A

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GOVERNMENT OF THE DISTRICT Of COLON

DEPARTMENT OF HEALTH ALTH REGULATION ADMINISTRATIO

HE 325 NORTH CAPTTOL ST, N.E.,2tID FLO WASHI NGTON, DC. 2000

2

11-4.5- /0

W 120

FROM :MTS CORP. FAX NO. :2022448048

Nov. 23 _ NUV-10-2006 06:51 FROM:

70: 2448048

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MECIICatI SERVICES

BURNERS OF DEFICIENGE3 PROMORFUELIPPLIEIGG-R AND PUN OF CORRECTION IEENTIREATION NUNBER

2010 11: 31AM P 2

P.1 , 10

PRINTED: 11/17/2010 FORM APPROVED

20ISQLSiMaar *wenn SURVEY

COMPIJITEn 00* ButorwLecomsynucnon A. BIASING

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TAG REGULATORY OR LSO wewnrmay strcarsAtore

W 000 ' norm COMMENTS

NAME OF PROVIDER OR (SUPPLIER

WAILTMERAPAITIG SERVICES, INC

SMUT CORMS, OTC STATE, 22P CODE 927 5SM num NC WAstrelsTON,13c 20019

ID PRIM

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A recertification survey was conducted from November 3, 2010 through November 4, 2010, utilizing Ms fundamental survey process. A I random sample of three clients was selected from a population of five females with various levels of developmental

The findings of the survey were based on observations at the group home, two day programs. interviews with oilers and staff, end cite review of clinical and administrative records including incident reports.

W 120' 483A10(dX3) SERVICES PROVIDED WITH OUTSIDE SOURCES

The facility must fissure that outside services meet the needs of tech client .

This STANDARD Is not met as evidenced by: gesed on observation, Interviews, and record review, the facility felled to ensure that dents' day programs implemented training programs and/or provided a complete meal In accordance With nutritional needs, for two of the three clients la the sample. (clients *2 and *3)

The findings include:

1. On November 3. 2010,..Cdentila was observed et her day program from 11:25 a.m, until too pant At the outset the dent was observed manipulating plastic objects (boo items) as pig of her instructional program. At 12:20 p.m., the client, her peers and that direct support staff left the treatment room and walked to the adularia. The client did not wash her hands before eating lunch. During the lunch, staff was observed

DRY twerp • earSuPPLER

PROVIDERS RAN OF CORRECTION MACH CORRECtarE Acton SHOULD DE

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

1 et

Searcy teatement endow an Salk (1 denotes s defame the Reetulien ray ee erased conectIno ProPISSM It b dlawmind 1St other PaREIRRIO wsvias wawa Noncom tome paints (See inetructione.) Except for =Nap hems, the Endive Rao 'boa a elecloseble CO dips teeming the date of wary stealer or not s pen of eorredon is plodded. For SWISS Mmes. the stem *slings anti piens of corractitaSit SSW. 14 days reireang the date them documents are node table to the heap. if defielencies are sited, an WRNS pis analITICEOR to a tonfilloul program Oefeelpee00.

Forst as , souriesTh Peas Vets awaits ENO 0 MIMI Feat 09G096 JfoortiawsoasAeetPage 10(14

DEPARTMENT OF HEALTH AND HUMAN sSERVICES

a c

Nov. 23 2010 11:31AM P 3

P.2/ie PRINTED: 11,17303143

FORM APPROVED

FROM : MTS CORP. FAX NO. : 2022448048 nuso- iv-COUb O • J1 h MUM:

TO:244804e

SSE coSESS. arc stem 72 cooe ray sent sTeetr,Ne vinaterGiON, DC 2001e

PROVIDEPre KAM Of CORRECTION wee (EleitECEVE MEOW stouto BE

onossatensweicso TO THE APPnceellAre oencirercr

NAME oF PRON404.14 OR SUPPLIER

guen-lliERAPEtrnC SEtivICES, INC sumwav orgramorr ochaDicas

root oshcamov war at paccacED ev euti. NsawAroetv OR lee cermtnes meoftw210/0

W 120 i Continued From page 1 wiping Client 02's mouth White napkinwithout

' eliminate ellent any verbal cannot opportunly to participate in the Moufhwriping,

At 12:45 p.m., review of Client 02% training programs revealed that she had an objectival°

, wash her hands before lunch and another objective to teem haw tavime her mouth with* napkin. Observations on November 3. 2010. however, revealed that day program staff did riot consistently Implement her training **Nivea.

2. On November a, 2010. Cleft/twos observed at her day program from 12,45 p.m. until approximetely 1:10 p.m. She finished sating her lunch at 1:05 p.m. and after receiving a verbal prompt from staff, she cleared her piece staffing. The client's lunch had consisted of chopped meatballs (without tomato sauce) mashed potatoes, a slice of watt whole wheat bread (chopped): there was no dessert offered.

At approximately 1;15 p.m., interview With the direct support staff revealed that she had not offered the client a fruit cup because her diet orders said to avoid citrus fruits (due to the acidity). [Note: Observation of the true cups In question revealed/3o Sus products were in the nExtere of chopper fruits.) Further Interview with the direct support staff also confirmed the she had pot offered the client a substitutefood Item for dessert.

At approximately 1:30 p.m., Interview with the day program rasa manager revealed that Client CS was expected to receives full lunch; Including a dessert, as long as the foods were not wick and did not contain lactose milk sugar, it accordance with her diet orders: chopped, regular, no-scid, no

110ee 013-2147102444 Avian Weskits Obake Est 111021211 F.Sbt. MOW If oorenuoNori MOO Poop 2 of 14

FROM : MTS CORP. • 4.= rmuri;

FAX NO. : 2022448048 Nov. 23

T0:2448048

2010 11:31AM P 4

P.31 10

PRINTED; 11n7/2010 FORM APPROVED

NrataAMMIEL DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICA & MEDICAID SERVICES

STATEMENT OP DEFICIENCIES CM) PROMORROTRIPPLOUCUA ARO MAN OF CARRECTRIN IDENTIFICATION eta co) Mat PIE CONSTRUCTION A.Mum*

pat DATII SURVEY COUPLET=

B.WING

STREET ADDRESS.. OTT. STATE. LP COO! art SEM STREET. ma WAS}UNSTOld, DC 20010

NAME OF PROYMER OR SUPPLIER

lititliMwTHERAPEUTiC SERVICES, INC

(ea) ID pumas

TAG r

campunaw oint

lb PREF X

TAG

SteatARY OTATtlearr or ogROMICM0 CEAcm ITEFICIENCY MUST OE PRECEDED BY FULL

REGULATORY OR 4SC MENTIFYINa INFOOMATMN) PROADERa RAN CfOORREETION

fEACH CORRECITVE ALMON SHOULD BE CROSSAIMERENESIO

iv me APPROPRIATE

osnosemo W 120 Oondnued From page 2

dairy products. A MOMINtt later, review Of the clients physician's orders dated October 2010, cenfrmed the diet orders as described:

On November 4, 2010, the qualified mental retardation professional (OMRP) was interviewed in the tacky. beginning at 1:20 p.m. She stated that "a few month? before the survey, she and the house manager had given the day program a Oat of food Items that were appropriate for Client 03's reernotedrUet The OMAR then acknowledged, however, that she had not returned to The day program 10 abeam a. kmtat and to ensure that the client received a full meal In accordance wen her mews

tW124 483.420(a)(2) PROTECTION OF CLIENTS RIGHTS

I The facility must ensure the rights of all clients. Therefore the fealty must inform each client,

. Parent (if the client is a minor), or legal gua'Sn, of the esent's medical condition, developmental and behavioral status. attendant risks of treatment and of the right to refuse treabnent

This STANDARD is not met as evidenced by: Based- on observation, staff interview, and record review, the facility failed to esbblish a system that would ensure clients' family members were informed of the risks and benefits of clients' Vestment, for one of the three clients in the sample. (Client *1)

The finding includes:

' The faciley failed tcrensura that informed consent was obtained from Cliental'sfamily member

