were tested

monthly for 30 seconds and annually for 90

minutes. During a tour of the facility at 4:18 p.m.

with the Training Coordinator and the House

K S100 K0100- General

Requirements-Other

BCS failed to ensure that 1 of 2

interior lights was maintained.

Corrective Action:

1. The battery powered

emergency light at the rear door

that did not illuminate on testing

was replaced on 1/23/20 by the

Maintenance Supervisor.

Person’s responsible:

Maintenance department and

supervisor

Completion date: 1/23/20

01/23/2020 12:00:00AM

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

Manager, the battery powered emergency light at

the rear door did not illuminate when tested

several times. Based on interview at the time of

observation, the Maintenance Supervisor agreed

the light failed to illuminate when tested and

would need to be replaced

NFPA 101

Egress Doors

2012 EXISTING (Prompt)

Doors and paths of travel to a means of

escape shall not be less than 28 inches.

Bathroom doors shall not be less than 24

inches. Doors are swinging or sliding. Every

closet door latch shall be readily opened from

the inside in case of an emergency. Every

bathroom door shall be designed to allow

opening from the outside during an

emergency when locked. No door in any

means of escape shall be locked against

egress when the building is occupied.

Delayed egress locks complying with

7.2.1.6.1 shall be permitted on exterior doors

only. Access-controlled egress locks

complying with 7.2.1.6.2 shall be permitted.

Forces to open doors shall comply with

7.2.1.4.5.

Door-latching devices shall comply with

7.2.1.5.10. Corridor doors are provided with

positive latching hardware, and roller latches

are prohibited.

Door assemblies for which the door leaf is

required to swing in the direction of egress

travel shall be inspected and tested not less

than annually in accordance with 7.2.1.15.

33.2.2.5.1 through 33.2.2.5.7, 33.7.7, 42 CFR

483.470(j)(1)(ii)

K S222

Bldg. 01

Based on observation and interview, the facility

failed to ensure 1 of 6 exterior exit doors was K S222 K0222-Egress Doors

BCS failed to ensure that 1 of 6 01/23/2020 12:00:00AM

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

provided with only one latching mechanism to

release the door and open. 33.2.2.5.7 refers to

7.2.1.5.10 which states a latch or other fastening

device on a door leaf shall be provided with a

releasing device that has an obvious method of

operation and that is readily operated under all

lighting conditions. 7.2.1.5.10.4 states the

releasing mechanism shall open the door leaf with

not more than one releasing operation. 7.2.1.5.10.1

states the releasing mechanism for any latch shall

be located not less than 34 inches, and not more

than 48 inches, above the finished floor. This

deficient practice could affect all occupants in the

facility.

Findings include:

Based on observation with the Training

Maintenance Supervisor on 01/21/20 at 4:16 p.m.,

the front entrance/exit door was equipped with

two latching devices, a regular door handle and a

separate deadbolt lock. This was acknowledged

by the Training Coordinator and the Maintenance

Supervisor at the time of observation.

exterior exit doors was provided

with only one latching mechanism

to release the door and open.

Corrective Action:

1. The front entrance/exit door

which was equipped with two

latching devices, regular door

handle and separate deadbolt

lock, had the dead bolt removed

from the door on 1/23/20 by the

maintenance department.

Maintenance Supervisor and crew

Completion date: 1/23/20

NFPA 101

Fire Alarm System - Testing and

Maintenance

Fire Alarm System - Testing and

Maintenance

2012 EXISTING (Prompt)

A fire alarm system is tested and maintained

in accordance with an approved program

complying with the requirements of NFPA 70,

National Electric Code, and NFPA 72,

National Fire Alarm and Signaling Code.

Records of system acceptance, maintenance

and testing are readily available.

9.7.5, 9.7.7, 9.7.8, and NFPA 25

K S345

Bldg. 01

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

failed to maintain 1 of 1 fire alarm systems in

accordance with NFPA 72, as required by LSC 101

Section 9.6. NFPA 72, Section 14.3.1 states that

unless otherwise permitted by 14.3.2, visual

inspections shall be performed in accordance with

the schedules in Table 14.3.1, or more often if

required by the authority having jurisdiction.

Table 14.3.1 states that the following must be

visually inspected semi-annually:

a. Control unit trouble signals

b. Remote annunciators

c. Initiating devices (e.g. duct detectors, manual

fire alarm boxes, heat detectors, smoke detectors,

d. Notification appliances

e. Magnetic hold-open devices

This deficient practice could affect all building

occupants.

