PRINTED: 01/03/2018 DEPARTMENT OF HEALTH AND HUMAN ...
Transcript of PRINTED: 01/03/2018 DEPARTMENT OF HEALTH AND HUMAN ...
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
W 0000
Bldg. 00
This visit was for a fundamental
recertification and state licensure survey.
Survey Dates: November 13, 14, 15 and
16, 2017
Facility Number: 000872
Provider Number: 15G357
AIM Number: 100239670
These deficiencies also reflect state findings
in accordance with 460 IAC 9.
Quality Review of this report completed by
#15068 on 11/28/17.
W 0000
483.430(e)(1)
STAFF TRAINING PROGRAM
The facility must provide each employee with
initial and continuing training that enables the
employee to perform his or her duties
effectively, efficiently, and competently.
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Bldg. 00
Based on observation, record review and
interview for 5 of 5 clients living in the group
home (#1, #2, #3, #4 and #5), the facility
failed to ensure the direct care staff received
competency-based training for the use of
client #2's hearing aids, client #2's hypoxia
(deficiency in the amount of oxygen reaching
the tissues) risk plan and staff #4 conducting
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Staff Training Program – The
facility must ensure that direct
care staff receive competency
based training for use of client
hearing aids as well as hypoxia
risk plans. The facility must also
ensure that direct care staff are
trained on conducting drills,
including overnight drills.
12/16/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete
Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin
other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to
continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
_____________________________________________________________________________________________________Event ID: 433Y11 Facility ID: 000872
TITLE
If continuation sheet Page 1 of 26
(X6) DATE
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
overnight drills.
Findings include:
1) On 11/13/17 from 4:07 PM to 6:19 PM
and 11/14/17 from 5:55 AM to 7:40 AM,
observations were conducted at the group
home. During the observations, when staff
spoke to client #2, the staff used loud voices
to speak to her. Staff was observed to
repeat themselves several times, on
occasion, until client #2 appeared to
comprehend what the staff was asking her to
do.
On 11/13/17 at 4:47 PM, the Home
Manager (HM) indicated client #2 did not
have hearing aids that she was aware of.
The HM stated, "Never seen her wear
hearing aids... Needs them."
On 11/13/17 at 4:57 PM, staff #2 located
one of client #2's hearing aids. Staff #2
indicated she was unsure if the hearing aid
worked or not. Staff #2 indicated she was
unsure if client #2 wore one or two hearing
aids. Staff #2 indicated client #2 refused to
wear her hearing aids. Staff #2 indicated
she was unsure if client #2 had a plan to
address her refusals to wear her hearing aid.
On 11/14/17 at 12:48 PM, a review of
Corrective action for resident(s)
found to have been affected
(1) Staff will be trained on Client
#2’s hearing aids and how best to
encourage usage by Client #2; (2)
Staff will be trained on Client #2’s
hypoxia risk plan; and (3) Staff #4
will be trained on conducting
overnight drills.
How facility will identify other
residents potentially affected &
what measures taken
Hearing aid and Hypoxia training
affects only Client #2. Drill training
potentially affects all residents,
and corrective measures address
the needs of all clients.
Measures or systemic changes
facility put in place to ensure no
recurrence
Stone Belt Nurse will train on
hearing aids and hypoxia risk
plan, Coordinator or QIDP will train
on overnight drills.
How corrective actions will be
monitored to ensure no recurrence
A new Director of Supported
Group Living (SGL) was hired and
will ensure all corrections are in
place and monitored. She
supervises the QIDP and
Coordinator who will provide
monitoring.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 2 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
client #2's record was conducted. Client
#2's 9/5/17 Physician's Orders indicated,
"May use hearing aids at her discretion...."
Client #2's most recent hearing examination
(6/22/15) indicated, "(Right) mixed hearing
loss, (left) severe hearing loss
(sensorineural- hearing loss caused by
damage to the inner ear or the nerve from
the ear to the brain) & (and) ETD
(Eustachian Tube Dysfunction - the tube
between the middle ear and the back of the
nose (the Eustachian tube) doesn't work
properly). Follow-up with ENT (Ear, Nose
and Throat doctor). Appointment 6/23/15."
There was no documentation in client #2's
record of an ENT appointment on 6/23/15.
