PRINTED: 09/01/2016 DEPARTMENT OF HEALTH AND HUMAN ... · (x1) provider/supplier/clia department of health and human services centers for medicare & medicaid services printed: 09/01/2016

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

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

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

BLOOMINGTON, IN 47404

15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

W 0000

Bldg. 00

This visit was for the Post Certification

Revisit (PCR) to the PCR (completed

4/22/16) to the full annual recertification

and state licensure survey which included

the investigation of complaint

#IN00182639 completed on 2/19/16.

Complaint #IN00182369: Not corrected.

This visit was in conjunction with the

investigations of complaints

#IN00199715 and #IN00201181.

Survey Date: June 24, 27, 28, 29 and 30,

2016

Facility Number: 001221

Provider Number: 15G643

AIM Number: 100240220

These deficiencies also reflect state

findings in accordance with 460 IAC 9.

Quality Review of this report completed

by #15068 on 7/8/16.

W 0000

483.410(a)(1)

GOVERNING BODY

W 0104

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

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

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

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

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

continued program participation.

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

_____________________________________________________________________________________________________Event ID: TMND13 Facility ID: 001221

TITLE

If continuation sheet Page 1 of 33

(X6) DATE




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15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

The governing body must exercise general

policy, budget, and operating direction over

the facility.

Bldg. 00

Based on record review and interview for

6 of 6 clients living in the group home

(A, B, C, D, E and F), the facility's

governing body failed to exercise

operating direction over the facility by

failing to ensure there was an effective

system in place to monitor the

administration of the clients' medications

to ensure there were no recurrent issues

with medication errors.

Findings include:

On 4/22/16 during the Post Certification

Revisit (PCR) to the full annual

recertification and state licensure survey,

the facility was cited for on-going issues

with medication errors to clients A, B, C,

D, E and F at W331 and W368. The

facility's 5/22/16 Plan of Correction

(POC) indicated the following for W331

and W368, "Nursing staff and QIDP

(Qualified Intellectual Disabilities

Professional) will monitor medication

administration weekly at least 4 (2

supervised medication passes each) times

a week, until 2 weeks of zero medication

errors, then QIDP will continue

monitoring medication passes 2 times a

week until 2 weeks of zero medication

errors. Moreover, QIDP will be

W 0104 W104 Governing Body

Corrective action for

resident(s) found to have been

affected All house staff, including

QIDP will be re-trained in

medication administration and

new medication administration

system(multi-dose packages).

Stone Belt will introduce

multi-dose packs(changed from

single dose packs currently

used)of medication for 2 clients.

These multi dose packs are

currently used in other Stone Belt

residential programs and have

been shown to decrease

medication errors in the homes

they are used in(SLP) Increased

senior management monitoring in

home, daily checks for proper

medication administration. How

facility will identify other

residents potentially affected &

what measures taken All

residents potentially are affected,

and corrective measures address

the needs of all clients. Measures

or systemic changes facility

put in place to ensure no

recurrence There will be

increased monitoring by senior

management at the home to

ensure medication administration

is completed properly and without

errors. Senior management will

ensure medication policies are

being followed by house staff,

including proper documentation of

all medication transactions.

07/30/2016 12:00:00AM

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15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

monitored by Director, weekly, to ensure

corrective actions are being completed

and visits are being made. All residents

potentially are affected, and corrective

measures address the needs of all clients.

Director will meet with QIDP and

nursing staff to ensure all supervised

medication monitoring is taking place.

Director (or designee) will meet with

QIDP weekly to review all incident

reports including all medication errors

and corrective actions and supervised

medication administration." Although

the facility conducted the monitoring of

medication administration as indicated in

the facility, the medication errors were

not resolved as evidenced by the number

of medication errors since the 4/22/16

PCR.

The POC was ineffective in addressing

the facility's on-going medication errors.

From 4/22/16 to 6/30/16, there were 37

medication errors at the facility affecting

clients A, B, C, D, E and F.

1) Please refer to W331. For 6 of 6

clients living in the group home (A, B, C,

D, E and F), the facility's nursing services

failed to ensure staff administered the

clients' medications in accordance with

their physician's orders.