Findings include:

Based on record review of the fire alarm system

inspection documentation with the Training

Coordinator, House Manager and Maintenance

Supervisor on 01/21/20 at 3:14 p.m., no

documentation could be provided regarding a

visual semi-annual fire alarm system inspection six

months prior to the annual inspection completed

on 07/31/19. Based on interview at the time of

record review, the Maintenance Supervisor agreed

that a visual semi-annual inspection of the

fire-alarm system was not completed.

K S345 K0345-Fire Alarm

System-Testing and

Maintenance

BCS failed to provide a visual

semi-annual fire alarm system

inspection six months prior to the

annual inspection.

Corrective Action:

1. B Secure who provides the

BCS SGL annual Fire Alarm

inspections and monitoring was

contacted by the Maintenance

Supervisor on 1/23/20 and will be

providing semi-annual fire alarm

system inspections effective 2020.

The last annual fire alarm

inspection was completed on

7/31/19 and the Maintenance

Supervisor was unaware of the

semi-annual visual inspection so

there was no documentation. The

Maintenance Department does a

regular monthly fire alarm

check/inspection; however, we

have not had the outside

monitoring by B Secure done

semi-annually in the past.

2. The B Secure owner has

added semi-annual inspections for

SGL homes effective six months

following the 2020 annual

inspections.

Maintenance Supervisor.

02/20/2020 12:00:00AM

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

Target Completion Date: Annual

inspection June 2020 and

semi-annual inspection six

months following the annual

inspection date.

NFPA 101

Corridor - Doors

Doors shall meet all of the following

requirements:

1. Doors shall be provided with latches or

other mechanisms suitable for keeping the

door closed.

2. No doors shall be arranged to prevent

the occupant from closing the door.

3. Doors shall be self-closing or

automatic-closing in accordance with 7.2.1.8

in buildings other than those protected

throughout by an approved automatic

sprinkler system in accordance with 33.2.3.5.

Door assemblies with leaves required to

swing in the direction of egress travel are

inspected and tested annually per 7.2.1.15.

33.2.3.6.4, 33.7.7

K S363

Bldg. 01

Based on observation and interview, the facility

failed to ensure 1 of 4 client sleeping room doors

would close completely and latch automatically

into the door frame. This deficient practice could

affect all clients.

Findings include:

Based on observation with the Training

the southeast client sleeping room door did not

K S363 K0363- Corridor-Doors

BCS failed to ensure 1 of 4

consumer sleeping room doors

would close completely and latch

automatically into the door frame.

Corrective Action:

1. The southeast bedroom door

that was not closing and latching

automatically had the door latch

replaced by the Maintenance

Supervisor on 1/23/20.

01/23/2020 12:00:00AM

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

close completely and latch automatically when

tested several times. Based on interview at the

time of observation, the Training Coordinator

stated the facility is aware the sleeping room door

doesn't latch and has submitted a work order for

the repair of this sleeping room door.

2. The Maintenance Department

will continue to provide monthly

group home inspections using

their checklist for regular repairs

as needed and/or residential

manager and/or designee can

complete work orders to have

problems corrected as they arise

related to consumer safety.

Persons responsible: Maintenance

Supervisor and maintenance crew

Target completion date:

1/23/20

NFPA 101

Fire Drills

1. The facility must hold evacuation drills at

least quarterly for each shift of personnel and

under varied conditions to:

a. Ensure that all personnel on all shifts are

trained to perform assigned tasks;

b. Ensure that all personnel on all shifts are

familiar with the use of the facility's

emergency and disaster plans and

procedures.

2. The facility must:

a. Actually evacuate clients during at least

one drill each year on each shift;

b. Make special provisions for the

evacuation of clients with physical

disabilities;

c. File a report and evaluation on each drill;

d. Investigate all problems with evacuation

drills, including accidents and take corrective

action; and

K S712

Bldg. 01

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

e. During fire drills, clients may be

evacuated to a safe area in facilities certified

under the Health Care Occupancies Chapter

of the Life Safety Code.

3. Facilities must meet the requirements of

paragraphs (i) (1) and (2) of this section for

any live-in and relief staff that they utilize.

42 CFR 483.470(i)

failed to ensure fire drills were held at varied times

for 1 of 3 employee shifts during 3 of 4 quarters.

This deficient practice could affect all clients in

the facility.

Findings include:

Based on review of the facility's fire drills with the

Training Coordinator, House Manager and the

four of four second shift fire drills were performed

between 5:30 p.m. and 6:45 p.m. During an

interview at the time of record review, the Training

Coordinator and House Manager acknowledged

the times the second shift fire drills were

performed and agreed the times were not varied

enough.

