w 0000 - indiana · 2019. 9. 23. · waiting list and they couldn't make agencies take her. they...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

09/23/2019PRINTED:

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

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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TAG

IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

BRISTOL, IN 46507

15G024 08/28/2019

ADEC INC

807 MOTTVILLE RD (ST ROAD 15 N)

00

W 0000

Bldg. 00

This visit was for a pre-determined full

recertification and state licensure survey. This

visit included the investigation of complaint

#IN00302866. This visit resulted in an Immediate

Jeopardy.

Complaint #IN00302866: Substantiated, Federal

and state deficiencies related to the allegations are

cited at: W102, W104, W122, W149, W153, W154,

W157, and W186.

Survey dates: 8/19, 8/20, 8/21, 8/22, 8/23, 8/26, and

8/28/19.

Facility Number: 000590

Provider Number: 15G024

AIMS Number: 100248560

These deficiencies also reflect state findings in

accordance with 460 IAC 9.

Quality Review of this report completed by #15068

on 9/6/19.

W 0000

483.410

GOVERNING BODY AND MANAGEMENT

The facility must ensure that specific

governing body and management

requirements are met.

W 0102

Bldg. 00

Based on observation, record review and

interview, the facility failed to meet the Condition

of Participation: Governing Body for 3 of 3

sampled clients (A, B and C) plus 4 additional

clients (D, E, F, and G). The governing body

neglected to implement their Abuse, Neglect, and

Exploitation Policy to prevent client C from

W 0102 All facility staff were trained on the abuse, neglect, exploitation policy

on 9/6/19 this included timely

reporting of peer to peer as well as

investigative questions to pursue

when an incident occurs. On

8/29/19, all protective services

staff were trained on timely

09/11/2019 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: R01611 Facility ID: 000590

TITLE

If continuation sheet Page 1 of 61

(X6) DATE




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physically harming and emotionally abusing

clients A, B, D, E, F, and G. The governing body

neglected to immediately report to an

administrator and to BDDS (Bureau of

Developmental Disabilities Services) within 24

hours regarding incidents of client to client

aggression. The governing body neglected to

complete thorough investigations for incidents of

client to client aggression. The governing body

neglected to implement corrective measures to

prevent client C from physically harming and

emotionally abusing clients A, B, D, E, F, and G.

The Governing Body failed to exercise general

policy, budget and operating direction over the

facility to ensure the facility met the Condition of

Participation: Client Protections for 3 of 3 sampled

clients (A, B, and C) plus 4 additional clients (D, E,

F, and G).

Findings include:

1. The governing body neglected to implement

their Abuse, Neglect, and Exploitation Policy to



The governing body neglected to immediately

report to an administrator and to BDDS (Bureau of









Please see W104.

2. The governing body failed to meet the

Condition of Participation: Client Protections for 3

reporting of all incidents including

peer to peer to the BDDS reporting

system within 24 hrs.

The facility made good faith effort

to protect all individuals including

the aggressor during and after all

incidents. Over the course of the

past seven months, the BDDS

staff was notified on a weekly

basis or more by the individuals

guardian and agency VP stating

the client was in dire need of

alternate residential placement.

The facility was repeatedly

informed by BDDS that there is a

waiting list and they couldn't make

agencies take her. They noted

that there was a home but they

were not taking admissions due to

lack of staff. ADEC staff called

every hospital in the State of

Indiana looking for help and

nobody would serve her due to her

low IQ. We had inpatient

placement twice locally and they

would not see her again stating

there is nothing they could do for

her. We had weekly contact with

her psychiatrist who did all she

could during this situation. The

facility did what wes in the best

interest of all individuals in

attempting to separate the

aggressor during prime times

when she was excited. this

included having the individual eat

meals before others so that she

would not have such stipulation.

This intervention worked and there

were no further meal time

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R01611 Facility ID: 000590 If continuation sheet Page 2 of 61




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of 3 sampled clients (A, B, and C) plus 4 additional

clients (D, E, F, and G). The governing body

neglected to implement their Abuse, Neglect, and

Exploitation Policy to prevent client C from


clients A, B, D, E, F, and G. The governing body






complete thorough investigations for incidents





Please see W122.

This federal tag relates to complaint #IN00302866.