2) Please refer to W368. For 6 of 6

Specifically,the QIDP,

co-operative QIDP(QIDP from

another group home), Director,

Associate Director and Manager

of Nursing Services will monitor

house for medication

administration accuracy daily(7

days a week), until 2 weeks of no

medication errors. After 2

weeks of no medication errors,

senior management will monitor

house 5 days a week until 2

weeks of no medication errors.

After 2 more weeks of no

medication errors,senior

management will monitor house 3

days a week, until 2 more weeks

of no medication errors. After 2

more weeks of no medication

errors, assigned QIDP,

Director(or designee) and nurse

will resume regular house

monitoring, in accordance with

regulations. Stone Belt will adopt

a new medication administration

system and train staff for

competency. All staff training on

proper medication administration

How corrective actions will

be monitored to ensure no

recurrence A QIDP with 20 years

experience in residential services

has been added to the group

home program as Senior Director

to oversee all corrective action.

The Senior Director will supervise

the Director. The QIDP is

supervised by the SGL Director,

they will meet weekly for an

oversight meeting to ensure that

all corrective action is being

followed for the Plan of





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15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

clients living in the group home (A, B, C,

D, E and F), the facility failed to ensure

staff administered the clients'

medications in accordance with their

physician's orders.

9-3-1(a)

Correction(POC). The meeting

will be chaired by SGL Director(or

designee). The QIDP is

responsible for program

implementation and monitoring of

the facility.The SGL Director will

provide all documented training.

The SGL Director will ensure that

all corrections are in place and

that documentation is available at

resurvey.

483.420(d)(4)

STAFF TREATMENT OF CLIENTS

If the alleged violation is verified, appropriate

corrective action must be taken.

W 0157

Bldg. 00


7 of 21 incident/investigative reports

reviewed affecting clients A, C, D, E and

F, the facility failed to implement

appropriate corrective actions to address

client to client abuse and medication

errors.

Findings include:

On 6/24/16 at 1:28 PM, a review of the

facility's incident/investigative reports

was conducted and indicated the

following:

1) On 5/3/16 at 2:00 PM, client D

returned to the group home with staff #11

and #12. Staff #11 went inside the group

home while client D was in the van with

staff #12 lying across the back seat

yelling and throwing shoes. The former

W 0157 W 157 Staff Treatment of

Clients Corrective action for


affected QIDP will be re-trained

on use of corrective action in

managing medication errors and

to prevent client to client abuse,

by investigating all incidents of

client to client abuse and

analyzing effectiveness of BSP vs

staff non-compliance with

following BSP. How facility will

identify other residents

potentially affected & what

measures taken All residents

potentially are affected, and

corrective measures address the

needs of all clients. Measures or

systemicchanges facility put in

place to ensure no recurrence

Increased senior management

monitoring in the home, as

detailed previously. Moreover,

QIDP and Director will meet

weekly to review all incident

reports, review incidents of

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Home Manager went outside to assist

staff #12. Client D exited the van and

seemed calm. Client D held staff #12's

hand and walked into the group home.

Client D released staff #12's hand and

was in front of staff #12. Staff #11 was

at the dining room table doing billing.

Staff #2 was standing with client E in the

living room. Client D went to client E

and grabbed his hair on the right side.

Client E held out his left hand to push

client D away. Client D bit client E's left

middle finger just above the first knuckle.

Client D leaned back and pulled client E

down while biting his finger. Staff

intervened and got client D to release his

bite on client E's finger. Client E was

taken to the hospital.

The 5/3/16 Client to Client Aggression

Inquiry conducted by the group home

Coordinator indicated, "BSP (behavior

support plan) followed for each client

involved. Staffing patterns and/or

partnering schedule was followed." The

inquiry indicated this was a recurring

issue between these two clients. There

was no documentation of corrective

action being implemented.

The 5/10/16 Client to Client Aggression

Inquiry conducted by the day program

Coordinator indicated, "BSP followed for

each client involved. Staffing patterns

suspected abuse neglect of

exploitation and injuries of

unknown origin, patterns of

behavior leading to injury, any

incident that client needs medical

attention and all client to client

abuse incidents. How corrective

actions will be monitored to

ensure no recurrence A QIDP

with 20 years experience in

residential services has been

added to the group home

program as Senior Director to

oversee all corrective action. The

Senior Director will supervise the

Director. The QIDP is supervised

by the SGL Director, they will

meet weekly for an oversight

meeting to ensure that all

corrective action is being












resurvey.





