w 0000 · 2020. 7. 17. · 4412 s b st 00 observation was conducted at the group home. at 6:15 am,...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

07/17/2020PRINTED:

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

RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

W 0000

Bldg. 00

This visit was for a pre-determined full

recertification and state licensure survey. This

visit included the Covid-19 focused infection

control survey.

Dates of Survey: June 16, 17, 22 and 23, 2020.

Facility Number: 000971

Provider Number: 15G457

AIM Number: 100244800

These deficiencies also reflect state findings in

accordance with 460 IAC 9.

Quality Review of this report completed by #15068

on 7/1/20.

W 0000

483.430(e)(2)

STAFF TRAINING PROGRAM

For employees who work with clients, training

must focus on skills and competencies

directed toward clients' health needs.

W 0192

Bldg. 00

Based on observation, record review and

interview for 1 of 3 sampled clients (#3), the

facility failed to ensure staff demonstrated

competence in reporting client #3's high blood

pressure to the agency nurse as indicated in the

hypertension (high blood pressure) risk plan.

Findings include:

On 6/16/20 from 4:00 PM to 6:15 PM an

observation was conducted at the group home. At

4:05 PM, staff #4 took client #3's blood pressure.

Client #3's blood pressure reading was 171/104.

The nurse was not notified.

On 6/17/20 from 5:55 AM to 7:55 AM an

W 0192 Name and Address of Provider: McSherr, Inc., 4412 S

B St, Richmond

Date Survey Complete:

06/23/2020

Provider Identification Number:

15G457

Survey Event ID: O9MO11

Finding: W 192 The facility

failed to ensure staff

demonstrated competence in

reporting high blood pressure

to the agency nurse as

indicated in the hypertension

risk plan.

07/23/2020 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: O9MO11 Facility ID: 000971

TITLE

If continuation sheet Page 1 of 22

(X6) DATE




07/17/2020PRINTED:

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OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

observation was conducted at the group home.

At 6:15 AM, staff #1 took client #3's blood

pressure. Client #3's blood pressure reading was

168/95. The nurse was not notified. At 7:10 AM,

staff #1 took client #3's blood pressure again and

the reading was 148/86.

On 6/22/20 at 2:00 PM, client #3's record was

reviewed. Client #3's 6/8/20 hypertension risk

plan indicated: "Supports and Interventions: All

staff will be trained on risk plan prior to working in

the home, as needed, and a minimum of annually.

Signs of Hypertension: blood pressure of greater

than 150/90. Symptoms of Hypertension:

headache, blurry vision, dizziness or syncope

(fainting), dyspnea (shortness of breath) or chest

pain, excessive fatigue (tiredness) and weakness.

Staff will monitor twice daily blood pressure

readings. Staff will also monitor [client #3] for

signs of hypertension as stated above. Nurse or

home management will notify physician or nurse

practitioner for appointment or for orders if

hypertension is not well controlled. Nurse will

coordinate with PCP (primary care physician) for

routine medical appointments and labs as ordered.

Nurse will coordinate with dietary manager to

ensure that [client #3] is on the appropriate diet

for diagnosis of hypertension. Monitoring and

(sic) Notification and Documentation: Staff will

notify manager if signs of hypertension are

observed or if [client #3] complains of symptoms.

If no response from home manager after 30

minutes then call nurse. Staff will document blood

pressure twice daily on log. -IF TOP NUMBER IS

> (greater than) 200, HAVE HIM REST AND

REPEAT B/P (blood pressure) IN ONE HOUR. If it

is still elevated: notify nurse if blood pressure is

greater than 150/90 or if systolic (top number) is

150 or over and if diastolic (bottom number) is 90

or over. Staff will notify nurse if systolic BP is

What corrective action(s) will

be accomplished for these

residents found to have been

affected by the deficient

practice?

·Staff will be retrained to call the

agency nurse when blood

pressure top number is above 150

or below 90.

·House Management team will

monitor through in-house

observations, reporting process

and meetings

·QIDP, SSC, HSC and CEO will

monitor through reporting process,

meetings, and in-house

observations

·Team will monitor through

monthly IDT

How will McSherr identify other

residents having the potential

to be affected by the same

deficient practice and what

corrective action will be taken?