9-3-1(a)

occurrences. The facility

continues to wait for an alternative

residential placement for the

individual and she is kept

secluded from others rather than

in her home with her peers. At this

time her peers are missing her

and asking why she cannot be

with them. The agency will

continue to reach out to the

provider who said they would

provide her services top determine

a move date. BDDS is not aware

of when this move will take

place. The facility will keep current

protocols in place until then.

In the future, when there are

similar occurrences, we will

continue to reach out to BDDS for

assistance assuming that it will

happen sooner than this

occurrence. We will hope that

individuals we place in our home

do not have new psychiatric

issues that change the services

they need. If they do we will reach

out to BDDS and make all

attempts possible to keep

everyone safe. We will continue

to look for alternate placement on

our own calling every hospital and

provider of services to aggressive

individuals.

Failure to report timely , the

incidents of abuse, neglect and

exploitation will result in

disciplinary action. Failure to

complete a full investigation will

result in disciplinary action.

Person responsible: VP residential





09/23/2019PRINTED:

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OMB NO. 0938-039




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, BDDS

483.410(a)(1)

GOVERNING BODY

The governing body must exercise general

policy, budget, and operating direction over

the facility.

W 0104

Bldg. 00

Based on observation, record review, and

interview for 3 of 3 sampled clients (A, B, and C)

plus 4 additional clients (D, E, F, and G), the

governing body failed to implement their Abuse,

Neglect, and Exploitation Policy to prevent client

C from physically harming and emotionally

abusing clients A, B, D, E, F, and G. The

governing body failed to immediately report to an




aggression. The governing body failed to



failed to implement corrective measures to prevent

client C from physically harming and emotionally

abusing clients A, B, D, E, F, and G. The

governing body failed to remove and replace a

broken recliner in the group home.

Findings include:

1. Observations were completed in the group

home on 8/19/19 from 3:58 PM through 6:05 PM,

8/20/19 from 5:34 AM through 8:50 AM, 8/21/19

from 2:55 PM through 3:55 PM, 8/22/19 from 3:15

PM through 4:25 PM, 8/23/19 12:21 PM through

1:24 PM, and 8/26/19 from 11:45 AM through 12:05

PM. During each observation period a dark red

recliner sat in the living room and was broken.

Staff #1 was interviewed on 8/23/19 at 12:54 PM

and stated it had been broken for "at least 6

W 0104 The recliner with the broken cord was replaced on 8/27/19. The cord

was fixed several times and proof

of one of the occurrences was

provided. We maintain our homes

and equipment. It was in the

process of being replaced when

this survey took place. We will

continue to maintain our facilities.

All facility staff were trained on the

abuse, neglect, exploitation policy























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15G024 08/28/2019

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months if not longer and it does not leave enough

seats for clients and staff to sit in the living room

altogether if they wanted to."

Work orders were requested for the broken

recliner on 8/26/19 at 1:14 PM and on 8/28/19 at

1:15 PM. The facility was unable to provide work

orders for the recliner during the survey.

The Qualified Intellectual Disability Professional

(QIDP) and Vice President of Residential

Operations (VPRO) were interviewed on 8/26/19 at

1:14 PM. The VPRO and QIDP stated their

maintenance staff had been out to try and fix it

"multiple times" and a new one had been ordered.

2. The governing body neglected to implement

their Abuse, Neglect, and Exploitation Policy to



The governing body neglected to immediately

report to an administrator and to BDDS within 24



complete thorough investigations regarding

incidents of client to client aggression ensuring

clients and staff were interviewed. The facility




Please refer to W149.

3. The governing body failed to immediately

report to an administrator and to BDDS within 24


aggression for clients B, C, D, F, and G. Please

refer to W153.

4. The governing body failed to ensure a

thorough investigation was completed for













































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incidents of client to client aggression for clients

A, B, C, D, E, F, and G, ensuring clients and staff

were interviewed. Please refer to W154.

5. The governing body failed to ensure corrective

measures were put in place to protect clients A, B,

D, E, F, and G from client C's physical and

emotional abuse. Please refer to W157.


9-3-1(a)

















individuals.








, BDDS

483.420

CLIENT PROTECTIONS

The facility must ensure that specific client

protections requirements are met.