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15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

and/or partnering schedule was

followed." The inquiry indicated this

was a recurring issue between the two

clients. The Recommendations section

indicated, "Staff will assist [client D] by

having a hand on his belt when he is near

other clients at home, behaviorist has

been consulted about changes to BSP."

On 6/24/16 at 1:56 PM, a review of client

D's record was conducted. Client D's

BSP had not been revised or updated

since 1/13/16. There were no changes to

client D's BSP following the incident on

5/3/16. There was no documentation

client D's support team convened to

discuss the incident and corrective

actions.

On 6/27/16 at 2:14 PM, the Coordinator

indicated following the incident, the staff

received retraining on client D's behavior

plan on 6/9/16. The Coordinator

indicated client D's behavior plan was in

place to prevent client to client

aggression. The Coordinator indicated

client D bolted through the front door and

aggressed on client E. The Coordinator

indicated the staff implemented client D's

behavior plan. The Coordinator stated

client D's plan "isn't fully effective." The

Coordinator indicated the

recommendations made by the day

program Coordinator were already in





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15G643 06/30/2016

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1006 W 11TH ST

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client D's plan. The Coordinator

indicated there were no changes made to

client D's behavior plan following the

incident.

On 6/28/16 at 12:52 PM, the Behavior

Consultant (BC) indicated at the time of

the incident, there were 4-5 staff at the

group home with two clients. The BC

indicated there was no communication

from the staff who was with client D

outside the home with the staff who were

inside the home. The BC indicated the

staff did not get in between clients D and

E which was part of client D's behavior

plan. The BC indicated the plan directed

staff to stay between client D and his

peers. The BC indicated the plan was not

implemented as written. The BC stated,

"there are things the staff could have

done differently." The BC indicated the

staff should implement client D's

behavior plan as written. The BC

indicated the purpose of client D's

behavior plan for physical aggression was

to prevent physical aggression against his

peers. The BC indicated if the staff were

between client D and his peers at all

times, there would be no physical

aggression. The BC indicated the staff

needed to be proactive, communicate

with each other and be aware of client D's

peers location. The BC indicated the

incident could have been prevented. The





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1006 W 11TH ST

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BC indicated there were no revisions or

updates to client D's behavior plan since

1/13/16. The BC indicated the day

program Coordinator's recommended

corrective action was already part of

client D's behavior plan. The BC

indicated there were no revisions needed

to client D's behavior plan based on the

investigation's recommendations.

2) On 5/22/16 at 7:00 PM, the

Coordinator, staff #7 and #8 did not

administer client A's HS (hour of sleep -

bedtime) medications as ordered by his

physician. The medications included

Benztropine 1 mg (milligrams)

(drooling), Buspirone 10 mg (agitation),

Divalproex Sodium 500 mg (seizures),

Fluticasone 0.05% nasal spray (allergies),

Montelukast 10 mg (allergies),

Multivitamin (supplement), Refresh

ophthalmic (eye) ointment (moisturizer),

Restasis 0.5% eye drops (moisturizer),

and Topiramate 50 mg (seizures).

There was no documentation the facility

implemented corrective action with staff

#8.

On 6/24/16 at 1:58 PM, the Group Home

Director (GHD) indicated the facility did

not implement corrective actions with

staff #8. The GHD indicated the MER

was incorrect. The GHD indicated after





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1006 W 11TH ST

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discussing the incident, the facility

determined the Coordinator was

responsible. The GHD indicated

although the MER indicated staff #7 and

#8 were also responsible, there was no

corrective action with staff #8. The GHD

stated the Coordinator came in to conduct

the overnight shift and "assumed" staff

#7 or staff #8 administered client E's

medications. The GHD indicated the

client did not receive his medications on

5/22/16.

On 6/27/16 at 10:50 AM, the Nurse

Manager (NM) indicated the clients'

medications should be administered as

ordered by their physicians.


indicated the clients' medications should

be administered as ordered by their

physicians. The Coordinator stated,

"Med errors are a concern."