A 9/29/15 Outside Services Report with an
ENT indicated, "...may use hearing aids at
her discretion." Client #2's 7/31/17 Nurse
Quarterly Physical indicated in the Adaptive
Equipment section, "...bilateral hearing
aids...."
On 11/14/17 at 12:07 PM, the nurse stated
she "believed" client #2 had two hearing
aids. The nurse indicated client #2 refused
to wear her hearing aids. The nurse
indicated client #2 purposefully breaks her
hearing aids. The nurse indicated the staff at
the group home should know she has
hearing aids and make them available to her.
The nurse indicated staff needed to be
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 3 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
retrained on client #2's hearing aids.
On 11/14/17 at 1:51 PM, the Assistant
Group Home Director (AGHD) indicated
the staff needed to be aware she had hearing
aids and offer them to her. The AGHD
indicated the staff needed to be retrained.
2) An observation was conducted at the
group home on 11/13/17 from 4:07 PM to
6:19 PM. During the medication
administration to client #2, the Home
Manager (HM) informed the surveyor that
client #2's oxygen level would be checked at
her bedtime medication pass. The surveyor
asked the HM if there was a plan for the
staff to implement if client #2's oxygen levels
were low. The HM stated "ideally" there
would be a plan. The HM indicated she
was not aware of a plan. The HM indicated
she wanted the staff to notify the nurse if
client #2's oxygen level was less than 90
percent. The HM indicated there was no
documentation of this in writing.
On 11/14/17 at 12:48 PM, a review of
client #2's record was conducted. Client
#2's 5/4/17 Hypoxia risk plan indicated,
"...If [client #2's] O2 (oxygen) levels are
below 88% have [client #2] take deep
breaths in (and) out slowly. Staff will also
encourage [client #2] to walk for 10
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 4 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
minutes. If [client #2's] O2 continues to
drop after walking and deep breathing call
the nurse...."
On 11/14/17 at 12:07 PM, the nurse
indicated the staff need to be retrained on
client #2's hypoxia risk plan to ensure they
know what to do when her oxygen levels
were low.
On 11/14/17 at 1:51 PM, the Qualified
Intellectual Disabilities Professional (QIDP)
indicated the staff needed to be retrained on
client #2's risk plan.
3) On 11/14/17 at 6:13 AM, staff #4 (staff
who worked the overnight shift from 10:00
PM to 8:00 AM) indicated she had not
conducted an overnight evacuation drill since
working at the group home. Staff #4 stated
she was "so-so" with the evacuation process
and felt "somewhat comfortable" in
evacuating the clients. Staff #4 indicated she
had worked at the home for approximately
3 months. This affected clients #1, #2, #3,
#4 and #5.
On 11/13/17 at 12:42 PM, a review of the
evacuation drills was conducted. There was
no documentation staff #4 participated in or
conducted evacuation drills at the group
home in the past 6 months during the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 5 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
overnight shift.
On 11/15/17 at 2:53 PM, the QIDP sent
documentation staff #4 received training on
Fire, Drills & (and) Safety on 9/5/17 for
another group home. The QIDP indicated
in the email, "I have attached a training sheet
for [staff #4] that shows that she has been
trained on drill procedures and
documentation." The QIDP did not provide
documentation staff #4 received the training
at client #1, #2, #3, #4 and #5's group
home. There was no documentation staff #4
received training indicating the location of
the fire box, executing a drill, evacuation
procedures, fire watch checklist and the
location of fire extinguishers.
On 11/15/17 at 1:58 PM, the AGHD
indicated staff #4 did not conduct an
overnight drill by herself. The AGHD
indicated staff #4 participated in a drill
during training but she had not completed an
evacuation drill at the group home during the
overnight shift.
9-3-3(a)
483.440(c)(4)
INDIVIDUAL PROGRAM PLAN
The individual program plan states the
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Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 6 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
specific objectives necessary to meet the
client's needs, as identified by the
comprehensive assessment required by
paragraph (c)(3) of this section.
Based on record review and interview for 1
of 3 clients in the sample (#1), the facility
failed to develop a plan to address the
recommendations from client #1's Physical
Therapist.
Findings include:
On 11/14/17 at 11:17 AM, a review of
client #1's record was conducted. On
9/1/17, the Physical Therapist (PT)
recommended the following:
"-Stand patient 5-10 times a day for 1-2
minutes, progress 1-2 minutes every week.
Goal is to stand for 15 minutes at a time.