W 0122

Bldg. 00

Based on observation, record review and

interview, the facility failed to meet the Condition

of Participation: Client Protections for 3 of 3

sampled clients (A, B, and C) plus 4 additional

clients (D, E, F, and G). The facility neglected to

implement their Abuse, Neglect, and Exploitation

Policy to prevent client C from physically harming

and emotionally abusing clients A, B, D, E, F, and









09/11/2019 12:00:00AM





09/23/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




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B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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(X5)

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BRISTOL, IN 46507

15G024 08/28/2019

ADEC INC


00

G. The facility failed to immediately report to an

administrator and to BDDS within 24 hours

regarding incidents of client to client aggression.

The facility failed to ensure a thorough

investigation was completed for incidents of client

to client aggression ensuring clients and staff

were interviewed. The facility neglected to

implement corrective measures to prevent client C

from physically harming and emotionally abusing

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

This noncompliance resulted in an Immediate

Jeopardy. The Immediate Jeopardy was identified

on 8/21/19 at 9:32 AM. The Vice President of

Residential Operations was notified of the

Immediate Jeopardy on 8/21/19 at 10:30 AM. The

Immediate Jeopardy began on 8/19/19. The facility

neglected to prevent client C from physically

harming and emotionally abusing clients A, B, D,

E, F, and G. The facility neglected to implement

corrective measures to prevent client C from



The facility submitted a Plan for Removal of

Immediate Jeopardy on 8/21/19 at 11:01 AM. The

facility's Plan for Removal of Immediate Jeopardy

indicated the following:

" ...we will staff [client C] at the home 1:1 (one on

one) during awake hours. She does not wake at

night and has to be woke (sic) in the am. She has

had no ON (overnight) incidents since she has

lived with ADEC. In the event she woke (sic) up,

they can call on call to come in. We usually have

two overnight staff, so if she did wake, we would

have 1:1 for her naturally ...".

Based on observation, interview and record

review, it was determined the facility's Plan for













































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Removal of Immediate Jeopardy had removed the

Immediate Jeopardy. The Immediate Jeopardy was

removed on 8/26/19 at 1:15 PM. While the

Immediate Jeopardy was removed on 8/26/19, the

facility remained out of compliance at the

Condition level in that the facility needed to

demonstrably implement its policy and procedures

to prevent client to client physical and emotional

abuse regarding clients (A, B, C, D, E, F, and G).

Observations were completed in the group home

on 8/21/19 from 2:55 PM through 3:55 PM. At 2:55

PM, client C was observed in the home with 2

peers (clients B and D) present and the House

Manager (HM). Client B indicated she, client C,

and client D had been home all day besides going

to get their hair done at the beauty shop. At 3:31

PM, clients A, E, F, and G arrived home with 2

staff. Client C helped the House Manager put

supplies away.

Observations were completed at the group home


PM clients A, B, D, E, F, and G arrived home on

the group home van with staff #4 and #7. Staff #4

indicated client C was at the day service building

until bedtime. Staff #4 indicated the plan was for

client C to be at the day service building or out in

the community during awake hours and she would

come home at bedtime. Staff #4 indicated when

the other clients were at day service client C

would be at home with staff.


on 8/23/19 from 12:21 PM through 1:24 PM and

8/26/19 from 11:45 AM through 12:05 PM. During

both observation periods client C was with the

HM and no other clients were home. The HM was

interviewed on 8/26/19 at 11:55 AM and stated

client C "seemed to be doing better with 1:1 (one
































individuals.








, BDDS





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on one) staff and the other clients in the home are

coming out of their rooms to hang out more."

Findings include:

1. The facility neglected to implement their Abuse,



abusing clients A, B, D, E, F, and G. The facility



regarding incidents of client to client aggression.

The facility neglected to complete thorough

investigations regarding incidents of client to

client aggression ensuring clients and staff were

interviewed. The facility neglected to implement

corrective measures to prevent client C from


clients A, B, D, E, F, and G. Please refer to W149.

2. The facility failed to immediately report to an


regarding incidents of client to client aggression

for clients B, C, D, F, and G. Please refer to W153.

3. The facility failed to ensure a thorough


to client aggression for clients A, B, C, D, E, F,

and G, ensuring clients and staff were interviewed.