3) On 5/22/16 at 7:00 PM, the

Coordinator, staff #7 and staff #8 did not

administer client C's medications as

ordered by the physician. The

medications included Buspirone 10 mg

(depression), DDAVP 0.2 mg (enuresis -

bed wetting), Metformin ER (extended

release) 500 mg (diabetes), Metoprolol

Tartrate 25 mg (hypertension),

multivitamin (supplement), Myrebetriq





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1006 W 11TH ST

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50 mg (enuresis), Risperidone 1 mg

(psychotic disorder), Simvastatin 50 mg

(cholesterol/hypertension), Tamsulosin

0.8 mg (enlarged prostate), Welchol 625

mg (cholesterol) and Lantus 13 units

(diabetes). The 5/23/16 BDDS report

indicated, in part, "...05/23/2016, this

med error was found during buddy check

by overnight staff... There was no

noticeable effect to [client C] due to this

med error."



#8.

















5/22/16.





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1006 W 11TH ST

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4) On 5/22/16 at 8:00 PM, the


administer client D's bedtime

medications as ordered by the physician.

The medications included Clonidine 0.1

mg (reactive aggression), Docusate

Sodium 100 mg (constipation), and

Quetiapine Fumarate 400 mg (anxiety

disorder). The 5/24/16 BDDS report

indicated, in part, "On 05/23/2016, this


by overnight staff; nurse was notified in

the AM with instructions to monitor

[client D] for any side effects and

continue with normal medication routine.

There was no noticeable effect to [client

D] due to this med error."



#8.






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1006 W 11TH ST

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5/22/16.




ordered by their physician. The NM

indicated the Coordinator, staff #7 and

staff #8 were responsible for client E's

medication errors. The NM indicated the

staff failed to communicate during shift

change. The NM indicated the

Coordinator arrived on 5/22/16 at 9:00

PM and staff #7 and #8 left at 9:00 PM.

The NM indicated he informed the GHD

that the Coordinator, staff #7 and staff #8

should receive medication errors.







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"Med errors are a concern." The

Coordinator stated on 5/23/16, client D

was "more agitated" after not receiving

his medications on 5/22/16.

5) On 5/22/16 at 7:00 PM, the


administer client F's HS medication as


medication was Levothyroxine 125 mg

for hypothyroidism. The 5/23/16 BDDS

report indicated, "On 05/22/2016 at 7:00

PM, staff did not administer HS

medication to [client F]... On

05/23/2016, this med error was found

during buddy check by overnight staff.

Client support Coordinator and nurse

pager notified with instructions to

monitor [client F] for side effects and



F] due to this med error."



#8.










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5/22/16.










6) On 5/22/16 at 7:00 PM, the


administer client E's bedtime (HS - hour

of sleep) medications as ordered by his


Clonazepam (anxiety) 0.5 mg

(milligrams), Depakote Sprinkles 1000

mg (seizure disorder), Levocarnitin 330

mg (carnitine deficiency), MAPAP 500

mg (tylenol), Prevastatin Sodium 20 mg





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1006 W 11TH ST

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(high cholesterol), Multivitamin with iron

(nutritional supplement), Vimpat 200 mg

(seizure disorder), and Cephalexin 500

mg (infection). The 5/23/16 Bureau of

Developmental Disabilities Services

(BDDS) incident report indicated, "On


during buddy check by overnight staff...


E] due to this med error."


took corrective action with staff #8. The

5/23/16 Medication Error Report (MAR)

indicated, in part, "Supervisor: Document

action taken: Written warning, retake

Med Admin Course + (plus) 3 passes (3

supervised medication administration

passes)." The MER indicated, in part,

"Failure to properly perform buddy check

resulting in missed med." There was no

documentation the facility implemented

the corrective action recommended with

staff #8.














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1006 W 11TH ST

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5/22/16.


Manager (NM) indicated the

Coordinator, staff #7 and staff #8 were

responsible for client E's medication

errors. The NM indicated the staff failed

to communicate during shift change. The

NM indicated the Coordinator arrived on

5/22/16 at 9:00 PM and staff #7 and #8

left at 9:00 PM. The NM indicated he

informed the GHD that the Coordinator,

staff #7 and staff #8 should receive

medication errors and corrective action.

The NM indicated the staff should

administer the client's medications as

ordered by the physician.