-Pt (patient) to start standing while changing
[incontinence brief].
-Pt to begin standing in shower to rinse off
@ (at) end for 1-2 minutes. Progress
standing time in shower as able...."
Client #1's record did not include
documentation the PT's recommendations
were implemented. There was no
documentation the PT's recommendations
were incorporated into a plan for staff to
implement. The PT's recommendations
were included on client #1's 11/7/17
Medication Information Sheet. There was
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Individual Program Plan – The
facility must ensure a plan is
developed to address
recommendations from Physical
Therapist.
Corrective action for resident(s)
found to have been affected
QIDP, with the assistance of
Stone Belt Nurse, will create a
goal for Client #1’s physical
therapy recommendations and
train staff in implementation of that
goal.
How facility will identify other
residents potentially affected &
what measures taken
This affects only Client #1
Measures or systemic changes
facility put in place to ensure no
recurrence
QIDP will create a goal for Client
#1’s physical therapy and develop
tracking for progress toward goal
achievement.
How corrective actions will be
monitored to ensure no recurrence
A new Director of Supported
Group Living (SGL) was hired and
will ensure all corrections are in
place and monitored. She
supervises the QIDP and
12/16/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 7 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
no documentation indicating a progression
for staff to follow based on the PT's
recommendations. There was no schedule
for the staff to implement indicating where
client #1 was on his progression.
On 11/14/17 at 12:07 PM, the nurse
indicated the PT's recommendations were
copied, verbatim, into client #1's Medication
Information Sheet. The nurse indicated
there was no documentation of the
implementation of the recommendations.
The nurse indicated there needed to be a
clear plan for staff to follow and implement.
The nurse stated it "got missed." The nurse
stated the facility needed to "develop a plan
and implement the plan."
On 11/14/17 at 1:44 PM, the Assistant
Group Home Director indicated client #1
needed to have a plan developed and
implemented. There needed to be
documentation the PT's recommendations
were implemented.
On 11/14/17 at 1:44 PM, the Qualified
Intellectual Disabilities Professional (QIDP)
indicated client #1 needed to have a plan
developed and implemented. The QIDP
indicated there needed to be documentation
the PT's recommendations were
implemented.
Coordinator who will provide
monitoring.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 8 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
9-3-4(a)
483.440(d)(1)
PROGRAM IMPLEMENTATION
As soon as the interdisciplinary team has
formulated a client's individual program plan,
each client must receive a continuous active
treatment program consisting of needed
interventions and services in sufficient
number and frequency to support the
achievement of the objectives identified in the
individual program plan.
W 0249
Bldg. 00
Based on observation, record review and
interview for 1 of 3 clients in the sample (#3)
and one additional client (#4), the facility
failed to ensure the clients were engaged in
active treatment and meaningful activities.
Findings include:
Observations were conducted at the group
home on 11/13/17 from 4:07 PM to 6:19
PM and 11/14/17 from 5:55 AM to 7:40
AM:
-During a majority of the observations, client
#3 sat on the couch in the living room with a
magazine (during the evening observation) or
a straw (during the morning observation).
Client #3 was not engaged by staff with the
exception of receiving her medications or
during meals. The remainder of the
observations, client #3 sat on the couch.
W 0249 W 249
Program Implementation – The
facility must ensure that clients
are engaged in active treatment
and meaningful activities.
Corrective action for resident(s)
found to have been affected
Team will develop activities for
Clients #3 and #4 based on their
respective ISP goals.
Coordinator/QIDP will develop
schedules that engage these
clients in active treatment and
meaningful activities.
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
Coordinator and QIDP will review
12/16/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 9 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
Client #3 was not engaged in meaningful
activities. Client #3's active treatment
schedule was not implemented. Client #3
did not assist with making breakfast or
dinner.
-During a majority of the observations, client
#4 was in a wheelchair moving from the
dining room, living room and hallway. Client
#4 was holding a magazine most of the time
she was sitting in her wheelchair. Client #4
was not engaged by staff with the exception
of receiving her medications or during meals.
Client #4 was not engaged in meaningful
activities. Client #4's active treatment
schedule was not implemented. Client #4
did not assist with putting away her laundry.
Client #4 did not assist with making her
breakfast.