4. The facility failed to ensure corrective measures

were put in place to protect clients A, B, D, E, F,

and G from client C's physical and emotional

abuse. Please refer to W157.


9-3-2(a)





09/23/2019PRINTED:

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OMB NO. 0938-039




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483.420(a)(11)

PROTECTION OF CLIENTS RIGHTS

The facility must ensure the rights of all

clients. Therefore, the facility must ensure

that clients have the opportunity to participate

in social, religious, and community group

activities.

W 0136

Bldg. 00

Based on record review and interview for 3 of 3

sampled clients (A, B, and C) plus 2 additional

clients (F and G), the facility failed to ensure

clients had the opportunity to participate in

community activities outside of the facility.

Findings include:

Client A's record was reviewed on 8/23/19 at 3:09

PM. Client A's 8/23/19 Individual Program

Summary Report (IPSR) indicated for 6/2019 client

A participated in 2 activities for the month, for

7/2019 client A participated in 1 activity, for 8/2019

client A participated in 0 activities. Client A's

8/23/19 IPSR indicated "Why did the individual

not participate?- no opportunity.", and was

marked 30 times for 6/2019, 25 times for 7/2019,

and 24 times for 8/2019. Client A's 8/23/19 IPSR

indicated activities included out to eat/drink 1 time

in 6/2019, and visit with family and friends 1 time

in 7/2019.

Client B's record was reviewed on 8/23/19 at 3:55

PM. Client B's 8/23/19 IPSR indicated for 6/2019

client B participated in 2 activities for the month,

for 7/2019 client B participated in 2 activities, for

8/2019 client B participated in 1 activity. Client B's



marked 27 times for 6/2019, 23 times for 7/2019,

and 23 times for 8/2019. Client B's 8/23/19 IPSR

indicated activities included out to eat/drink 1 time

in 6/2019, and visit with family and friends 2 times

W 0136 The facility has an activity calendar and individuals are

encouraged to participate. The

ladies in the home enjoy movies

and going out to eat. Those with

family involvement go out weekly.

The manager and QIDP will put in

to place an opportunity for each

individual to go out 1:1 in addition

to group activities. they will

document if they went or chose

not to. The QIDP will be

responsible for nothing if the

activities took place or not on the

monthly reviews.

Person Responsible QIDP

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in 7/2019.

Client C's record was reviewed on 8/19/19 at 3:00

PM. Client C's 8/23/19 IPSR indicated for 6/2019

client C participated in 2 activities for the month,

for 7/2019 client C participated in 0 activities, for

8/2019 client C participated in 1 activity. Client C's



marked 26 times for 6/2019, 5 times for 7/2019, and

23 times for 8/2019. Client C's IPSR indicated client

C refused activities 1 time in 7/2019. Client C's

8/23/19 IPSR indicated activities included out to

eat/drink 1 time in 6/2019, and out to eat/drink 1

time in 8/2019.

Client F was interviewed on 8/22/19 at 3:45 PM

and indicated she would like to go out more and

she is not able to go out as much because client C

will refuse or they only have 2 staff working

Client G was interviewed on 8/22/19 at 3:45 PM.

Client G indicated she does not get to go out on

the weekends and indicated client C made it hard

to go out.

Client B was interviewed on 8/22/19 at 3:45 PM.

Client B indicated she does not get to go out on

the weekends because client C doesn't want to go

and they do not have enough staff.

Confidential Interview (CI) #3 stated the clients

"do not get to go on outings because there is not

enough staff on the weekends. Clients A, B, D, E,

F, and G] need assistance with their wheelchairs

and walkers. [Client C] is the only one in the home

that does not use a walker or wheelchair, but she

refuses to go most of the time and will just sit on

the couch."





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The Qualified Intellectual Disability Professional

(QIDP) and Vice President of Residential

Operations (VPRO) were interviewed on 8/26/19 at

1:14 PM. The VPRO indicated she expected the

clients to get out in the community once a month.

The VPRO indicated sometimes the clients will

refuse to go out when it is time for an outing.

9-3-2(a)

483.420(d)(1)

STAFF TREATMENT OF CLIENTS

The facility must develop and implement

written policies and procedures that prohibit

mistreatment, neglect or abuse of the client.