W W120 I20

The QMRP will met with ea slay ptomains of Cline 02 god Clicra 03 to dun tee feelhack from W120. The QMRP Mil Inc that dtedally mashy xhodeles Ire modified at the day magma to Sect 11311d0C haplementation of the objealam- 11404 0 me day Program of Client 03 win he maidsd veldt a amulet list Maw Mod Items CHM 03 and have end Substlasks-..114040 Additimady, the QMRP will lone that she oltemet lonet meads Minis ratite ovatably visits to the program or her denims will do lima° (the facility noasol). 114. rD

W 124

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Fears morsoontam Presets Worms omega Event Ili: Meth stay icaigteas treenanuedon der Pape 3 of 14

FAX NO '2022448048 FROM :MTS CORP. so-cove rmuM:

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE) MEDICAID SERV&ES

STATEMENT OF DEFICIENCIES OM PROVIDERAWPMERICUA M115 PLAN OF CORREETION IDENTOICATION NUMBER

Nov. 23 2010 11 : 32AM P 5

TO: 2448048 P.4/10

PRINTED; 11/17/2010 FORM APPROVED gla NO. 093a-0301

02) MULTIPL4 CONETAuCTION pmn2ATE MIMI communto A Eta NO ,

H1$12010 NAME OF PROVIDER on suPPuEst

MuL11411ElteefuTIO SERVICES. INC

summary srmatmarr OR DERCENCES . (EACH DEFICIENCY our BE PRECEDED NY FULL

MatEATORy Oft Lac memFvfNO INPORNIATION)

W Till Continued From page 3 prbr tO theadMinistratIon of her psychob'opic medieetkone.

During the entrance conference on November 3, 2010, beginning at GOO am., the qualified mental rotardation professional (OMRP) indicated that Client #1 received peyehotrOple medications to address her realadapove beholders. Further Interview revealed the client did not have the capacity to give informed consent for the use of medications and habilitation services.

Observations luring the medication adminishiation on November 3, 2010, at 5;30 p.m., revealed Client #1 receiving Clonazeparn 2 mg.

Review of Client #1's current physician orders (POS) dated October 26, 2010, on November 3, 2010, beginning at 10:20 am., revealed an order for Clonezeeam 2 mg, twice a Clays

The cet4RP's statement was verified on November 4, 2010, at 9:30 a.m., through review of Client #1's psychological assessment doted December 5, 2000. Accenting to the assessment the client "does not evidence the capacity to make decisions on her own behalf In treatment, habilitation. residential placement, arid financial matters." Further Interview with the OMRP during the survey, revealed that the client had a family member that was. Involved in her habilitation planning and decision making.

Record verification on November 4, 2010, et 10:00 a.m., revealed that Cilectrile family member had given intoned consent on Amain 5,2010. for Cinnamon 1 mg. Soca dor

MO ID PREFIX TM

STREET ADDREss, Car, MATE Ea CODE 927 56TH MEET, NE INAEMINGTOW, OC 2000

W 124

ID PREFIX

TAO

PROVIDERS PLAN OF annum (EACH CORRECINEACTiON MOULD OE cROSaREPOPENCED To THE APPROPRIATE

tariCENCeo

GOAD* DOE

FORM IDASOSIO10240) Provista Version 0b t. Est Itt OK1 K1 1 FacIPD*014006 contintetim sheet RIDA 4 of 14

P,5/10 PRINtED: 11M7/2010

FORM APPROVED

TO:2449048 FAX NO. :2022448048 FROM : MTS CORP.

l_uum loo.oc rmu•:

DEPARTMENT OF HEALTH AND HUMAN SERVICES -.ILL - • : M•CAR= & M ()MAID SERVIC

Nov. 23 2010 11:32AM P 6

NAME OF PROVIDER ON SUPPLIER

muLTITNIERAPEtnt SERVICES, INC STREET •ooRESS. Cr??. STATE. ZIP CODE sr WM STREET, NE wasmiNGrrott, DC 20019

P(4) ID PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES MACH DEFICIENCY MUST SE PRECEDED ST Mt.

REOulATORY OR LSO mENTEVING INFORMATION)

.

PREFIX TAG

PROYMER'S PLAN OF Cameron (EACH COIRECTNE ACTION SHOULO

ICROESREFERENCED TO Y)

vesAIMROPRIATe OEFOONC

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W 124 1 Continued From page 4 Interview with the Registered Nurse confirmed that Client #1's family member had not given informed consent for the use of Clonearepern 2 ,

mg twice daily. W 126 483.420(a)(4) PROTECTION OF CUENTS

RIGHTS

The facility must ensure the rigid; of all clients, Therefore. the facility must allow individual clients to manage their financial afters and teach theM to do so to the rodent of their capabilities.

This STANDARD is not met es evidenced by •Based on Interview and record review, the facility 1 fafied to ensure clients were being taught to manage their finances to Me best of their abilities,

l for one of the three Silts in the sample. (Client pg

The finding IncludES:

On November 4, 2010, beginning at 12:35 p,m., review of ceentorearecard revealed that her Interdisciplinary team had met on Moult 12. 2010 for her annual review. Review of the new program plan revealed sic goals for which flees

i training objectives had been established. There •was no money-related talninesoat or obit:cave . note& At 12:51 p.m., review of the client's money . management slob assessment (dated i September 2, 2010) revealed (Steaming skill

needs:

I • couldnot Ili out deposit andwehdrawel slim

- could not spend money wet some plactnira land, I

FORm CI1S-256710240Premees venters Ouse and Cr Okla')

W 124 wI24

I The RN us& in sear in complains the coast form for Client 03. iotileodog on mg of the rooktkutfon when the thud Eau watvro, TMs RN mated dew slate cestiood Sc error and sutoRitiod anew otogoot etrin karma's Os roper dove rep), Theelotei has provided eons for W 126 propordome.1 t-t?2,24 Sot

. tiro RN Was will revise complied 00AMAS

farms bake Ow me sett kith to than m labetattoo itt occonoc...11.22-10

Fuca/ SS MONO If condnueSon that Pap Bon 10

FROM :MTS CORP. NOV-10-2006 06•53 FROM:

M CND IC AND PUN OP conRECTION STATEMENT op co Ficsaces (Xi) PROMDERovITKEIVOLIA

owiTIFICATION wan

NAME OF PROVIDER OR SUPPLIER

MILTI•THERAPEUTIP SERVICES. INC

TO:2448048

p(2) LIVI.TIFLE CONSTRUCTION A BUILDER)

B. WING

STREET ADDRESS, ary, STATE, ZIP CODE P27 MTN STREET, NE WASHINGTON, DC 20019

FAX NO • 2022448048

Nov. 23 2010 11:32AM P 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES TERS • R M

P.6/10

MOW; 11/17/2010 FORM APPROVED B NO. 4101

cm CATE Summy colors)

11/040M0

614) ID Pewee

TAO REGULATORY ea LSO IDENTIFYING INFORMAIE3

W 126 Continued From page 5 - could not control her own major expenditure&

Interview with the qualified mental rotardatien prefessiOn al (OMRP) on November 4, 2010, beginning at 1:50 p.m., confirmed that although Clientga was able to make small Flintiest* with stiff assistance, ebe Wee not capablaCI managing her own finance& Instead, the factity `leas responsible for managing the clients finances In collaboration with the Department of Disability Services. The QMRP also stated that the client received Supplemental Security income In the amount of $70.00 monthly as well as a small stipend ($1 per day) for attendance at her day program. The CIMRP then acitnowledged that Clientel3 was netrecelving meetly

/Management skills bakingattic Veit W1.40 4139.42oMX1)(i) CLIENT FlNANcES

The facility must establish and maintain a system that assures a full and complete atcourft of clients' personal funds entrusted to the on behalf of clients.