K S712 K0712-Fire Drills

BCS failed to ensure that fire drills

were held at varied times for 1 of 3

employee shifts during 3 of 4

quarters.

Corrective Action:

1. The Administrative Assistant

who oversees the annual schedule

for drills (1 per shift per quarter)

found that the staff at the group

home had changed the times of

three drills during the course of the

2019 drill rotation without following

the procedure of notifying

residential on-call and/or an

administrator if they needed to

change a time frame for the drills.

The schedule for the 2020 drill

rotation has been resent to each

group home with the addition of

the instruction that the on-call

and/or manager must be notified

on any changes.

2. Any drills found with a change

in time or date will have to be

re-run at the originally designated

time frame and that on-call must

be notified of any discrepancies.

Person’s responsible: Residential

01/23/2020 12:00:00AM

02/25/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

(X4) ID

PREFIX

DEFICIENCY)

COMPLETION

BERNE, IN 46711

15G132 01/21/2020

423 WIND RIDGE TR

Management team; Training

Coordinator; Administrative

Assistant & Residential

Administrator.

E 0000Facility Number: 000669 Provider Number: 15G132 AIM Number: 100234280 At this Emergency...

Documents

The Problems of Implementing a 911 Emergency Telephone Number

Global emergency response in Europe · 2019-04-15 · Emergency Response Number (ADR) • No legal obligation to provide an emergency response number under ADR, although appropriate

Product Safety Data Sheet · msds@rheinkalk.de 1.4. Emergency telephone number Emergency telephone number (Europe) 112 This telephone number is available 24 hours per day, 7 days

Emergency Order Number 2 Palm Beach County COVID-19 … · Order Number 2020-002 EMERGENCY ORDER NUMBER 2 PALM BEACH COUNTY COVID-19 WHEREAS, COVID-19, a respiratory illness caused

24 Emergency Vendors Company Contact Name Phone ......2012/03/29 · Vendors Company Contact Name Phone Number Email Address Fax Number 24 Emergency Phone Number Architect Beyer Blinder

Trauma Fellowship for Emergency Medicine Physicians Number

European-wide emergency number: 112 - Upo

ITAÚ CULTURAL - d3nv1jy4u7zmsc.cloudfront.netd3nv1jy4u7zmsc.cloudfront.net/wp-content/uploads/itau_pdf/000669.pdf · Ilustradores retratam o significado artístico do rio Os rios

911 EMERGENCY TELEPHONE NUMBER SYSTEM--A PROPOSAL …

Section 8 Original Page 1 A. ENHANCED UNIVERSAL … Us... · A. ENHANCED UNIVERSAL EMERGENCY NUMBER SERVICE (E911 Service) - PSAPS . 1. General . Enhanced Universal Emergency Number

Health Science Career Cluster Emergency Medical … Science Career Cluster Emergency Medical Responder Course Number: 25.45000 Course Description: The Emergency Medical Responder (EMR)

8141 OP Pesticides - az621941.vo.msecnd.netaz621941.vo.msecnd.net/documents/d6c207e7-76b2-4b62-86ba-aa79844ea... · info@phenova.com - 1.4. Emergency telephone number Emergency number

LT-2087 Emergency Phone Application Guide · 1.1.2 Number of Emergency Phones If you have a small number of Emergency Phones, you can use Grandstream Analog Telephone Adapters (ATAs)

Emergency Order Number 2 Palm Beach County COVID-19discover.pbcgov.org/PDF/COVID19/Emergency-Order-Number-2.pdf · Order Number 2020-002 WHEREAS, the tri-county area of South Florida,

EMERGENCY NUMBER: 1-800-794-0981

EMERGENCY MANAGEMENT PROGRAM AND EMERGENCY …€¦ · Page 1 of 56 TOWN OF AURORA . EMERGENCY MANAGEMENT PROGRAM AND EMERGENCY RESPONSE PLAN . By-law Number 6174-19 Schedule “A”

A24. EMERGENCY REPORTING SERVICES A24.1 Universal Emergency Number Service - 911cpr.att.com/pdf/fl/g024.pdf · 2016. 4. 1. · A24.1 Universal Emergency Number Service - 911 (Cont'd)

Presentation to: European Emergency Number Association

MC311: Montgomery County's Non-Emergency Information Number

EMERGENCY NUMBER SYSTEMS BOARD ANNUAL REPORTmsa.maryland.gov/megafile/msa/speccol/sc5300/sc5339/000113/00… · The Emergency Number Systems Board, hereafter ENSB, or Board, is charged