W 0149

Bldg. 00

Based on observation, record review, and

interview for 3 of 3 sampled clients (A, B, and C)

plus 4 additional clients (D, E, F, and G), the

facility neglected to implement their Abuse,



abusing clients A, B, D, E, F, and G. The facility





aggression. The facility neglected to complete

thorough investigations regarding incidents client

to client aggression ensuring clients and staff

were interviewed. The facility neglected to

implement corrective measures to prevent client C

from physically harming and emotionally abusing


Findings include:

The facility's BDDS reports and investigations

were reviewed on 8/19/19 at 2:48 PM and indicated

the following:

























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1. A 6/20/19 BDDS report indicated on 6/19/19

"client (C) was at home and walked up to another

client (G) and grabber (sic) her wrist. There were

no injuries present from this incident ...staff

immediately intervened to ensure safety and

separated the individuals. There were no injuries

present and the guardian was notified."

An undated Person Served Aggression Report

Investigation Findings (PSARIF) indicated

"Investigation into peer to peer on 6/19/19 at

6:00pm. Safety measures in place. No injury to

individuals. No further concerns."


"...at 3:30pm, client (C) was at her home. ADEC

staff reported this client was in the kitchen when

another client (D) walked by, this client then

shoved them ...staff immediately intervened to

ensure safety and separated the individuals.

There were no injuries present and the guardian

was notified of this incident."

A 6/28/19 PSARIF indicated "Investigation into

peer to peer on 6/27/19 (at) 3:30pm. Safety

measures in place. No further concerns.

Individuals separated. No injuries noted. Guardian

notified."

3. A 6/27/19 BDDS report indicated "...at 6:30pm,

client (C) was at her home. ADEC staff reported

this client hit another client (unknown) on their

shoulder as they were walking by ...Staff

immediately intervened to ensure safety and

separated the individuals. There were no injuries

present and the guardian was notified of this

incident."















































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Individuals separated. No injuries noted. Guardian

notified. Caretracker (online record) behavior data

reviewed and sent to team for concerns of

increased behaviors towards clients and staff."

4. A 7/1/19 BDDS report indicated on 6/29/19 "...at

9:00am, client (F) was at her home. ADEC staff

reported another client (C) hit her on the upper

right arm ...Staff immediately intervened to ensure

safety and separated the individuals. There were

no injuries present and the guardian was notified

of this incident."




Individuals separated. No injuries sustained.

Guardian notified.

5. A 7/1/19 BDDS report indicated on 6/29/19 "...at

12:45pm, client (C) was at her home. ADEC staff

reported this client approached another client (D)

in what seemed a friendly manner, when this client

approached the client, this client shoved them

...Staff immediately intervened to ensure safety

and separated the individuals. There were no

injuries present and the guardian was notified of

the incident."

A 7/1/19 BDDS report for client D indicated client

D "is a 90 year old female ...".





Guardian notified."

















individuals.








, BDDS





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FORM APPROVED

OMB NO. 0938-039




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BRISTOL, IN 46507

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"...Client (C) had tried to take a housemate's

(unknown) breakfast twice and had thrown a can

opener. Agency nurse contacted [mental health]

hospital for admission for continued physical

aggression from client. Client was picked up at

3:00 PM by [mental health] hospital transportation

and was transferred to [mental health] Hospital

...".

A 7/12/19 Incident Follow-up Report (IFR)

indicated "client continues in [mental health]

hospital. Client for the past week had continued to

have aggressive behavior while at the [mental

health] hospital. Client (C) had been pulling hair,

grabbing people, raising her shirt and exposing

her breasts and sleeping well. Client had been

given several medications through IM

(Intramuscular) throughout the week including

Thorazine (anti-psychotic), Haldol

(anti-psychotic), Geodon (anti-psychotic), Ativan

(for anxiety), and Benadryl (antihistamine) ....".

A 7/19/19 IFR indicated "client remains inpatient

at [mental health] Hospital. Client is scheduled to

be discharged back to home on 7/22/19."

A 7/26/19 IFR indicated "Client (C) was

discharged to home on 7/22/19. Client was given

new orders of Invega (antipsychotic) ER

(extended release) 6 mg (milligrams) once daily,

Melatonin (for sleep) 3 mg at bedtime daily,

Trazodone (for sleep) 50 mg at bedtime daily,

Clonidine (for attention deficit hyperactivity

disorder) .1 mg once daily, and Clonazepam (for

behaviors) 1 mg three times daily. Staff and family

have been trained on these new orders. The IDT

(Interdisciplinary Team) meets regularly to

discuss concerns with client ...".