This STANDARD Is not met as evidenced by: I Eased on staff interview and record review, the tadilly tailed to ensure a system had been implemented to maintain a complete amounting of clients' personal funds. for three of the three clients in the sample. (Clients 01, #2 and *3)

The findings Include:

On November 4. 2010, at approximately 1:30 • P•m., interview with the qualified mental I retardation professional (QMRP) and review of , Clents01,.02. and tAlreinoncial records from I November 2009 through October 2010( revealed

ID I PROVOSTS PLAN OF CORRECTION

PREFIX • 1001 0ORRECOVE ACTION CROWD BE TAO I CROSSITNERENCED TO TIE APPROPRIATE

DEnciENCY)

W 178! w126 In theta Oleo on hat Had maw repteeranit oolootwo lowlesentrd as nor. She wet babel to she Ampk purchases Jed although she did not mec9

keepaufaux, she eemhed her mulamm mends level rake rarclasc with meal atattance saift). k an (*Ion Oda LOT Its coast 03 Slew pound to develep Rather In this *111 wit The QMRP will donates roe slaw w he' area end CUM 4/3 wO1 loromodly be

provided I vI-22-10at opportunities to sinks panda of Is chola..

W 140

summery STATEMENT OF DEF1OENCIES (Roes e3/4FIC1ENCY lour se PRECEDED STEVLI.

Nimirrbersomp....r)

roe.) 011-266R024/16Prevleus VS** Obsolete Evan 10:0K1KI Fatal a MOW tf continuation shoat Pips 0 of 14

FAX NO. : 2022448048

Nov. 23 2010 11:32AM P

TO:244804S

FROM :PITS CORP. muv - 10- 006 06:53 FROM:

DEPARTMENT OF HEALTH AND HUMAN SERVICES ER FORM 01 MED k 'Sr ES

STATEMENT OF DEFICIENCIES Oct) PRWDERISUPPLrERtla AND PLAN OP CORRECTION SENTIFICATION NUMBER! P2) MULTIPLE cotanstuanon A.SWAM

B.WHO

NAME OF PROVIDER OR SUPPLIER

PREP ID 'x

TAG

W 140 condnued From page e W 140 that the facility assisted the clients wilt maintaining their Maness. Further record review

' revealed a withdrawal from each of the clients' personal accounts on. Match 11, 2010, in the amount of $25-00.

InterView with the house manager (HM) on i November 4, 2010, at 2;15 p.m., indicated that I the money Wog requested for Bo cuing to the ; eta There were no receipts, however, for such an outing and no evidence that the funds had been redeposited into the clients' personal accounts, Moments is the NM explained that

' the clients never went to the skarn became the funds went notrnade available !nitrates the outing: The NM, therefore, never picked-up the check, The HM reviewed the documentation and acknowledged that the money had not been I redeposited. hack Into the dents! aeleounts. She further acknowledged that the facility had not Previously identified the overnight

11f0W2010

I ROweRs FLOW OF CONREGMON UCH connective AMMO! ENO= BE

CROESSEFERENCED To DM anaRDIPRIATE DEFICIENCY)

WI40

The out dins cm downfun Wan todapadted in each Cheat aims bus at aneennontion rand did not Need MIL Plc deamaanaion sword has beat annsred...11-ZI. to KM Ha hired • %Eons staff for Go Flow DapStawm art is chops with oversooina CEng Parand Mann the air Accouata Maggot and On WE, matsga Nna suet Inalfhts to =view the status of all client mars tnutsations to ban Ora an arc anninnetcd Mid reconduci Ina tinny masuar...11-22-10

etogrgrON OATE

P. 7/10

PRINTED; 11/17/21110 FORM APPROVED

WEIMugaMit gggDATE Noway

CONIIILEWD

MULTI-THERAPEUDC 8CRVaa, INC

0(1—.71f71 aggitORY STncATOMSN7 OF DEFICIENCIES PREFIX (EACH osncev MUST BE PREP gy puts TAO RSOLEATORY OR LSC EIDITIFYINO INFORMATION)

At the time of the survey, the facility failed to establish and maintain an effective accounting

W 26/ I 483.440(0(3) PROGRAM MONITORING & W 281 system for the clients' persons accounts,

CHANGE

I The feather must designate and use a specially , Constituted oarnmittee or committees consisting j of members of facility staff, parents, bagel I guardians, clients (as appropriate), qualified person* who have either experience or training in contemporary practiOes to change inappropriate client behavior, and Persons with no chfalarahtaar controlling interest in the facility.

net Can CDT, STATE, ZIP CODE 02751T14 nom NE WASHINGTON, DC 20010

This STANDARD Is not met as evidenced by: ORM CAL54747(02411) Powwow Vectors ammo Even ID. Oltue Rana co 0 Gorda nation shoot Pap 7 of 14

FROM : MTS CORP. FRX NO '2022448048

DEPARTMENT OF HEALTH AND HUMAN SERVICES c • F M CAR & D SRis IC --

Nov. 23 2010 11: 32RM P 9 TO:2448048 P.8/10

PRINTED: 11/17/2010 FORM APPROVED

■ . NO skes . • : 1

MIME OF FROMM/ OR SUPPUEA

MULWINERAPkyTIC SERVICES, INC

mni to FREFIR TM

ro MFG

TAO

SUMIA4RY STATEMENT OF OCFCIENGES (EACH CENCIENCY MST BC PRECEORD SY FULL

REGULATORY OR LSO ce WWII% INFORMATION)

CITY. STATE. DP CODE ONE DC 20010

P)tONMPS PLAN OF CORRECTION CORRECTIVE ACTION MOULD CI

oeED THEAPPROPRIATE

en

STRETIF de 927 55TH is WASHING

Pen 00011•12TON

DATE

W 281 I Continued From page 7 Based on observation, Interview and review of the Human Rights Committee (HRC) documentation, the facility felled to ensure that persons with no Ownership or controlling interest in the facility reviewed and approved clients' Behavior Support Plans (BSPa) and Invasive medical pronsdurea, for two of the three clients In the sample. (Client/I an and 42)4 The findings include:

1, During the entrance Conference on November 3. 2010. beginning at 8:30 am., the qualified mental retardation professions! (QMRP) revealed That Client #1 received psyehotropie medications for her maladaptive behaviors. Observations during the medication administration on November 3. 2010. at 5%0 p.m.. revealed Client #1 received CNorapraminza NM 100 mg, Cionazepam 2 mg and PSI 20 mg. On November 4, 2010. beginning at 11:20 a.m., review of MAC-related documentation in Client *Vs record revealed agendas and signature sheets for meetings held on January 29, 2010, March 26, 2010, May 26, 2010, July 30, 2010, September 24, 2010 and October 26, 2010. There we no minutes, however, that . documented the FMC's deliberation& Attached to the agenda for the October 26, 2010, meeting was a list of NAG members who voted to "approve" the change in Client #1's medication. Review of the fist, however, mead na signatures of the persons indicated elsewhere as beim; *community representatives - 2. On November 4, 2010, at approximately 103:18 a.m., review of HNC-related documentation In

I Client #2's record revealed agendas and signature sheets for meetings held on January

FORM 043414F(0149) Pnw1044 Tenlons C6401414 Even1

W 261

Fealty 090008

STATEMENT OF DEFICIENCIES ANC MAN OF CORPECRON

11041100010nahest Pate 8 et 14

SateARY STATEMENT OF DEFICIENCIES /nevi DEFICettcY Muer BE EftEcE0ao ov RECIRATORy OR tsc manna wsonwatoin

(X4) 10 Flan% tut

DEPARTMENT OF HEALTH AND HUMAN SERVICES FOR & D D S RVIC

8TA7EMENE OF oancesciee AND PLAN OF CORRECTION PRoVIDER/SUFPLIERCUA

fOENTWICAnou RUMOR fag soutitiha A BUILDING

Nov. 23 2010 11:33AM P 10 TO: E440040 P. 9, 10

PRINTED: finnan° FORM APPROVED

ONIILNAgeadail ou (x3) ten MIES Comolatte

FROM :MTS CORP. r rt1411;