7) On 6/11/16 at 9:00 AM, client C was

given one of two Omeprazole 20 mg

capsules. Staff #3 was responsible for





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15G643 06/30/2016

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1006 W 11TH ST

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the error. The 6/18/16 BDDS report

indicated, in part, "The 20 missed

milligrams of Omeprazole had no

negative side effects on [client C]... Staff

will be disciplined per the med error

policy and retrained on this client's

medication administration."



#3.










This deficiency was cited on 4/22/16 and

2/19/16. The facility failed to implement

a systemic plan of correction to prevent

recurrence.

9-3-2(a)

483.460(c)

NURSING SERVICES

W 0331





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1006 W 11TH ST

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The facility must provide clients with nursing

services in accordance with their needs.

Bldg. 00



(A, B, C, D, E and F), the facility's

nursing services failed to ensure staff

administered the clients' medications in

accordance with their physician's orders.

Findings include:




following:

1) On 5/16/16 at 8:30 PM, former staff

#10 failed to administer client D's

medication as ordered. Staff #10

administered client D his 300 mg

(milligram) dose at 8:30 PM instead of

400 mg as ordered. The 5/16/16

Medication Error Report (MER) did not

indicate which medication was involved

in the error.

2) On 5/22/16 at 7:00 PM, the





Clonazepam (anxiety) 0.5 mg, Depakote

Sprinkles 1000 mg (seizure disorder),

Levocarnitin 330 mg (carnitine

W 0331 W 331Nursing Services

Corrective action for


affected All house staff, including

QIDP will be re-trained in

medication administration and

new medication administration

















what measures taken All



the needs of all clients. Measures



recurrence There will be









all medication transactions.

Specifically, the QIDP,

07/30/2016 12:00:00AM





09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

deficiency), MAPAP 500 mg, Prevastatin

Sodium 20 mg (high cholesterol),

Multivitamin with iron (nutritional

supplement), Vimpat 200 mg (seizure

disorder), and Cephalexin 500 mg

(infection). The 5/23/16 Bureau of







On 5/23/16 at 1:30 PM, client E was in

his room asleep while staff was assisting

another client in the shower. A second

staff was doing paperwork and listening

for client E's bedroom alarm. The

5/24/16 BDDS report indicated, in part,

"The alarm either did not go off or was

not audible over the other sounds of the

home. Staff 2 heard faint

moaning/sounds of distress from the

living room and went to investigate.

[Client E] was found on the living room

floor bleeding from a wound on his

forehead. There was blood on the carpet,

but none found on any other surface in

the home... [Client E] was also

experiencing multiple, close together

seizures while lying on the floor. Nurse

directed staff to call 911. [Client E] was

transported to [name of hospital] ER

(emergency room) via ambulance.

co-operative QIDP(QIDP from

another group home), Director,

Associate Director and Manager

of Nursing Services will monitor

house for medication



medication errors. After 2 weeks

of no medication errors, senior


days a week until 2 weeks of no

medication errors. After 2 more


senior management will monitor

house 3 days a week, until 2

more weeks of no medication

errors. After 2 more weeks of no

medication errors, assigned

QIDP, Director(or designee) and

nurse will resume regular house

monitoring, in accordance with





proper medication administration

How corrective actions will

be monitored to ensure no

recurrence A QIDP with 20 years

experience in residential services

has been added to the group

home program as Senior Director

to oversee all corrective action.

The Senior Director will supervise

the Director. The QIDP is

supervised by the SGL Director,

they will meet weekly for an

oversight meeting to ensure that

all corrective action is being








09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

[Client E] received eight staples to close

the wound on his head after it was

cleaned...."

On 6/27/16 at 11:01 AM, the NM

indicated he did not know what caused

the injury to client E's head. The NM

indicated he received a call from the staff

saying client E's head was bleeding and

the staff needed assistance to stop the

bleeding. The NM went to the home.

The NM indicated staff #3 told him he

(staff #3) was in the med room at the

time and client E had been in his

bedroom. Staff #3 indicated to the NM

he heard client E cry out. Staff #3 found

client E on the living room floor,

bleeding from his head. The NM

instructed the staff to call 911. The NM

stated client E "had a few mini-seizures

while lying there. The NM indicated the

facility should have conducted an

investigation. The NM stated "maybe

she (GHD) didn't correlate the dates (of

the medication errors and the injury to

client E)." The NM indicated client E

could have fallen out of bed and fallen in

the living room. The NM indicated he

was unsure if the medication errors on

5/22/16 and client E's injury on 5/23/16

were connected due to no one witnessing

how client E was injured. The NM stated

client E's medication errors on 5/22/16

"could have been related to the injury on




the facility. The SGL Director will





resurvey.