09/23/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




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"...at 8am, client (C) was getting on the group

home van to be transported to day program.

ADEC staff reported this client grabbed another

client's (E) collar after they tried to praise her

...ADEC staff immediately intervened to ensure

safety. Staff reported this client would not let go

of the client's collar until staff physically removed

the clothing from client's hand. Staff used

MANDT technique to release a clothing hold.

Client suffered no injury from this incident.

Guardian was notified."


"...at 8:45pm, client (A) was at her home. ADEC

staff reported the client was sitting on the couch

near another client (C) when they took hold of her

arm and squeezed when she tried to get away. The

other client then laughed at her ...ADEC staff

immediately intervened to ensure safety. Clients

were separated. No injury was sustained from this

incident. Guardian was notified."





Guardian notified."

A 7/23/19 Person(s) Served Aggression

Assessment (PSAA) indicated "[Client A] was

upset and expressed fear of [client C]."


"...at 3pm, client (C) was at day program. ADEC

staff reported this client was sitting with a staff

person when another client approached to talk to

staff, this client hit the other client (unknown) on

the arm ...ADEC staff immediately intervened to

ensure safety. Clients were separated. No injury

was sustained from this incident. Guardian was





09/23/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




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notified."





Guardian notified."

10. A 7/26/19 BDDS report indicated " ...at 11am,

client (C) was at day program. ADEC staff

reported this client (C) was upset with another

client (unknown) and couldn't reach her to grab

her so she threw a water bottle at her...ADEC staff

intervened to ensure safety. Clients were

separated. No injury sustained from this incident.



peer to peer on 7/26/19 (at) 11:00am. Safety



Guardian notified."

11. A 7/26/19 BDDS report indicated " ...at

11:45am, client (C) was at day program. ADEC

staff reported this client threw her pop, her green

beans, and her Jell-O at other clients (unknown). It

was discovered after she ate lunch that she

needed to use the restroom, then client was calm

... ADEC staff intervened to ensure safety. Clients

were separated. No injury sustained from this






Guardian notified."

12. A 7/26/19 BDDS report indicated " ...at





09/23/2019PRINTED:

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OMB NO. 0938-039




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12:45pm, client (C) was at day program. ADEC

staff reported this client walked by another client

(unknown) and hit them on the arm ... ADEC staff








Guardian notified."



staff reported this client was yelling at another

client (G) every time she talked then scratched the

client on her hand. Client then got up from the

table as staff were intervening and this client hit

another client (F) as she waked (sic) by. Staff

intervened and went to assist another client, when

this client hit another client (G)...ADEC staff








Guardian notified."


"...client (C) was at her home. ADEC staff reported

this client was sitting at the kitchen table, reached

over and hit another client (B) twice then laughed.

The client then proceeded to scream whenever

another client tried to talk (G) ...ADEC staff







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Guardian notified."

15. An 8/2/19 BDDS report indicated on 8/1/19

"...at 1:40pm, client (A) was at her home. ADEC

staff reported they found another client (C) in this

client's room with her holding onto her wrist. This

client was asking the other client to let go. Staff

had to intervene and verbally ask client to let go,

and client did ...ADEC staff intervened to ensure

safety. Clients were separated. No injury

sustained from this incident. Guardian was

notified."

An 8/2/19 PSARIF indicated "Investigation into




Guardian notified."

An 8/1/19 PSAA indicated client A "was visible

(sic) upset because [client C] would not let her go.

[Client C] just laughed."

16. An 8/2/19 BDDS report indicated on 8/1/19 "

...at 4:10 pm, client was at her home. ADEC staff

reported this client (C) hit another client (F) on

their arm when staff turned their back ... ADEC

staff intervened to ensure safety. Clients were










09/23/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




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Guardian notified."


...at 6:10pm, client (C) was at her home. ADEC

staff reported this client approached another

client (unknown) and hit them on their shoulder ...

ADEC staff intervened to ensure safety. Clients







Guardian notified."