FAX NO ' 2022448048

MGM 144MG OF PROVIDER OR CUPp1.101

MthavnteRAPEUTic sEnvICESowc

W 261 ' continued From page 8 • 29, 2010, March 26. 2010 and several other dates during 2010. Each signature sheet contained one or two signettues by Individuals listed as "community representatives." The agenda for the January 29, 2010, meeting Indicated that Client as REP, medication regimen, and incidents were to be reviewed by the committee. There vras no indication, however, that a vote WM taken and there are no minutes glatdocumented the. committeere deliberations on the issues identified on the agenda

I At approximately 10:15 a.m., a airliner agenda Was attathe4 to a signature meet dated March '26, 2010. The agenda indicated that in addition I to Client *2% MP, medication regimen, and I incidents, the HRC wee to review a recommendation that the client undergo an invasive procedure (Esophagegatdroduodenoseopy, EGO). Attached tO the agenda was a lest of signatures. The, signature sheet indicated that 9 out of 9 HRC members who voted.were irragreement" with the recommended procedure. However, further review of the signatures revealed no signatures of the persons indicated elsewhere as being "communky representative*/

On November 4, 2011). at 1:21 p.m., the OMRP was asked if the community remesentatives had participated in the deliberations. She replied yes but then acknowledged that the documentation available for review failed to show evidence of their participation and/or that they (the community representatives) had voted March 26, 2010 to approve Client fit's EGO. She then

, acknowledged that there we re,sto minutest that [documented the committee's deliberations.

0. WINO

67RECTADDREat CRY, STRIA ZIP coca err sem nem us wAStONCITgN. DC 20019

NIDERa PUN Or conitecrce, OataecTive ACTION SHOULD BE I ceeitrote IEF6/NCED TO tea xepitoFRIATE Waa DEFIciEeme

W 261

11164 4016

ID

TAG TI14 CRO

PQM 0443444/01440) PAIVI011* V•IgOall MOSS esitIO:OK1K11 Flak Ex male If conanuotion sheet Per 9 of 14

P. 10/10

PRINTED: 11/17/2010 FORM APPROVED

• • as• Lt. _I r ^ •

Nov. 23 2010 11:33AM P 11 FROM :MTS CORP. FAX NO. : 2022448048 NOV- 10-2006 06•55 FROM:

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FO MEDICAR & MED ID S

STATEMENT OF DEFICIENCIES AND MAN OP Coutarn314 IDENVICATION NUMBER •

(XI) pRCNIDER/SUPPUER/OUA

TO:2440040

Oddi MULTIPLE CONSTR =ow OMDAMESMEMY n.ELliunrro COMPLETED

9, YANG 090098 LL r Oa NAME OP *WIDER OR SUPPLIER

MULTI-THERAPEUTIC SERVICES, INC STREET ADDRESE CITY, STATE. ZIP COVE

56TH WIRSET. NE WAstuissTON. DC 20019

qA) ID PREFIX

TAG SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED SY FUu. RECULATDRY OR CSC IDENThrem0 MFORMATION)

Wi2S1 Continued From page 9 The Variety's HRC felled to show evidence that Persons with no ownership Or controlling Interest in the facility participated in committee deliberatiOns end voting,

W 283 483.440(f)(3)(19 PROGRAM MONITORING & CHANGE

ID PROVIDERS PLAN of CORRECTION PREFIX (EAC.4 CORRECTIVE ACTION SHOULD BE

The W261 -IstFREPERENCED TO TIE Appnomewra • -. - negcRENC)

Tut issue Rind will be eddressecissonm is W 1 0EIFIRFIRY ICreSeirdetiven %CCM kir the eftscmsion. This i wni occur ty...12.15-10. An needs be developed foreach teeth* and the

will he the Why attic partleipmingQMP, ' fin Steel TRIO be reviewed bs mates that

W „Aft, reviewed IS append' by the Direst of 4.‘" to

COIMITION

The Mesa:fin mix in compiedeg the consent them for Client IN, Skied% ow rug of the etedieelion whet dm stud does waste% The RN Sled the sister, eepidned the aver bed satedtted t new consent fa= indicating the panne sae (2 espy The sister has prodded anima fee the proper inle....11-22-10. Beth the End the QMRP will review completed amen Ernithey a non forthto base ell is emonde., 1.22.10

W 325

This STANDARD is not met as evidenCed by: Based on Interview end record review, the faciRty's specially-constituted damnifies (Human Rights Committee) failed to ensure that restrictive

; Programs were and only with written Consent, fOr ; one of the tMee clients in the sample. (Cliental)

The finding Includes:

I Cross-refer togdiaGe, Client fl's Behavior Support Plan, dated December 6, 2009,

i incorporated the use of peychotropic medication. The client was receiving Olonezepam 2 mg twice daily. •The facIllry's human. rightscommittesfaled to ensure that informod consent hadbeenit

' obtained from 011enttl is substituted health essm decielorsmaker (Le. family member) for the dose

' that wen observed being admintsteeed. =25 ! 482.480(a)(3)01) PHYSICIAN 88RviOES

I ' The facility must provide or obtain annual physics! examinations of each client that at a minimum includes routine screening laboratory examinations as determined necessary by the physician.

ROMA C1.L421187(0240) Previous version% OWNS Event IMOKIKI

The committee should insure that these programs are conducted only wilt, the widen informed consent of the client Parents (if the Went in minor) or legal guardian,

won Dena= If cartInuadon ohne Page 10 or 10

FAX NO. : 2022448048

Nov. 23 2010 11:33AM P 12

P.1/12

PRINTED: 11/172010 FORM APPROVED

• , - .0. o• CM) DATE SURAT

COMPLETED

FROM :MTS CORP. NOV-10-2006 07:02 FROM:

DEPARTMENT OF HEALTH AND HUMAN SERVICES ens F MED & ME ■ CHID a ICE STATEMENT OF tenciaNaEs (XI PROVICER/SUPPUERMUA AND PLAN OF CORRECTION IDENTIFICATION NUMBEIt

0400913 NMIE OF PROVIDER OR SUMER

MULTI-THERAPEUTIC SERVICES, INC

TO: 2441E048

co) MULTWILt CONS

A BUILDING

WIND 11

STREET 50thi

WASH ON, DC

CITY, STATE, ZIP COOS ,NE

(X4) pawn( TAG

ID PREFIX

TAD

SUMMARY STATEMENT OF DEFICENC1111 (EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LOC IDENTIFYING INFORMATION) PLAN OF CORRECTION! ate

CORRECTNE ACTION SHOULD BE CRO REPERENCED TO THE APPROPRIATE ens

DERCJSMCYI

W 325 I Continued From page 10

This STANDARD is net met as evidenced by: ; Based on staff interview and record verification, the facility's nursing staff felted to ensure routine laboratory testing was scheduled as ordered by the primary Care physician (POP), for one of the three clients in the sample, (Client 01)

The finding includes

During the entrance conference on November 3, 2010, beginning at 8:30 a.m., the qualified mental retardation professional indicated thataeattl was recently diagnosed with NephrogeniC Diabetes Inslpidult. Review of Client #1 I; mediae record on November 3, 2010, beginning at 1020 I a.m., revealed physician's order. dated from March 2010 through November 2010, II:Komplett laboratory Studies for liver Itraction.testevwf three months. Further review of the record revealed no evidence of the laboratory indict

Interview with the registered nurse on November 4, 2010, at approximately 11:00 a.m., confirmed that the leboratoly Set had, not been completed as orderer

The facilltys nursing services felled to maintain an effective internal system to ensure that Cirthrthe laboratory studies were performed at the frequencies ordered by the PCP.

3410 483,4600c)(2) DRUG ADMINISTRATION

The system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.

This STANDARD is not met as evidenced by:

W 325 9/325

Client S ha CMP lab obit mootorii b.-weakly. As et the • that me manttoted in liver flutedon act am

I covered the Cm.. Dhoti I tab wart het hewn levels to de extent Mu It has beat vectionettled

tlatthem ethels cut be done aithithly as opthseint to hi. relevant lives females lama will be cheathid weakly.

math ra ecalithetien with the Catos...12.1-10

W See

FORM CLEMS37(0241)) Previous Vain Om** Ethel 113:01(1101 Facts th; OGG= UcontintaUon Wet Pees 11 ed 14

rmurv.