On 11/14/17 at 1:13 PM, a review of client
#3's record was conducted. Client #3's
3/27/17 Individualized Support Plan (ISP)
indicated she had the following goals and
objectives: participate in
occupational/physical therapy exercises,
increase her communication skills,
medication administration skills and
ambulating safely.
On 11/14/17 at 2:04 PM, a focused review
of client #4's record was conducted. Client
#4's 7/25/17 ISP indicated she had the
activities and schedules for all
clients. Coordinator/QIDP will also
review client billing
documentation for each client at
least weekly as a means of
ensuring that staff are actively
engaging the clients in meaningful
activities.
How corrective actions will be
monitored to ensure no recurrence
The facility will monitor on site
through unannounced visits to the
home for direct observation by the
Coordinator/QIDP to ensure staff
are following the schedule and
engaging clients in active
treatment. A new Director of
Supported Group Living (SGL) was
hired and will ensure all
corrections are in place and
monitored. She supervises the
QIDP and Coordinator who will
provide monitoring.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 10 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
following goals and objectives: increase her
choice making by grabbing/reaching for an
item, increase her communication skills,
participate in community activities, sensory
activities and safe use of her wheelchair by
not running into others.
On 11/14/17 at 1:51 PM, the Qualified
Intellectual Disabilities Professional (QIDP)
indicated the clients should be engaged in
meaningful activities. The QIDP indicated
the clients should be prompted to participate
in their goals and objectives. The QIDP
indicated the staff should prompt the clients
to engage in activities at least every 15
minutes.
On 11/14/17 at 1:51 PM, the Assistant
Group Home Director (AGHD) indicated
the clients should be engaged in meaningful
activities. The AGHD indicated the clients
should be prompted to participate in their
goals and objectives. The AGHD indicated
the staff should prompt the clients to engage
in activities at least every 15 minutes.
9-3-4(a)
483.440(d)(2)
PROGRAM IMPLEMENTATION
The facility must develop an active treatment
schedule that outlines the current active
W 0250
Bldg. 00
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 11 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
treatment program and that is readily
available for review by relevant staff.
Based on observation, record review and
interview for 1 of 3 clients in the sample (#3)
and one additional client (#4), the facility
failed to ensure the clients had current active
treatment schedules for the staff to
implement.
Findings include:
Observations were conducted at the group
home on 11/13/17 from 4:07 PM to 6:19
PM and 11/14/17 from 5:55 AM to 7:40
AM:
-During a majority of the observations, client
#3 sat on the couch in the living room with a
magazine (during the evening observation) or
a straw (during the morning observation).
Client #3 was not engaged by staff with the
exception of receiving her medications or
during meals. The remainder of the
observations, client #3 sat on the couch.
Client #3 was not engaged in meaningful
activities. Client #3's active treatment
schedule was not implemented. Client #3
did not assist with making breakfast or
dinner.
-During a majority of the observations, client
#4 was in a wheelchair moving from the
dining room, living room and hallway. Client
#4 was holding a magazine most of the time
W 0250 W 250
Program Implementation – Facility
must ensure that clients have
active treatment schedules for
staff to implement.
Corrective action for resident(s)
found to have been affected
Team will develop activities for
Clients #3 and #4 based on their
respective ISP goals and will
develop schedules that engage
these clients in active treatment.
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
Coordinator with assistance of
QIDP will review activities, daily
schedules and implementation by
staff.
How corrective actions will be
monitored to ensure no recurrence
A new Director of Supported
Group Living (SGL) was hired and
will ensure all corrections are in
place and monitored. She
supervises the QIDP and
Coordinator who will provide
monitoring.
12/16/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 12 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
she was sitting in her wheelchair. Client #4
was not engaged by staff with the exception
of receiving her medications or during meals.
Client #4 was not engaged in meaningful
activities. Client #4's active treatment
schedule was not implemented. Client #4
did not assist with putting away her laundry.
Client #4 did not assist with making her
breakfast.
On 11/14/17 at 1:13 PM, a review of client
#3's record was conducted. There was no
documentation in her record of an Active
Treatment Schedule. On 11/14/17 at 2:04
PM, the Assistant Group Home Director
(AGHD) provided an undated Active
Treatment Schedule. Based on the
information on the AGHD's computer, the
Active Treatment Schedule was last updated
in August 2015. Client #3's Active
Treatment Schedule indicated the following:
"-6:00 AM to 6:20 AM - Wake [client #3],
help make her bed, help her put away
laundry if needed. Help [client #3] pick out
clothes for the day. Assist her with rest
rooming & (and) shower, assist her with
brushing teeth and getting dressed. Morning
meds.