"...at 5:00pm, client was at her home. ADEC staff

reported this client (C) hit another client (G) in the

head. ADEC staff did not witness this incident ...



incident. Guardian was notified. This incident was

reported late due to lack of information from

reporting staff. ADEC will continue to report all

allegations of ANE (Abuse, Neglect, and

Exploitation) within the required 24 hours."





Guardian notified. This incident was reported late

due to lack of information from reporting staff.

ADEC will continue to report all allegations of

ANE within the required 24 hours."







09/23/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




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staff reported this client threw her iPad and

headphones at another client (B) ... ADEC staff





"...at 7:45pm, client (F) was at her home. ADEC

staff reported this client was sitting at the table

finishing her snack when another client (C)

walking by, hit her ... ADEC staff intervened to

ensure safety. Clients were separated. No injury

sustained from this incident. Guardian was

notified."

An 8/12/19 PSARIF report indicated

"Investigation into peer to peer on 8/9/19 (at)

7:45pm. Safety measures in place. No further

concerns. Individuals separated. No injuries

sustained. Guardian notified."



staff reported this client was standing at the

dinner table and attempted to hit a client (G) with

one arm while staff redirected, this client used the

other arm to hit a client (G) on their shoulder ...




An 8/12/19 PSARIF report indicated

"Investigation into peer to peer on 8/11/19 (at)

12:00pm. Safety measures in place. No further

concerns. Individuals separated. No injuries

sustained. Guardian notified."



staff reported this client was yelling every time





09/23/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039




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another client talked, staff attempted to redirect

the client. The client then picked up her glass of

milk and threw it at another client (G) ...ADEC staff


separated. No injury was sustained from this






Guardian notified."

An 8/11/19 PSAA indicated " ...[client G] was very

upset and angry while [client C] was yelling."


"...at 5:00pm, client (B) was at her home. ADEC

staff reported this client was hit and pinched by

another client (C) on her arm ...ADEC staff


separated. No injury was sustained from this

incident."




Individuals separated. No injuries sustained."

Further review of BDDS reports indicated client C

had hit or punched her peers 8 times between the

period of 3/20/19 and 5/30/19.



PM, client C was sitting in the living room

watching her iPad. At 4:10 PM, staff #2 went to

the office to start passing medications. Staff #2

indicated every client in the home used a walker or

was in a wheelchair except for client C. Staff #2





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closed both doors to the office during the

medication pass. From 4:10 PM through the end of

medication pass at 4:50 PM, client C could be

heard yelling through the kitchen and then

laughing. Staff in the home could be heard asking

client C to not be so loud and to not laugh at

peers. At 4:58 PM, client C sat at the kitchen table

and made short high pitched sounds and smacked

the table with her open hand multiple times. Client

F jumped when client C made this loud noise and

client C laughed. At 5:24 PM staff #6 started

having a conversation with client G. When client

G would talk, client C would start yelling, so staff

#6 could not hear client G. Staff #6 told client C to

use her inside voice and to leave client G alone.

At 5:40 PM, client B came to the table and asked

staff #6 if staff would help her if client C "tries to

scare me."


on 8/20/19 from 5:34 AM through 8:50 AM. At

8:20 AM, clients A, B, C, D, E, F, and G went to

the van and staff helped load them onto the van.

At 8:35 AM, staff #6 came in and told the

Residential Manager client C had grabbed client

E's arm on the bus and they had moved client E

further away from client C.

Client B was interviewed on 8/19/19 at 4:34 PM.

Client B stated she was scared of client C and "It's

not fair to me or other clients to be hit."

Client G was interviewed on 8/19/19 at 4:50 PM.

Client G stated she was "scared" of client C and "I

don't like being hit and it hurts me."

Confidential Interview (CI) #1 stated "[Client C]

knows most of her peers are scared of her and she

thinks it is funny because she laughs after she

does stuff."





09/23/2019PRINTED:

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OMB NO. 0938-039




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CI #2 indicated when client C targets client F, she

hits her from behind or on her paralyzed side

because she knows client F cannot hit her back

because she is in a wheelchair and paralyzed on

her left side. CI #2 indicated all of the clients are

jumpy around client C because she is

unpredictable. CI #2 stated client C had "pushed

[client D] and [client D] was able to catch herself

on the counter, otherwise it could have ended her

life because of her age and how fragile she is." CI

#2 stated she thought client C was "tired of the

people she lives with since she is 26 years old and

the next closest aged person is 51 years old in the

home."