DEPARTMENT OF HEALTH AND HUMAN SERVICES CE m.". MEDI EDI

smear OF DEFCENCIES AND PLAN OF CORRECTION PNOVIDERNMIPPLISRICUA IDENTIFICASION NUMBER

Nov. 23 2010 11:33AM P 13 FROM : MTS CORP.

111042010 NAME OF PROVIDER OR SUPPLIER

MULTI•THERAPEUTIC SERVICES, INC

WA) ID aDtiOAADY DTATEMIDET OF DEFIOBJCIES Rpm , (EACH DEFICIENCY Must s memo ex pou. TAO I REGULATORY OR LSO 10ENTIPYING INPORMATION)

W 360: Continued From page 11

I Based on observation, staff interview, and record verification, the facility's nurse failed to ensure drug actratigetrationwelaschalnislaradeetihout e rnx for one of the three clients in the sample. (Otint 01)

The finding includer

During the entrance conference an November 3, 2010, beginning at 8:30 am., the qualified mental retardation professional (OMRP) ; stated that

Jasentittepsychotropic medications had been I recently adjusted due to significant side affects !geolatswelliag). Observation of the evening i medication administration on November 3, 2010, et 5:30 p.m., revealed the nurse administering Memel Tbarazine 100 rage After administering

I the medication, the nurse also stated that Ctient I *Vs Thorazine had been adjusted recently.

On November 4, 2010, at approximately 11:30 : a.m., review and reconagation of the medication observation and physician orders (PCs) ,dated

: October 26, 2010, revealed en order to i discontinue Thorazine HCL 200 mg, twice a day and begin, Thor-sins HU. 100 mg, Wee a day. The Human Rights Committee held a special review on October 25, 2010 and at that tgne, they approved the decrease to 100 Rig, twice a day. Further review of the records revealed a consent form that was signed by the Wants fame/ member on October 29, 2010.

However. on November 4, 2010, at 1220 p,m,, review of Client /Ws medication administration records (MARS) for October and November 2010, revealed that the client had continued receiving

I Thoretine200 mg, Meta day. through October 131, 2010. the drop to 100 mg was only reflected

oce musks oogarrsuCnos A BURDENS Il

ff

VoANI3

STREET ADDRESS, CITY, STATE, 2IP COOS 927 MTH STHEET, NE WASHINGT314, DC 20010

ID PRovwEIPS PLAN OF CORRECTION ix0) PREFIX CoRRECTIVE ACTION SHOULD cc amPLAMN TAG I GRO MINCED To reterbreoerwere

Denman)

W 369 :

FAX NO. :2022448048 TO:2448048 P.2, 12

PROMO: 111170010 FORM

OMB baSSIT APPROVED

. Oes) DATE auRVEr

COMPtEnEl

row CHS-2587(02-00) Previous Vendons Mole% Eve,, ID: °KIM I Fed* D: It contIngethee sheik Pan 12 of 14

FROM :MTS CORP. FAX NO 2022448048 Nov. 23 2010 11: 33AM P 14 TO:2448048 P.3•12

PRINTED: 11N7A010 FORM APPROVED

CletaJahl sea) DATE ease

GOIPLETE0

DEPARTMENT OF HEALTH AND HUMAN SERVICES RS FOR ME EDI 'SERV ES

siniteen OF DEFICIENCIES MI) PROUIDEINSUFFUEFICIJA AND PLAN OF COMMONON IDENTIRSATION NUMBER: (AN MuLTIPIZ cOresyNUCTION

A. BUILDING

ale64111 NAME OF PROVIBER ON SUPPLIER

eltILWTHERAPEttng soma INC

b. _ QTY. STATE, 731" CODE

NE DC 20019

smear rn 5014 WASHIN

4410112040

rrsuri;

SUMMARY STATEMENT OF OeFictectss (EACH DEFICIENCY MUST as prrectose sr mu ItSOUIATORY OR LSO IDENTIFYING NO

Continued From page 12 beginning on November 1, 2010. When interviewed a few momenta later, the registered nurse explainser that she had fad to vette the new medication order on the MAR on October 29, 2010. The medication nine, therefore, had continued administering the higher dose of Thorazine (200 mg) for an additional two days.

■ The fecal' felled to ensure firmly implementation of Client re physician's orders.

SCI074 483,480(b)(2)(M) MEAL SERVICES

Food must be served in a form consistent with the developmental level of the client.

i This STANDARD is not met as evidenced by. Based on observation, Interview and record review. the (sewer failed to ensure all clients received their meats In the form and consistency that was prescribed, for one of three clients in the sample. (Client SI)

The finding includes:

On November 3, 2010, at 8:10 a.m,;Cfrent*1 was observed eating cheese puff belie. Later that der, at 3:30 p.m., she was observed eating whore cheese crackers. At approximately 3:45 p.m., review of Client itts physician orders, dated November 4070, revealed a diet order of fiber Mhd:una GO en!, noes a day, high fiber, row chotesterol, bite size with ground meter

On November 4, 2010, at 12:20 p.m, Cliental was observed eating a chbkert (lunch meat) sandwksh.that was cut Into bite size pieces.' Later that afternoon, at 2:00 p.m., she wee observed eatingtheese puff cult

PROVIDENS PLAN OF CONewnOta Weal c.cauteeTNE ACTION SNOOP SE

CROSSMIEFERENCED TO THE APPROPRIATE DEFICIENCY)

w 369 W369 Am ladiatatt the medic,' dim was given for two eta Sys sr Re ear veva lerresu. Wawa that it we mewed es. The R

ED( Medva additimml twitting from the DEreaar oiNtealna to kends all moduicadom snoSatiaR mhos= are implemented acantaly sod is fiend" racr...12-140.

The DON will Mad= Mb& sheds of Se MARE sad plaviehas'a aeries CO bur that they arentely Sled the aadicetien reshlien oft,* puma supperbm...12-1—to

O ID PREF%

TAG

MINIA.•••■••• W 369

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FORM 041-2567(0240) Previous Veto; Obsolete Event ID: OKIKI I Feely accoma conoruscon sheet Preis 19 of 14

FROM : NTS CORP. FAX NO. :2022448048

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICA ft MEDICAID SERVIcEs neSTATEMENT OF DEFICIENCIES (XI) PROVDERCUPPLIENCLIA pule OF CORRECTION IDENTIFICATION NUMBER

000098 *AC oF PROVIDER OR SUPPLIER

muLT1-114ERAPELMC SERVICES, INC

PREFIX ON) C TAG

REGULATORY OR LOC WENTIPANG INFORMATION) MACH DEPICIENCY MUST ag "'Rebate° BY PULL

SUMMARY STATIMENT OF DEFICIENCIES

W 474 CordInuad From page 13

On November 4, 2010, at approximately 1:30 p.m., Interview with the house manager hal Indicated that Client #1 wag prescribed a low cholesterol, high fiber, bite size diet (with no mention that her meats should be served ground texture)! At appoximately 2:33 p.m., review of the facilltys in-service training records reveaied that all staff had received training on October 15, 2010 on Client #1's health management care plan (HMCP), which included the current diet orders. rel There vies no evidence, however, that the train'

•had been effective:

a. WING

ID PREF/

TAG

Nov. 23 2010 11:33RM P 15 TO:2448040 P. 4/12

PRINTED: 1 111 72 0 1 0 FORM APPROVED

QMILtkano&V ece DATE SURvery

COMPLETED

PROVIDER'S PLAN OF CORMS-non (EACH cORRECIWE/CTION SINOLILD BE

CROEthREFERENCED TO IRE APPROPRIATE DIFICIENCV)

! col Ct4411111311

• PAM

142) tauLTIPIS cadreuCTION EN.01/10

BMW ADDRESS. CITY, STATE, EIP COOS an SRN SlItEET, NE WASHINGTON, DC 20010

W 474 w474

The RN will II:strait the soon the diet stpnee of Client *I to leave she S pnwthed with the thew texture ...12-10.10.

