(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
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
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 2 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 3 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
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
Based on record review and interview for
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
resident(s) found to have been
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
07/30/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 4 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
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
followed for the Plan of
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 5 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 6 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 7 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 8 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
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.
On 6/27/16 at 2:01 PM, the Coordinator
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 9 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
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."
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
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 10 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
On 6/27/16 at 10:50 AM, the Nurse
Manager (NM) indicated the clients'
medications should be administered as
ordered by their physicians.
On 6/27/16 at 2:01 PM, the Coordinator
indicated the clients' medications should
be administered as ordered by their
physicians. The Coordinator stated,
"Med errors are a concern."
4) On 5/22/16 at 8:00 PM, the
Coordinator, staff #7 and #8 did not
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
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."
There was no documentation the facility
implemented corrective action with staff
#8.
On 6/24/16 at 1:58 PM, the Group Home
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 11 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
Director (GHD) indicated the facility did
not implement corrective actions with
staff #8. The GHD indicated the MER
was incorrect. The GHD indicated after
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 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.
On 6/27/16 at 2:01 PM, the Coordinator
indicated the clients' medications should
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 12 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
be administered as ordered by their
physicians. The Coordinator stated,
"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
Coordinator, staff #7 and staff #8 did not
administer client F's HS medication as
ordered by the physician. The
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
continue with normal medication routine.
There was no noticeable effect to [client
F] due to this med error."
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 13 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
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.
On 6/27/16 at 2:01 PM, the Coordinator
indicated the clients' medications should
be administered as ordered by their
physicians. The Coordinator stated,
"Med errors are a concern."
6) On 5/22/16 at 7:00 PM, the
Coordinator, staff #7 and #8 did not
administer client E's bedtime (HS - hour
of sleep) medications as ordered by his
physician. The medications included
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 14 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
(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
05/23/2016, this med error was found
during buddy check by overnight staff...
There was no noticeable effect to [client
E] due to this med error."
There was no documentation the facility
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.
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
discussing the incident, the facility
determined the Coordinator was
responsible. The GHD indicated
although the MER indicated staff #7 and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 15 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
#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
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.
On 6/27/16 at 2:01 PM, the Coordinator
indicated the clients' medications should
be administered as ordered by their
physicians. The Coordinator stated,
"Med errors are a concern."
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 16 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
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."
There was no documentation the facility
implemented corrective action with staff
#3.
On 6/27/16 at 10:50 AM, the Nurse
Manager (NM) indicated the clients'
medications should be administered as
ordered by their physicians.
On 6/27/16 at 2:01 PM, the Coordinator
indicated the clients' medications should
be administered as ordered by their
physicians. The Coordinator stated,
"Med errors are a concern."
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
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 17 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
The facility must provide clients with nursing
services in accordance with their needs.
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
nursing services failed to ensure staff
administered the clients' medications in
accordance with their physician's orders.
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 5/16/16 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
Coordinator, staff #7 and #8 did not
administer client E's bedtime (HS - hour
of sleep) medications as ordered by his
physician. The medications included
Clonazepam (anxiety) 0.5 mg, Depakote
Sprinkles 1000 mg (seizure disorder),
Levocarnitin 330 mg (carnitine
W 0331 W 331Nursing Services
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.
Specifically, the QIDP,
07/30/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 18 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
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
Developmental Disabilities Services
(BDDS) incident report indicated, "On
05/23/2016, this med error was found
during buddy check by overnight staff...
There was no noticeable effect to [client
E] due to this med error."
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
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
Correction(POC). The meeting
will be chaired by SGL Director(or
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 19 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
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
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 20 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
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
Coordinator, staff #7 and #8 did not
administer client A's HS medications as
ordered by his physician. The
medications included Benztropine 1 mg
(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).
4) On 5/22/16 at 7:00 PM, the
Coordinator, staff #7 and staff #8 did not
administer client F's HS medication as
ordered by the physician. The
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
continue with normal medication routine.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 21 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
There was no noticeable effect to [client
F] due to this med error."
5) 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
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."
6) On 5/22/16 at 8:00 PM, the
Coordinator, staff #7 and #8 did not
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).
The 5/24/16 BDDS report indicated, in
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 22 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
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."
On 6/27/16 at 2:01 PM, the Coordinator
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...."
8) On 6/3/16 at 6:00 PM (discovered on
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 23 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
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 6/3/2016 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...."
9) On 6/11/16 at 9:00 AM, client C was
given one of two Omeprazole 20 mg
capsules. Staff #3 was responsible for
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." There was
no documentation the facility
implemented corrective action with staff
#3.
10) On 6/27/16 at 5:49 PM, the
following MER was received by emailed
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 24 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
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."
On 6/27/16 at 10:50 AM, the Nurse
Manager (NM) indicated the clients'
medications should be administered as
ordered by their physicians.
On 6/27/16 at 2:01 PM, the Coordinator
indicated the clients' medications should
be administered as ordered by their
physicians. The Coordinator stated,
"Med errors are a concern."
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.
9-3-6(a)
483.460(k)(1)
DRUG ADMINISTRATION
The system for drug administration must
assure that all drugs are administered in
W 0368
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 25 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
compliance with the physician's orders.
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 failed
to ensure staff administered the clients'
medications in accordance with their
physician's orders.
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 5/16/16 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
Coordinator, staff #7 and #8 did not
administer client E's bedtime (HS - hour
of sleep) medications as ordered by his
physician. The medications included
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
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 takenAll
residents potentially are affected,
and corrective measures address
the needs of all clients.Measures
or systemic changes facility
put in place to ensure no
recurrenceThere 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. Specifically,the
07/30/2016 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 26 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
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
Developmental Disabilities Services
(BDDS) incident report indicated, "On
05/23/2016, this med error was found
during buddy check by overnight staff...
There was no noticeable effect to [client
E] due to this med error."
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
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 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
followed for the Plan of
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 27 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
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
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.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 28 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
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
Coordinator, staff #7 and #8 did not
administer client A's HS medications as
ordered by his physician. The
medications included Benztropine 1 mg
(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).
4) On 5/22/16 at 7:00 PM, the
Coordinator, staff #7 and staff #8 did not
administer client F's HS medication as
ordered by the physician. The
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
continue with normal medication routine.
There was no noticeable effect to [client
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 29 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
F] due to this med error."
5) 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
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."
6) On 5/22/16 at 8:00 PM, the
Coordinator, staff #7 and #8 did not
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).
The 5/24/16 BDDS report indicated, in
part, "On 05/23/2016, this med error was
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 30 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
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."
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...."
8) On 6/3/16 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 6/3/2016 at PM
med pass, staff had another clients (sic)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 31 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
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...."
9) On 6/11/16 at 9:00 AM, client C was
given one of two Omeprazole 20 mg
capsules. Staff #3 was responsible for
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."
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."
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 32 of 33
(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
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(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
BLOOMINGTON, IN 47404
15G643 06/30/2016
STONE BELT ARC INC
1006 W 11TH ST
00
On 6/27/16 at 10:50 AM, the Nurse
Manager (NM) indicated the clients'
medications should be administered as
ordered by their physicians.
On 6/27/16 at 2:01 PM, the Coordinator
indicated the clients' medications should
be administered as ordered by their
physicians. The Coordinator stated,
"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.
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.
9-3-6(a)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMND13 Facility ID: 001221 If continuation sheet Page 33 of 33