Client A was interviewed on 8/19/19 at 4:58 PM.

Client A stated she is scared of client C

"sometimes."

CI #4 indicated when client C was in the

psychiatric hospital clients in the home spent less

time in their rooms and more time out in the living

room doing activities. CI #4 stated 8/19/19 was a

good day for client C and "the other clients in the

home only get jumpy when [client C] is having a

bad day and is more unpredictable." CI #4 stated

client C's mood can turn bad "pretty fast." CI #4

stated "not a whole lot of activities have

happened due to [client C] refusing to go and not

having enough staff to take the other ladies out."

Client E was interviewed on 8/20/19 at 6:47 AM.

Client E indicated she doesn't like living in the

group home some days because client C yells and

hits. Client E stated client C had hit her and "it

hurts" and she doesn't like being hit, "especially

when it's for no reason." Client E stated "I'm

scared of what [client C] is going to do next."





09/23/2019PRINTED:

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OMB NO. 0938-039




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Client D was interviewed on 8/20/19 at 8:10 AM.

Client D stated client C had pushed her down but

she caught herself and client C "will grab my leg

and it hurts."

Client C's record was reviewed on 8/19/19 at 3:00

PM. Client C's 2/25/19 Behavior Support Plan

(BSP) indicated she had a behavior of aggressive

and threatening behavior defined as: "Hitting,

slapping, spitting, kicking, pushing, or performing

any other physical behavior (e.g., throwing items)

that may or does hurt another person. Taking out

anger or frustrations on objects in her

environment by pushing, shoving, kicking,

pounding upon, or hitting. Any time [client C]

acts out and is aggressive towards other clients."

Client C's 2/25/19 BSP indicated in the last year

(3/2018-2/2019) client C had 167 incidents of

aggressive and threatening behavior. Review of

the client's record indicated this was the current

plan being implemented.

The Day Program Manager was interviewed on

8/20/19 at 11:05 AM. The DPM indicated she has

seen the clients, who live in the home with client

C, scared of client C when she is in an agitated

state. The DPM indicated there was no pattern for

when client C would hit peers. The DPM indicated

she thought some of the behavior was client C

trying to communicate, but not all of it. The DPM

stated she thought "the clients in the home get

scared of [client C] when she is upset." The DPM

indicated it could be considered emotional

distress.

The Vice President of Residential Operations was

interviewed on 8/20/19 at 12:25 PM. The VPRO

stated she agreed "the clients in the home are

scared of [client C]" and they are most likely

under emotional distress from the "mean" things





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client C does to them.

The Agency's 5/14/19 Incident Reporting and

Management Policy (IRMP) was reviewed on

8/19/19 at 3:30 PM and indicated "It is the policy

of ADEC to ensure the health and safety of all

individuals served...not tolerate abuse, neglect, or

exploitation of individuals by staff members,

individuals or persons in the community...". The

5/14/19 IRMP indicated reportable incidents are

"1. Alleged, suspected or actual abuse...which

includes but is not limited to:...c. emotional/verbal

abuse, including but not limited to communicating

with words or actions in a person's presence with

intent to:...iii. cause the individual to experience

emotional distress or humiliation...".

The facility failed to immediately report to an




aggression for clients B, C, D, F and G. Please

refer to W153.

The facility failed to ensure a thorough


to client aggression for clients A, B, C, D, E, F,

and G, ensuring clients and staff were interviewed.


The facility failed to ensure corrective measures

were put in place to protect clients A, B, D, E, F,

and G from client C's physical and emotional

abuse. Please refer to W157.


9-3-2(a)





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483.420(d)(2)

STAFF TREATMENT OF CLIENTS

The facility must ensure that all allegations of

mistreatment, neglect or abuse, as well as

injuries of unknown source, are reported

immediately to the administrator or to other

officials in accordance with State law through

established procedures.

W 0153

Bldg. 00

Based on record review and interview for 2 of 3

sampled clients (B and C) plus 3 additional clients

(D, F, and G), the facility failed to immediately

report to an ad

w 0000 - indiana · 2019. 9. 23. · waiting list and they couldn't make agencies take her. they...

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