Tar and Say meager wit Noon st het ate meal per Alit (sepandely) to Sore that Ihe diet is COO settorat to„.;24.10, Mail It III be neveluoted by speech pathology to deteratht If indeed e aroma tame is needed far steam, The RN abillP eaealen dth ghee the ism dee aim el has sod denteestrotes to difRalOY dwoyINI and walla ,. 12.10-10 The tthat 11 fellow the itediegi dud tteeetrendstialsof the petbelogill otter ha awkw,..12-111-10

FoRm 0.02507(0240) Preston Verson ands ate ID:OK1K11 reeeky ID mete 11 tordinuadon sheet Pip 14 Of 14

FROM :MTS CORP. FAX NO. : 202244E1048 Nov. 23 2010 11:34AM P 16 TO:2448048 P.5/12

PRINTED: 1 1/172010 FORM APPROVED Health Reauiation AciminiStrattOn

BTMEM9IT OF DEFICIENCIES AND RAN or °MAMMON po) PRoADERADUPPLIER/CLUL

mENTSCATION NUMBER:

PIPDOS•ORZIE

(7t2) LIULTIRE OONSTRIIC11ON A. BUILDING e.

Op) DATE SURVEY CaPLETED

1010201Q NAME OF PFIONDER OR SUPPLIER

MULTI-THERAPEUTIC SERVICES, INC REET ADDRESS, CITY, STATE, ZIP CODE

027 Snit STREET, NE WASHINGTON, DC 20019

Cx4) SUMMARY ETATERENT OF Derrosnoes Ip rem( ; (EACH DEFICIENCY MUST BE PRECEDED By FULL PREFIX TAO REGULATORY OR LSC IDENTIFYING INFORMATION) TAG .

1 0001 INITIAL COMMENTS Igoe A fieentsire survey was conducted from November 3, 2010 through November 4, 2010. A random sample of three residents was selected from a population of five females with various levels of developmental disabiltieS. The findings of the survey were based on observations at the group home, two day

• programs, interviews with residents and staff, and the review of clinical end administrative records including incident reports.

181 3508.7 ADMINISTRATIVE SUPPORT I Each GHMRP shall maintain reads of residents I funds received and disbursed.

This Statute is not met as evidenced bs Based on staff Interview and rocord review, the Group Horne for Persons with Mental Retardation (CIHMRP) failed to ensure a system had been

' implemented to maintain a complete accounting of residents' personal funds, for three of the three residents in the sample.. (Residents *LS2 are say The findings include:

I On November 4, 2010, at approximately 1:30 I p,m., interview with the qualified mental

retardation professional (CARP) and review of ResIdents.$1.. 02, andlgitafirtanclatrecorderom Novemter 2009 through October 2010, revealed that the facility assisted the reside nts with maintaining their finances. Further record review revealed a withdrawal from ARCh of the residents' 1

! personal accounts on.Mangh 114010; b the amount of 525.00.

Ion AomlNexpEon

I tee

PROVIDERS PLAN OF CORRECTION Po) icActi CORRECTIVE ACTION Mourn BE CausETE CROSSREFERENCED TO The APPROPRIATE DOE owicila/cy)

MI DATE LABORATORY DIRECTORS OR PROVIDEROUPPLIER REPRESENTATNEE SIGNATURE STATE FORM ea OK1K11 oninuallon Meet I o

.1! I mei PRORCER/SURPLIERICLIA I CO) IHULTWLE CONSTRUCTION lostrrricemom MASER: A. ItuiLDING S. WING

NAME OF PROMDER ON SUPFUCR I STREET ADDRESS. CITY, STATE. Vta CODE

Health Regulation AdmbileatIon STATEMENT OF DEFICIENCIES MD FLAN OR CORRECTION

NV[10142211 lgai DATE SURVEY COMPLETED

FROM : MTS CORP. FAX NO. :2022448048 LeJ QUVO Witp

MOLT IA SERVICES, INc

I 188 Continued From page 1 • Interview with the house manager (HM) on November 4, 2010. at 2:15 p.m., Indicated that

; the rooneawas.reguested.tocanseuting4o4he i &out There were no receipts, however, for

such an outing and no evidence that the funds had been redeposited into the residents' personal account& Moments later, the 141 explained that the residents never went to the circus because

i the funds were not made available In time for the I outing, The MK therefore, never peeked-up the check The HM reviewed the documentation and acknowledged that the money had not been • redeposited beck Into the residents' accounts.

i She further acknowiedged that the GHMRP had not previoway identified the oversight. At the time of the survey, the facility failed to establish and maintain an effective accounting system for the residents' personal accounts.

I 2061 3509.6 PERSONNEL POLICIES Each employee, prior to employment and annually thereafter, shall provide a physician ' CedificatIon that a health inventory has been performed and that the employee' a health status would allow hIm or her to perform the required duties.

This Statute Fs not met as evidenced by: Based on Interview and record review, the Group Horne for Persons with Mental Retardation (GHMRP) felled to ensure each consultant had a current health cerIgkete, for six of the twaive oonsuitants. (three LPN's, PCP, Nutritionist, and RN)

i las 3509.7 Chaps 3S

I RATE

reds Aill-time few the Finance Dermenwat with month% chartPerseralAccent mertser lend Sc Suality wwWwwr will

to meow We Wiens WWI client flow

rammed n timely mama... 11-22 1 0 tronetwienr Wan We all ere deeweesied r n

The wee hs $23 dollen; hos teat pesdepatiticd in each elites acealut but Si decumermen sawed did not Sir this. The deeuteemtline reeled he beat matched. -11-22.- 0 Mrs ties that b The client men

1206

927 95114 STREET. NE WASHINGTON, DC 20019 I

sUMMART RTABRAENT OF CIERCIENCCS 0 FliOVIDERG PLAN OF CORRecrion

X IDENTIFYING INFORMATION) TAG il CltoStpREFERENCED TO THE APPROPRIATE

(EACH DtriCIENCY MUST GE PRECEDED RY FULL Peer% ma CORRECTNE ACTION $1401.1Lo RE REGULATORY OR I OINFICIENCY)

Nov. 23 2010 11:34AM P 17 T0:2448048 P.6/12

PRINTED: 11/172010 FORM APPROVED

-lea Regulation STATE FORM

Vt-^t nlehatiOn V eenteurier Neat 2 eft wa 01(1K11

FROM : MTS CORP. =weJo ; ; uo r Kum

tarDo3-ena

oh moons coieTAU tiCTioI

A SWUM B. WINO

Health Regulation AdrrIlithdratiOr! STATEMENT OF DEFICIENCIES AND PLAN OF OORRECRON

NAME OF PROVIDER OR SUPPLIER

MULTI-THERAPEUT1C SERVICES, INc

FAX NO. : 2022448048

STREET ADDRESS ant STATE EIP CODE 927 55TH STREET, NE WASHINGTON, DC 20fr10

Nov. 23 2010 11:34AM P 18

TO: 2448040 P.7/12 PRINTED:11/1712M

FORM APPROVED

ECIN DATESURVer COMPLETED

111041201D

movitmwsupo uratiguA ioesteicATIontM/41113t

ID PREFEC

TAO

PC•M I PEERS TAG I

sUMmARY STATEWENT OF DEFICIENCER (EACH DEFloreacY Muni SE PRECEDED SY MI

REGULATORY OR Lac IDEttrIFYIND orForevenon PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE ososseeFeasitcze To THE APPROPRIATE DEFICIENCY)

Pth C°1440ArE

208 Continued From pear 2 The finding includes:

Interview with the house manager (HM) and review of the personnel records on November 4,

I 2010, beginning at 11:45 a.m., revealed the GHMRP faded to provide evidence that current health certificates were on file, for slit of the twelve consultants (three LPN" #2,03, and 1 15, PCP, Nutritionist, and RN).