-6:20 AM to 6:50 AM - Help make
breakfast.
-6:50 AM to 7:00 AM - Get ready for
breakfast.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 13 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
-7:00 AM to 7:20 AM - Breakfast.
-7:20 AM to 7:30 AM - Restroom/shoes.
-7:30 AM - Get in van and go to day
program.
-4:30 PM to 4:45 PM - Restroom and
possibly PJ's
-4:45 PM to 5:00 PM - TV time/help with
dinner
-5:00 PM to 6:00 PM - Dinner.
-6:00 PM to 6:30 PM - Magazine and TV
time...."
On 11/14/17 at 2:04 PM, a focused review
of client #4's record was conducted. Client
#4's undated Active Treatment Schedule
(August 2015 based on when the document
was last updated on the AGHD's computer)
indicated the schedule had not been updated
since August 2015.
Client #4's Active Treatment Schedule
indicated the following:
"-6:00 AM to 6:20 AM - Morning meds.
-6:20 AM to 6:50 AM - Help make
breakfast.
-6:50 AM to 7:00 AM - Get ready for
breakfast.
-7:00 AM to 7:20 AM - Breakfast.
-7:20 AM to 7:30 AM - Restroom. Shoes
get in wheelchair for day program.
-7:30 AM - Get in van and go to day
program.
-4:30 PM to 4:45 PM - Restroom and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 14 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
possibly PJ's
-4:45 PM to 5:00 PM - Meds
-5:00 PM to 6:00 PM - Dinner.
-6:00 PM to 6:30 PM - Hang out around
the house...."
On 11/14/17 at 2:04 PM, the AGHD
indicated the clients' Active Treatment
Schedules should be reviewed and updated
annually.
9-3-4(a)
483.460(a)(3)
PHYSICIAN SERVICES
The facility must provide or obtain preventive
and general medical care.
W 0322
Bldg. 00
Based on record review and interview for 1
of 3 clients in the sample (#1), the facility
failed to ensure client #1 had an annual
physical.
Findings include:
On 11/14/17 at 11:17 AM, a review of
client #1's record was conducted. Client
#1's most recent annual physical was
conducted on 9/16/16. There was no
documentation client #1 had an annual
physical since 9/16/16.
On 11/14/17 at 12:34 PM, the nurse
W 0322 W 322
Physician Services – Facility will
ensure that clients have an annual
physical.
Corrective action for resident(s)
found to have been affected
Day Aide will schedule and
arrange transport for Client #1 to
his annual physical
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
12/16/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 15 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
indicated client #1 should have a physical
annually.
On 11/15/17 at 11:25 AM, the Qualified
Intellectual Disabilities Professional indicated
in an email when asked if there was
documentation of an annual physical for
client #1, "He did not. He is scheduled for
one in early December."
9-3-6(a)
facility put in place to ensure no
recurrence
Day Aide will review all client files
to ensure that annual physicals
are up to date and if not,
appointments will be scheduled.
How corrective actions will be
monitored to ensure no recurrence
A new Director of Supported
Group Living (SGL) was hired and
will ensure all corrections are in
place and monitored. She
supervises the QIDP and
Coordinator who will provide
monitoring.
483.460(c)
NURSING SERVICES
The facility must provide clients with nursing
services in accordance with their needs.
W 0331
Bldg. 00
Based on record review and interview for 1
of 3 clients in the sample (#1), the facility's
nursing services failed to ensure a plan was
developed, implemented and documented
based on the Physical Therapist's (PT)
recommendations on 9/1/17.
Findings include:
On 11/14/17 at 11:17 AM, a review of
client #1's record was conducted. On
9/1/17, the PT recommended the following:
"-Stand patient 5-10 times a day for 1-2
minutes, progress 1-2 minutes every week.
W 0331 W 331
Nursing Services – Facility nursing
services must ensure a plan is
developed, implemented, and
documented based on physical
therapist recommendations.
Corrective action for resident(s)
found to have been affected
QIDP, with the assistance of
Stone Belt Nurse, will create a
goal for Client #1’s physical
therapy recommendations and
train staff in implementation of that
goal.