09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

5/23/16." The NM stated, "can't say

100% for sure." The NM indicated client

E was having seizure activity following

the injury on 5/23/16.

3) On 5/22/16 at 7:00 PM, the


administer client A's HS medications as

ordered by his physician. The

medications included Benztropine 1 mg









4) On 5/22/16 at 7:00 PM, the



















09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00



5) On 5/22/16 at 7:00 PM, the




















med error."

6) On 5/22/16 at 8:00 PM, the







Quetiapine Fumarate 400 mg (anxiety).

The 5/24/16 BDDS report indicated, in





09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

part, "On 05/23/2016, this med error was

found during buddy check by overnight

staff; nurse was notified in the AM with

instructions to monitor [client D] for any

side effects and continue with normal

medication routine. There was no

noticeable effect to [client D] due to this

med error."


stated on 5/23/16, client D was "more

agitated" after not receiving his

medications on 5/22/16.

7) On 6/2/16 at 6:00 PM (discovered on

6/6/16 and reported to BDDS on 6/9/16),

client B was administered 2 capsules of

Tamsulosin 0.4 mg from another client's

medications. The 6/9/16 BDDS report

indicated, in part, "On 6/2/2016 at PM

med pass, staff had another clients (sic)

med in [client B's] med caddy and this

med was given to [client B]. It was the

correct med and dosage but under another

clients (sic) name... This error was found

when a duplicate pack showed up when

searching for another bubble pack. Nurse

and QIDP (Qualified Intellectual

Disabilities Professional (QIDP)

investigated further...." The 6/6/16 MER

indicated, in part, "Staff is resigning.

Retraining needed if she rehires...."






09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00



























medication administration." There was

no documentation the facility


#3.

10) On 6/27/16 at 5:49 PM, the

following MER was received by emailed





09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

from the Coordinator: On 6/27/16 at

2:00 PM, client D was administered

Quetiapine Fumarate 400 mg for anxiety

at the wrong time. Staff #13

administered the medication at 2:00 PM.

The medication was ordered to be

administered at HS. The 6/27/16 MER

indicated, "No observable effect as of

4:00 PM."













recurrence.

9-3-6(a)

483.460(k)(1)

DRUG ADMINISTRATION

The system for drug administration must

assure that all drugs are administered in

W 0368

Bldg. 00





09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

compliance with the physician's orders.



(A, B, C, D, E and F), the facility failed

to ensure staff administered the clients'

medications in accordance with their

physician's orders.

Findings include:




following:

1) On 5/16/16 at 8:30 PM, former staff

#10 failed to administer client D's

medication as ordered. Staff #10

administered client D his 300 mg

(milligram) dose at 8:30 PM instead of

400 mg as ordered. The 5/16/16

Medication Error Report (MER) did not

indicate which medication was involved

in the error.

2) On 5/22/16 at 7:00 PM, the





Clonazepam (anxiety) 0.5 mg, Depakote

Sprinkles 1000 mg (seizure disorder),

Levocarnitin 330 mg (carnitine

deficiency), MAPAP 500 mg, Prevastatin

W 0368 W 368 Drug

AdministrationCorrective

action for resident(s) found to

have been affectedAll house

staff, including QIDP will be

re-trained in medication

administration and new

medication administration

















what measures takenAll



the needs of all clients.Measures



recurrenceThere will be









all medication

transactions. Specifically,the

07/30/2016 12:00:00AM





09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

Sodium 20 mg (high cholesterol),

Multivitamin with iron (nutritional

supplement), Vimpat 200 mg (seizure

disorder), and Cephalexin 500 mg

(infection). The 5/23/16 Bureau of







On 5/23/16 at 1:30 PM, client E was in

his room asleep while staff was assisting

another client in the shower. A second

staff was doing paperwork and listening

for client E's bedroom alarm. The

5/24/16 BDDS report indicated, in part,

"The alarm either did not go off or was

not audible over the other sounds of the

home. Staff #13 heard faint

moaning/sounds of distress from the

living room and went to investigate.