I 229't 3510,5(t) STAFF TRAINING 1229 Each training program shall include, but not be limited to, the following:

I EDS 3509.E -

Mrs has fired a new Director Silt who he been duns, with tradta powomel ale reiphements for Mastiff IS Canthilau., The tadistamis cited lavabast ere, ondi:E10 provide upbeat beakb ortitkatee by 12-13-10. MI'S will nottvely tuck web requirements in the thrum sod Nulty bath steed amsokeete of upeamithq INNS Infanninith wai bowillectet wit Moat to Cc pees= 'het bv thsDirector othR...12-15- 10

; residents to be served Including, but not limited (t) Specialty areas related to the GHMRP and the

i to, behavior management sexuaRy. nutrition, I recreation, total communications and mist technologies:

1 Thle Statute is not met as evidenced by: Based on observation, Interview and record review, the Croup Home for Persons With Mental Retardation (GHMRP) failed to ensure all residents received their meals in the tam and I liCaeistency thatwas presonbad, for one of three

r residents in the sample. (Ftesident#1)

I I The finding Indulge;

On November 3, 2010, at 8:10 a.m., Residenttl was observed eating chatter puff ball• Later that day, at 3:30 p.m., she was observed eating whole cheese crackers, At apprtadmobsiy 3:45 p.m., •

I review of Resident Wi's physician orders. dated • November 201o, revealed a diet order of fiber mixture eo mi, twice a day, high fiber, low cholesterol, bite size with ground meats.

oath STATE Paw tat 0IE1E1 1 If =era' Ow 3 09

main the stiffen the alarmist. oftLiar the is provitke with the proper lease

Tho QMt end fenny sasoppyr will °Servoeuemt One anal weekly pet MR (separately) to Imre Rat the die S consillemly adhered to„ .12-1-10. Client II win be weveltered by womb penology to termite ir indeed a ground trews is needed Eir nests. The RN all QIIRP oucstios think*, the bathe Own II ha tees and dessooendes no difficulty chewing and awallOwits... 124040 11w teem MU follow the findings end recommaxledoes of the *ad pahologIst otter her toriew...12-16.10

The RN El to k consist

Nov. 23 2010 11:34AM P 19

TO:244804B P.9/12 PRINTED: 11/17/2010

FORM APPROVED

FROM :MTS CORP. FAX NO. :2022448048 or:uo hNum:

th ation mime n STATEMENT OP Dora mars emo PLAN OP CORRECTION

NAME OF PROVIDER OR SUPPLIER

(XI) PROVES/SUPPLIER/WA ICENITFICATION NUMBER:

10062.02311

012) MULTIPLE CON DON A BUILDING B. WINO

otsomesuever cotaterso

41/014016

MULTI-THERAPEUTIC SERVICES, INC STREET ADDRESS, env. STATE. CODE 921 85111 STREET, NE wAStimaorr, DC x0e19

puo SUMMARY STATEMENT OF EFICIENCIES PREFIX MACH DEFICIENCY Muer EE PRDECEDED BY FULL TAG REGULATORY OR LSC iterrreviee ireolawriosi

12291 Continued From page 3

On November 4, 2010, at 1220 pill, Resident I 01 was observed eating a chicken Qunch meat)

sandwich that was cut into bite size pieces. Later that afternoon. at 2:00 p.m.. she was observed eating cheese puff curls.

On November 4, 2010, at approximately 1;30 p.m., interview with the house manager had

• Indicated that Resident *1 was presented a low I cholesterol, high fiber. bite sae diet (with no

mention that her meats should be served ground texture). At approximately 233 p.m., review of the facility's in-service training rearms revealed

' that all staff had rer.elved training on October 16, 1 2010 on Resident *Ts health management cars I Plan (HMCP), which Included tits current diet orders. There was no evidence, however, that the Veining had been effective.

1405 3520.7 PROFESSION BERMES: GENERAL i-PROVISIONS

I Professional services shall be provided by programs operated by the GHMRP or personnel employed by the GHMRP or by arrangements between the GHMRP and other service providers, including both public and private agencies and individual practitioners.

This Statute is not met as evidenCed by: Based on observation, Interviews, and record review. the Group Home for Persons with Mental Retardation (GHMRP) felled to ensure Mat residents day programs Implemented training programs and/or provided a complete meal In accordanas with nutritional needs, for two of IS three residents hi the temple. (Residents tassel

. 7 fay_

The findings Include: -loam RegulagonAdoOMMSIon STATE FORM

ID PREFN

TAG I ccarline

OATE

1229

1405

0E1E1 t usiliatbri dint serf

PROVIDERS PLAN OF CORRECTOR (EACH CORRECTIVE ACTON SHOULD SE

CROIOVEMERENCSD TO nisiWpROPRLATE DERCENCY)

ss i o.sm

Nov. 23 2010 11:34AM P 20

P.9/12

FROM : MTS CORP. Of:Elb FHOMt

FAX NO 2022448048 TO:2449048

PRINTED: ifinizotO FORM APPROVED alal Regulation Adminler

sae 0101(11 STATE FORM W awilmadon sheet 4 OS

STATEMENT DERCIENC AND PLAN

F OF ooretticixerIES gra) secssuawsussupwcus

IDENTIFICATION NUMBER

NFO03-023a

om MULTIPLE A.WILDING B.YANG

I UCno coNSTRw f

03) CATE waver cOMMA110

411W/2010 HAM OF PROVIDER OR SUPPLIER

kILILTI-TREFtAPEUTIC SERVICES, ERVICES, INC VI nth r ADORES • CITY, STATE, ZIP coos ra erMi STREET, NE WAIN4INGTON, DC 20010 1

(X4) 10 ! SUMMARY STATEMENT OF DEFICIIMES m mute ' (ascii noutcrarcv Lear BE PRECEDED IV FULL TAO REGULATORY OR LSO ICENTaleid INFORMATION)

1

ID NNTM

TAG MACH

CROS•ITIFERENCED

PAVADIIRS PLAN OF CORRECTION COSIREC'NE ACTION SCUM BE

TOME APPROPRIATE osFiCAENGY)

PAM cattLitti

I Oar

I 406

'

1 .

Health RINILISNAP

Continued From page

; 1. On November 3, I observed at her day

until 1:00 p.m. At the observed manipulating Items) as part of her 1220 p.m., the resident, direct support staff left walked to the cafeteria. wash her hands before lunch. staff was observed moult with a napkin any verbal cues or opportunity mouth-wiping.

At 12:45 p.m., review programs revealed wash her hands before objective to learn how napkin. Observations however, revealed that rawisieheY Implement

2 On November 3, 2010, observed at her day until approximately 1:10 her lunch at 1:05 p.m. prompt from staff, she The residents lunch meatballs (without tomato POtatoes, a sitoe of soft (chopped); there was

At approximately 1:15 direct support staff revealed offered the resident a orders said to avoid acidity). [Note: Observation question revealed no mbdure of chopped fruits.]

AdrnInleiratinn

4

2010, Resident *2 was program from 11 25 a.m.

was

At

and not

the ita

dent in the

to

with a

NO not

p.m. eating

a verbal setting.

the not

diet

in in the

with

i 405

-

outgo!, the resident plastic objects (food

insbuctional program, her peers and their

the treatment room The resident did

embiglurnat During wiping Resident

without offering the to participate

of Resident IAN training that she had an objective

lunch and another to wipe her mouth on November 3, 2010, day program staff her training objectives.