How facility will identify other
residents potentially affected &
12/16/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 16 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
Goal is to stand for 15 minutes at a time.
-Pt (patient) to start standing while changing
diaper.
-Pt to begin standing in shower to rinse off
@ (at) end for 1-2 minutes. Progress
standing time in shower as able...."
Client #1's record did not include
documentation the PT's recommendations
were implemented. There was no
documentation the PT's recommendations
were incorporated into a plan for staff to
implement. There was no documentation
the staff received training on client #1's PT
recommendations. The PT's
recommendations were included on client
#1's 11/7/17 Medication Information Sheet.
There was no documentation indicating a
progression for staff to follow based on the
PT's recommendations. There was no
schedule for the staff to implement indicating
where client #1 was on his progression.
On 11/14/17 at 12:07 PM, the nurse
indicated the PT's recommendations were
copied, verbatim, into client #1's Medication
Information Sheet. The nurse indicated
there was no documentation of the
implementation of the recommendations.
The nurse indicated there needed to be a
clear plan for staff to follow and implement.
The nurse stated it "got missed." The nurse
what measures taken
This affects only Client #1
Measures or systemic changes
facility put in place to ensure no
recurrence
QIDP will create a goal for Client
#1’s physical therapy and develop
tracking for progress toward goal
achievement.
How corrective actions will be
monitored to ensure no recurrence
A new Director of Supported
Group Living (SGL) was hired and
will ensure all corrections are in
place and monitored. She
supervises the QIDP and
Coordinator who will provide
monitoring.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 17 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
stated the facility needed to "develop a plan
and implement the plan."
On 11/14/17 at 1:44 PM, the Assistant
Group Home Director indicated client #1
needed to have a plan developed and
implemented. There needed to be
documentation the PT's recommendations
were implemented.
On 11/14/17 at 1:44 PM, the Qualified
Intellectual Disabilities Professional (QIDP)
indicated client #1 needed to have a plan
developed and implemented. The QIDP
indicated there needed to be documentation
the PT's recommendations were
implemented.
9-3-6(a)
483.460(j)(4)
DRUG REGIMEN REVIEW
An individual medication administration
record must be maintained for each client.
W 0365
Bldg. 00
Based on observation, record review and
interview for 1 of 1 client (#3) observed to
receive her medications during the morning
medication administration from staff #2, the
facility failed to ensure staff #2 initialed the
Medication Administration Record (MAR)
after administering client #3's medications.
W 0365 W 365
Drug Regimen Review – Facility
must ensure that staff are trained
in Medication Administration
documentation, including initialing
the MAR after administering client
medication.
Corrective action for resident(s)
found to have been affected
12/16/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 18 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
Findings include:
On 11/14/17 from 5:55 AM to 7:40 AM,
an observation was conducted at the group
home. At 6:00 AM prior to administering
client #3's medications, staff #2 initialed
client #3's November 2017 MAR indicating
client #3's medications were administered.
Staff #2 closed client #3's medication
administration binder and put it away prior
to administering client #3's medications.
On 11/14/17 at 12:05 PM, the nurse
indicated staff #2 should have administered
client #3's medications and then
signed/initialed the MAR.
9-3-6(a)
All staff will have updated training
on Medication Administration
procedure
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
Updated training on Medication
Administration documentation will
be provided to staff
How corrective actions will be
monitored to ensure no recurrence
A new Director of Supported
Group Living (SGL) was hired and
will ensure all corrections are in
place and monitored. She
supervises the QIDP and
Coordinator who will provide
monitoring.
483.470(g)(2)
SPACE AND EQUIPMENT
The facility must furnish, maintain in good
repair, and teach clients to use and to make
informed choices about the use of dentures,
eyeglasses, hearing and other
communications aids, braces, and other
devices identified by the interdisciplinary
team as needed by the client.
W 0436
Bldg. 00
Based on observation, interview and record
review for 1 of 3 clients in the sample with
W 0436 W 436
Space and Equipment – The 12/16/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 19 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
adaptive equipment (#2), the facility failed to
ensure client #2's hearing aids were
maintained in working order and she was
taught to use her hearing aids.
Findings include:
On 11/13/17 from 4:07 PM to 6:19 PM
and 11/14/17 from 5:55 AM to 7:40 AM,
observations were conducted at the group
home. During the observations, when staff
spoke to client #2, the staff used loud voices
to speak to her. Staff was observed to
repeat themselves several times, on
occasion, until client #2 appeared to
comprehend what the staff was asking her to
do.