[Client E] was found on the living room

floor bleeding from a wound on his

forehead. There was blood on the carpet,

but none found on any other surface in

the home... [Client E] was also

experiencing multiple, close together

seizures while lying on the floor. Nurse

directed staff to call 911. [Client E] was

transported to [name of hospital] ER

(emergency room) via ambulance.

[Client E] received eight staples to close

QIDP, co-operative QIDP(QIDP

from another group home),

Director, Associate Director and

Manager of Nursing Services will

monitor house for medication



medication errors. After 2 weeks

of no medication errors, senior


days a week until 2 weeks of no


weeks of no medication

errors,senior management will

monitor house 3 days a week,

until 2 more weeks of no



assigned QIDP, Director(or

designee) and nurse will resume

regular house monitoring, in

accordance with





proper medication

administration How corrective

actions will be monitored to

ensure no recurrenceA QIDP

with 20 years experience in

residential services has been

added to the group home

program as Senior Director to

oversee all corrective action. The

Senior Director will supervise the

Director. The QIDP is supervised

by the SGL Director, they will

meet weekly for an oversight

meeting to ensure that all

corrective action is being






09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

the wound on his head after it was

cleaned...."

On 6/27/16 at 11:01 AM, the NM

indicated he did not know what caused

the injury to client E's head. The NM

indicated he received a call from the staff

saying client E's head was bleeding and

the staff needed assistance to stop the

bleeding. The NM went to the home.

The NM indicated staff #3 told him he

(staff #3) was in the med room at the

time and client E had been in his

bedroom. Staff #3 indicated to the NM

he heard client E cry out. Staff #3 found

client E on the living room floor,

bleeding from his head. The NM

instructed the staff to call 911. The NM

stated client E "had a few mini-seizures

while lying there. The NM indicated the

facility should have conducted an

investigation. The NM stated "maybe

she (GHD) didn't correlate the dates (of

the medication errors and the injury to

client E)." The NM indicated client E

could have fallen out of bed and fallen in

the living room. The NM indicated he

was unsure if the medication errors on

5/22/16 and client E's injury on 5/23/16

were connected due to no one witnessing

how client E was injured. The NM stated

client E's medication errors on 5/22/16

"could have been related to the injury on

5/23/16." The NM stated, "can't say











resurvey.





09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

100% for sure." The NM indicated client

E was having seizure activity following

the injury on 5/23/16.

3) On 5/22/16 at 7:00 PM, the


administer client A's HS medications as

ordered by his physician. The

medications included Benztropine 1 mg









4) On 5/22/16 at 7:00 PM, the




















09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00


5) On 5/22/16 at 7:00 PM, the




















med error."

6) On 5/22/16 at 8:00 PM, the







Quetiapine Fumarate 400 mg (anxiety).

The 5/24/16 BDDS report indicated, in

part, "On 05/23/2016, this med error was





09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00

found during buddy check by overnight

staff; nurse was notified in the AM with

instructions to monitor [client D] for any

side effects and continue with normal

medication routine. There was no

noticeable effect to [client D] due to this

med error."






























09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00





















medication administration."

10) On 6/27/16 at 5:49 PM, the

following MER was received by emailed

from the Coordinator: On 6/27/16 at

2:00 PM, client D was administered

Quetiapine Fumarate 400 mg for anxiety

at the wrong time. Staff #13

administered the medication at 2:00 PM.

The medication was ordered to be

administered at HS. The 6/27/16 MER

indicated, "No observable effect as of

4:00 PM."





09/01/2016PRINTED:

FORM APPROVED

OMB NO. 0938-0391




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION



15G643 06/30/2016

STONE BELT ARC INC

1006 W 11TH ST

00









"Med errors are a concern." The

Coordinator stated on 5/23/16, client D

was "more agitated" after not receiving

his medications on 5/22/16.




recurrence.

9-3-6(a)


Documents

PRINTED: 09/01/2016 DEPARTMENT OF HEALTH AND HUMAN ... · (x1) provider/supplier/clia department of health and human services centers for medicare & medicaid services printed: 09/01/2016