Resident a3 was program from 1205

p.m. She finished and after recekiing cleared her pia*/

had congaed of chopped sauce) teethed

whole wheat bread no deetiertofiered.

p.m., interview with that she had

fruit cup because her citrusfit (due to the

of the fruit cups clays products ware

Further interview

35202

The Cifall will mat with die programs of cabman aid ll4I 03 tr, that the evedbsok from wt2e4The Qbellf will insure Rut the daifr salving eshoduks ere modified n the day mean to Sleet routine

Odle cbjectses...1i413-113 The day of Client 03 win be provided !Oh GROW ea of the 'boo owns Clog n mono have end

... I 14040 ?Jai& the 041112 will went an she News lunch mesh hemming monthly visits to the program a !In will do Mewing' (ther nteneStn% 124-

10

FAX NO. :2022448048 Nov. 23 2010 11:35AM P 21

TO; 2448048 P.10/12

PRINTIED: inmoio FORM APPROVED

FROM :MTS CORP. muv- 10-2006 07'06 FROM:

STATEMENT OF DEFICIENCIES AND man OF CORRECTON

NAME OF PROVIDER OR SUPPLIER

MULTIMISSAPPEUTIC sown. INC

(X211AUL11Plai 03NSTRUCTION 4113) DATE Paver

1i 104n010

oorIPIETED

STREET ADDRESS, GYM srAre.TP CORE 927 gm STREET. NE WASHINGTON, DC 20519

A. SURDING B.WING

Health Reoulation Administration

(XI) PROVIDEMBIOPUERXXIA IDENTIFICATION NUMBER:

FIFDOS-0231

(44) n ! PREFIX •

TAG MOM TAG

SUMMARY STATEMENT Of OEFICIENCIES LEACH DEFICIENCY MUST SE PRIM:DEO RV

REGULATORY OR CSC mamma tNFORWATION)

SOARERS MAN OF CORRECTION 1 OW) I (EACH CORRECTIVE ACTION MOULD BE f mars

atossaireemiceo TO THE APPROPMATE DATE cencierce

405i Confined From Oar 5 the direct support staff also *unlined that she had not offend the resident a substitute food item for dessert

At approximately 1:30 p.m...intender/with the day program case manager revealed that ResidentSI

i was expected to receive a M lunch. Including a I dessert se long as the foods were not acidic end did not contain lactose milk sugar, In accordance with her diet orders: chopped, regular. noracia, no

j dairy products. A moment later, review of the i maiden's physic:km's orders dated October 2010, I confirmed the diet orders as described.

On November 4, 2010, the qualified mental retardation professional (QMRP) was Interviewed in the facility, beginning at 1:20 p.m. She stated that "a few months" before the survey, she and the house manager had given the day program a Ilst of food keens that were appropriate for

, Resident £3's restricted diet. TrsQf4Rp then acknyaledged, however, that she had not returned to the day program to °brain* lundi and to ensure that the resident received a full meal In accordance with her orders.

1405

1 443 14434. 3521.7(m) HABIUTATION AND TRNNINQ

The habilitation and training of residents by the GHMRP shell include, when appropriate, but not be limited to the following areas;

(m) Financial management (Including budgeting end banking);

This Statute Is not net as evidenced by: Based on Interview and record review, the Group Home for Persons with Mental Retardation (GHMRP) failed to ensure residents were being taught to manage their finances to the best of

Neat Rogulaticin Admhlierafem STATE FORM opeinuedoe Via 6 ere WM PROM

FRX NO. : 202244804E1 Nov. 23 2010 11:35AM P 22 TO ; 2446018 P.11/12

PRINTED:11/1712010 FORM APPROVED

FROM :MTS CORP. INUV- Itfreueb LI (: 07 FROM:

STATUE/1T OF DEFXSENCIES AND PAN OF CORRECTION namseenisueeunircue

'DEMARCATION Kuwait (TM MULTIPLE CONIMRUCTION A BUILOPIO

DO) DAtn SURVEY COMPLETED

Health Reputation Administration

litnessaste NAME OF PROVIDER OR SUP mat sitILTI-THERAPE0110 SERVICES, INC

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STREETADORESS. am STATE ZIP. CODE 121 MITIf STREET, NE WASHINGTON, DC 20010

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Ar)z SUMMARY 674TuulDITI7JEOP OEFICIENC:11 Tap REGuLATORY OR WC iterrianuo irearainoie

ORM/MERE PLAN OF CORRECTION OIN (FACIA CORRECTNE ACTION BROM° BE COMET.

CROBLLREFERENCED TO THE APPROPRIATE , DATE einCiENCY)

1 443 Continued From page 6 their abilities, for one of the three residents In the sample. (Resident 43)

The finding includes:

On November 4, 2010, beginning at 12:35 p.m., revIeW Reeldeilt record revealed that her interdisciplinary team had met on August 12, 2010 for hat annual review. Review of the new ascent plan revealed six goals for which specific training objectives had been established. There was no money-telatectIralMag goat or ablect/Manated. At 12:51 p.m„ review of Me residents money management skills assessment (dated September 2, 2010) revealed the following skill needs;

couklmot flitert depositandsithormel sap*:

- couldinot spend money with some p...hning; and,

• could not control her own major expenditures.

Interview with the qualified mental relardatbn professional (QMRP) on November 4, 2010, beginning at 1:50 p.m., confinned that although Resident *3 was able to make email purchases with staff assistance, she was not capable of managing her own finances. Instead, the facility was responsible for managing the residents finances in collaboration with the Department of Disability Services. The QMRP also Stated that the resident Supplemental Security Income in the amount of $70.00 monthly as well as a small stipend (S1 per day) for attendance at her day program. The QMRP then acknowledged that Resident It3 was not receiving money management stillstrainlitterthe dine.

1 443

7L 3521. •

in the Clan 13 has led money remesheent ahleadva implemented Sr her. She WIN mead ID make simple iambs= slid although she did not ranch helepahesee, Sc =Mad ha meriman pounce tree (an mac madam with velal assistance tram stet). it Is the *Moo of the Wm es client *3 hat !napoleons' to &nide emir a this dal atm. The QMRP will demotion this eMisig is In ants end Clint d3 will isfamelly bo providedWith opearttadtias to make punts= fiber theist

...I late

Meth Regulation Aerrunlaration STATE FORM as 01(11(11 If callbsolkin sleet 7 NO

FROM . MTS CORP. 111-0i- lu -CWUD 101;0( hKUM:

Health Regulation AdministfatIon

FAX NO. :2022448048 Nov. 23 2010 11: 35AM P 23

TO: 2448048 P.12/12

PRINTED! 11/1772010 FORM APPROVED

Enwremerato DEFICIENCTIS AND FLAN OF CORRECTION (X1) PROMDERAUPPLIERCLIA

IDENTIPICATION NUMBER;

IIFD03-02a6

DO) MULTIPLE A- BUILDING &WWI

CONSTRUCTION 1

DER GIATE SURVEY COMPLETED

I 1/040.010 1

RAVE OP PROVIDER OR SUPPLIER

heiLTI-THERJOWTIC SERVICES, INC STREET ADORERS. CITY STATE. EFT cote

UM MEET, tie 1 wA err

SNINGTON DC 20019 . Vol ID SummARY STATEMENT OF DEFICIENOES PREFIX (EACH DEFICIENCY MUST SE PRECEDED BY FULL

TAG ; REGULATORY OR LIC OENTIFYING INFORMA110N) ID

PREFIX TAO

(EACH ca0534tRFERENCED

§PROVIDERS Ma OF CORRECTION CORRECTIVE ACTION SHOULD BE .

TO THE AFINROPRIATE DEFICIENCY)

OM COMPLETE

DATE

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.

Continued From page 7

3523.1 RESIDENTS RIGHTS

Each GHMRP residence dlreaor shall ensure that the rights of residents are observed and protected in accordance with D.C. Law 2.137, this chapter, and otter applicable District and federal News.

This Statute is not met as evidenced by Based on observation, staff Interview, and record review, the Group Horns for Persons with Mental Retardation (GHMRP) failed to establish a system that would ensure residents' family members Were informed of their risks and benefit:a of residents' hammer* for one of the three residents in ihe sample. (Resident 914

The finding includes;

The facility falafel to ensure that informed consent was obtained from Resident 91's lam* member odor to the administration of her psychottopic medications.

During the entrance conference on NOvember 3, 2010, beginning at 810 am., the qualified mental retardation professional (QMRP) Indicated that Resident #1 received psychotropic medications to address her maladeptive behaviors. Further interview revealed the resident did not have the capacity to gNe informed consent for the use of medications and habilitation services,

0o/serrations during the medication administration on November 3, 2010, at 5:30 p.m., revealed Resident #1 receiving Clonazeparn 2 rng,

Review of Resident #1's current physician orders

1600

1500

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