On 11/13/17 at 4:47 PM, the Home
Manager (HM) indicated client #2 did not
have hearing aids that she was aware of.
The HM stated, "Never seen her wear
hearing aids... Needs them."
On 11/13/17 at 4:57 PM, staff #2 located
one of client #2's hearing aids. Staff #2
indicated she was unsure if the hearing aid
worked or not. Staff #2 indicated she was
unsure if client #2 wore one or two hearing
aids. Staff #2 indicated client #2 refused to
wear her hearing aid. Staff #2 indicated she
was unsure if client #2 had a plan to address
facility must ensure that client
hearing aids are maintained in
working order and clients are
taught to use their hearing aids.
Corrective action for resident(s)
found to have been affected
Day Aide will schedule an
appointment for Client #2 with her
ENT to check that hearing aids
are in proper order and provide
training to Client #2 on how to use
her hearing aids.
How facility will identify other
residents potentially affected &
what measures taken
This affects only Client #2
Measures or systemic changes
facility put in place to ensure no
recurrence
QIDP will ensure that this
appointment is completed and
information transmitted to other
staff as needed.
How corrective actions will be
monitored to ensure no recurrence
A new Director of Supported
Group Living (SGL) was hired and
will ensure all corrections are in
place and monitored. She
supervises the QIDP and
Coordinator who will provide
monitoring.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 20 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
her refusals to wear her hearing aid.
On 11/14/17 at 12:48 PM, a review of
client #2's record was conducted. Client
#2's 9/5/17 Physician's Orders indicated,
"May use hearing aids at her discretion...."
Client #2's most recent hearing examination
(6/22/15) indicated, "(Right) mixed hearing
loss, (left) severe hearing loss
(sensorineural- hearing loss caused by
damage to the inner ear or the nerve from
the ear to the brain) & (and) ETD
(Eustachian Tube Dysfunction - the tube
between the middle ear and the back of the
nose (the Eustachian tube) doesn't work
properly). Follow-up with ENT (Ear, Nose
and Throat doctor). Appointment 6/23/15."
There was no documentation in client #2's
record of an ENT appointment on 6/23/15.
A 9/29/15 Outside Services Report with an
ENT indicated, "...may use hearing aids at
her discretion." Client #2's 7/31/17 Nurse
Quarterly Physical indicated in the Adaptive
Equipment section, "...bilateral hearing
aids...."
On 11/14/17 at 12:07 PM, the nurse stated
she "believed" client #2 had two hearing
aids. The nurse indicated client #2 refused
to wear her hearing aids. The nurse
indicated client #2 purposefully breaks her
hearing aids. The nurse indicated the staff at
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 21 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
the group home should know she has
hearing aids and make them available to her.
The nurse indicated she was not aware of a
plan to teach client #2 to wear her hearing
aids. The nurse stated, "there needs to be a
plan." The nurse stated there was no
documentation in client #2's record her
hearing aids had been checked/assessed
since December 2014.
On 11/14/17 at 1:44 PM, the Assistant
Group Home Director (AGHD) indicated
client #2 should have two hearing aids. The
AGHD indicated client #2 broke one of her
hearing aids. The AGHD indicated client #2
could refuse to wear her hearing aids. The
AGHD indicated client #2, in the past, left
her hearing aids in order to lose them. The
AGHD indicated client #2's hearing aids
should be functional and made available to
her. The AGHD indicated client #2 needed
a plan to teach her to use her hearing aids.
On 11/14/17 at 1:44 PM, the Qualified
Intellectual Disabilities Professional (QIDP)
indicated one of the hearing aids was
missing. The QIDP indicated client #2's
hearing aids needed to be made available to
her to wear.
On 11/14/17 at 1:44 PM, the Coordinator
indicated client #2's hearing aids should be
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 22 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
available for her to wear.
9-3-7(a)
483.470(i)(1)
EVACUATION DRILLS
The facility must hold evacuation drills at
least quarterly for each shift of personnel.
W 0440
Bldg. 00
Based on record review and interview for 5
of 5 clients living in the group home (#1, #2,
#3, #4 and #5), the facility failed to conduct
quarterly evacuation drills for each shift of
personnel.
Findings include:
On 11/13/17 at 12:42 PM, a review of the
facility's evacuation drills was conducted.
