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(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
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
TITLE
If continuation sheet Page 1 of 22
(X6) DATE
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
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:
(1) Be based on and include a documented,
facility-based and community-based risk
assessment, utilizing an all-hazards
approach, including missing residents.
(2) Include strategies for addressing
emergency events identified by the risk
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:
(1) Be based on and include a documented,
facility-based and community-based risk
assessment, utilizing an all-hazards
approach, including missing clients.
(2) Include strategies for addressing
emergency events identified by the risk
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
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
423 WIND RIDGE TR
--
least every 2 years. The plan must do the
following:
(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, 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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 3 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 4 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
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:
(i) Federal, State, tribal, regional, and
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.
*[For ICF/IIDs at §483.475(c):] (2) Contact
information for the following:
(i) Federal, State, tribal, regional, and
local emergency preparedness staff.
(ii) Other sources of assistance.
(iii) The State Licensing and Certification
Agency.
E 0031
Bldg. --
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 5 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
423 WIND RIDGE TR
--
(iv) The State Protection and Advocacy
Agency.
Based on record review and interview, the facility
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:
Based on review of the facility's Emergency
Preparedness Plan with the Training Coordinator,
House Manager and Maintenance Supervisor on
01/21/20 at 3:48 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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 6 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
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
care.
(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. --
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 7 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
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).
Based on record review and interview, the facility
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)
(4). This deficient practice could affect all
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
WR.
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).
Target Completion Date: 2/20/20
02/20/2020 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 8 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
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:
(i) Initial training in emergency
preparedness policies and procedures to all
new and existing hospice employees, and
individuals providing services under
arrangement, consistent with their expected
E 0037
Bldg. --
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 9 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
423 WIND RIDGE TR
--
roles.
(ii) Demonstrate staff knowledge of
emergency procedures.
(iii) Provide emergency preparedness
training at least every 2 years.
(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
emergency preparedness training.
(vi) If the emergency preparedness
policies and procedures are significantly
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:
(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) After initial training, provide
emergency preparedness training every 2
years.
(iii) Demonstrate staff knowledge of
emergency procedures.
(iv) Maintain documentation of all
emergency preparedness training.
(v) If the emergency preparedness
policies and procedures are significantly
updated, the PRTF must conduct training on
the updated policies and procedures.
*[For LTC Facilities at §483.73(d):] (1)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 10 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
423 WIND RIDGE TR
--
Training Program. The LTC 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
role.
(ii) Provide emergency preparedness
training at least annually.
(iii) Maintain documentation of all
emergency preparedness training.
(iv) Demonstrate staff knowledge of
emergency procedures.
*[For CORFs at §485.68(d):](1) Training. The
CORF must do all of the following:
(i) 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.
(ii) Provide emergency preparedness
training at least every 2 years.
(iii) Maintain documentation of the
training.
(iv) Demonstrate staff knowledge of
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.
(v) If the emergency preparedness
policies and procedures are significantly
updated, the CORF must conduct training on
the updated policies and procedures.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 11 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
423 WIND RIDGE TR
--
*[For CAHs at §485.625(d):] (1) Training
program. The CAH must do all of the
following:
(i) Initial training in emergency
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
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 the
training.
(iv) Demonstrate staff knowledge of
emergency procedures.
(v) If the emergency preparedness
policies and procedures are significantly
updated, the CAH must conduct training on
the updated policies and procedures.
*[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.
Based on record review and interview, the facility
failed to ensure the emergency preparedness E 0037 E037
EPP Training Program
02/20/2020 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 12 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
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)
(1). 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 3:50 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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 13 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
423 WIND RIDGE TR
--
Assistant.
Person’s responsible: PD, RA,
AA, TC and RMT’s.
Target Completion Date: 2/20/20
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 14 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
423 WIND RIDGE TR
01
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
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 15 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
423 WIND RIDGE TR
01
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
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 16 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
423 WIND RIDGE TR
01
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
Coordinator, House Manager and the
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.
Person’s responsible:
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 17 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
423 WIND RIDGE TR
01
Based on record review and interview, the facility
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,
etc.)
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.
Person’s responsible:
Maintenance Supervisor.
02/20/2020 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 18 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
423 WIND RIDGE TR
01
Target Completion Date: Annual
inspection June 2020 and
semi-annual inspection six
months following the annual
inspection date.
NFPA 101
Corridor - Doors
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
Coordinator, House Manager and the
Maintenance Supervisor on 01/21/20 at 4:16 p.m.,
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 19 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
423 WIND RIDGE TR
01
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
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 20 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
423 WIND RIDGE TR
01
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)
Based on record review and interview, the facility
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
Maintenance Supervisor on 01/21/20 at 3:38 p.m.,
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 21 of 22
(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
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BERNE, IN 46711
15G132 01/21/2020
BI-COUNTY SERVICES INC
423 WIND RIDGE TR
01
Management team; Training
Coordinator; Administrative
Assistant & Residential
Administrator.
Target Completion Date: 1/23/20
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9VZ321 Facility ID: 000669 If continuation sheet Page 22 of 22