During the night shift (10:00 PM to 6:00
AM), the facility failed to conduct
evacuation drills from 6/21/17 to 11/13/17.
This affected clients #1, #2, #3, #4 and #5.
On 11/14/17 at 6:13 AM, staff #4 (staff
who worked the overnight shift from 10:00
PM to 8:00 AM) indicated she had not
conducted an overnight evacuation drill since
working at the group home. Staff #4 stated
she was "so-so" with the evacuation process
and felt "somewhat comfortable" in
evacuating the clients. Staff #4 indicated she
had worked at the home for approximately
W 0440 W 440
Evacuation Drills – Facility must
ensure that evacuation drills are
conducted quarterly for each shift
of personnel.
Corrective action for resident(s)
found to have been affected
The drill schedule in place did not
have sufficient variation of shifts. A
new schedule will be developed
and implemented by QIDP.
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
Evacuation scheduled will be
revised and implemented in the
home, monitored by Coordinator
and QIDP.
How corrective actions will be
monitored to ensure no recurrence
12/16/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 23 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
3 months.
On 11/13/17 at 2:24 PM, the Assistant
Group Home Director indicated the facility
should conduct one drill per shift per
quarter.
On 11/14/17 at 10:43 AM, the Coordinator
indicated the facility should conduct one drill
per shift per quarter.
9-3-7(a)
A new Director of Supported
Group Living (SGL) was hired and
will ensure all corrections are in
place and monitored. She
supervises the QIDP and
Coordinator and will provide
training and monitoring.
W 9999
Bldg. 00
State Findings
The following Community Residential
Facilities for Persons with Developmental
Disabilities Rules were not met:
460 IAC 9-3-3 Facility Staffing
(e) Prior to assuming residential job duties
and annually thereafter, each residential staff
person shall submit written evidence that a
Mantoux (5TU, PPD) tuberculosis skin test
or chest x-ray was completed. The result of
the Mantoux shall be recorded in millimeter
of induration with the date given, date read,
and by whom administered. If the skin test
W 9999 W 9999
Facility Staffing – Facility must
ensure that annual Mantoux
tuberculosis screenings are
conducted.
Corrective action for resident(s)
found to have been affected
Mantoux tuberculosis screenings
will be completed for staff
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
12/16/2017 12:00:00AM
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 24 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
result is significant (ten (10) millimeters or
more), then a chest film shall be done with
other physical and laboratory examinations
as necessary to complete a diagnosis.
Prophylactic treatment shall be provided as
per diagnosis for the length of time
prescribed by the physician.
This state rule was not met as evidenced by:
Based on record review and interview for 1
of 3 staff (#2), the facility failed to ensure
annual Mantoux (5TU, PPD) tuberculosis
(TB) screenings were conducted.
Findings include:
On 11/13/17 at 1:59 PM, a review of the
employee's files was conducted. Staff #2's
most recent TB test was conducted on
10/10/16. There was no documentation
staff #2 had an annual TB test since
10/10/16.
On 11/13/17 at 2:22 PM, the Assistant
Group Home Director indicated the staff
should have an annual TB test.
On 11/14/17 at 12:30 PM, the nurse
indicated the staff should have an annual TB
test.
recurrence
A new Organizational
Effectiveness Coordinator has
been hired and will develop a
tracking system for these
screenings. Monthly reminders will
be developed for staff from this
tracking with alerts also going to
Coordinator and QIDP for follow
up.
How corrective actions will be
monitored to ensure no recurrence
A new Director of Supported
Group Living (SGL) was hired and
will ensure all corrections are in
place and monitored. She
supervises the QIDP and
Coordinator who will provide
monitoring.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 25 of 26
(X1) PROVIDER/SUPPLIER/CLIA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
01/03/2018PRINTED:
FORM APPROVED
OMB NO. 0938-039
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING
(X3) DATE SURVEY
COMPLETED
NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIE
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION
PREFIX
TAG
IDPROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
DEFICIENCY)
(X5)
COMPLETION
DATECROSS-REFERENCED TO THE APPROPRIATE
BLOOMINGTON, IN 47401
15G357 11/16/2017
STONE BELT ARC INC
3502 FESTIVE DR
00
9-3-3(e)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 433Y11 Facility ID: 000872 If continuation sheet Page 26 of 26