All South B clients have the

potential to be affected.




or below 90.




and meetings




observations


FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O9MO11 Facility ID: 000971 If continuation sheet Page 2 of 22




07/17/2020PRINTED:

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OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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TAG




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TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

less than 110 prior to administering his Metoprolol

(for high blood pressure) and hold med

(medication) if Systolic is less than 110. Home

mgmt (management) team will review daily notes

and report any documented signs of

hypertension. Staff will contact 911 if [client #3]

has chest pain or shortness of breath...."

Client #3's blood pressure form dated June 2020

was reviewed and indicated the following blood

pressure readings were not reported to the nurse

by staff:

6/1/20: 6:00 AM: 191/88 177/74

6/2/20: 6:00 AM: 188/82 174/71

6/3/20: 6:00 AM: 182/96

6/4/20: 6:00 AM: 174/96 164/92 4:00 PM: 160/82

6/8/20: 6:00 AM: 181/92 172/71

6/9/20: 6:00 AM: 182/87 164/70 4:00 PM: 152/91

6/10/20: 6:00 AM: 191/76 180/69

6/11/20: 6:00 AM: 175/100 129/76 4:00 PM:

177/98 160/82

6/12/20: 4:00 PM: 162/102

6/13/20: 6:00 AM: 167/98 4:00 PM: 151/86

6/14/20: 6:00 AM: 155/99

6/15/20: 6:00 AM: 157/95

6/16/20: 6:00 AM: 158/92 4:00 PM: 171/104

6/17/20: 6:00 AM: 148/86 (initial reading not

documented)

On the bottom of the form the following statement

was highlighted in yellow marker: "Call nurse if

blood pressure is: Top number is above 150 or

below 90. Bottom number is above 90 or below

60".

On 6/16/20 at 4:05 PM, staff #4 was interviewed

and stated client #3's blood pressure "normally

runs high and he takes a pill for it". Staff #4

indicated all they do is document the reading on

the form.

monthly IDT

What measures will be put into

place or what systemic

changes you will make to

ensure that the deficient

practice does not recur?




or below 90.




and meetings




observations


monthly IDT

How will the corrective

action(s) be monitored to


practice will not recur (quality

assurance program, etc.) and

how will it be put into place?




or below 90.




and meetings




observations






07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

On 6/17/20 at 7:15 AM, staff #1 was interviewed.

Staff #1 indicated the nurse should be notified if

the top number is over 190 and they document the

reading on the form when it's less than 190. Staff

#1 was asked to review the highlighted section of

the blood pressure form. Staff #1 stated, "She

changed it and didn't tell staff". Staff #1 indicated

the nurse should be notified when the blood

pressure is above 150. Staff #1 indicated he

hadn't been contacting the nurse because he

wasn't aware of the change.

On 6/17/20 at 9:00 AM, the RM (Residential

Manager) was interviewed. The RM stated, "I

know it's changed so I have to look at it. I

thought it was over 190 (top number)". The RM

indicated staff should be trained on when to call

the nurse about client #3's blood pressure.

On 6/22/20 at 4:00 PM, the CEO (Chief Executive

Officer), QIDP (Qualified Intellectual Disabilities

Professional), RN (Registered Nurse) and the SSC

(Social Services Coordinator) were interviewed.

The RN indicated she should be notified if client

#3's blood pressure was over 150 or below 90 (top

number). The RN indicated staff need to be

retrained on client #3's risk plan. The RN

indicated the protocol hasn't been changed in

over one year and all staff working in the home

have been trained on the protocol.

9-3-3(a)

monthly IDT

What is the date by which the

systemic changes will be

implemented?

·7/23/2020

483.440(d)(1)

PROGRAM IMPLEMENTATION

As soon as the interdisciplinary team has

formulated a client's individual program plan,

each client must receive a continuous active

treatment program consisting of needed

interventions and services in sufficient

W 0249

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07/17/2020PRINTED:

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OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

number and frequency to support the

achievement of the objectives identified in the

individual program plan.


interview for 3 of 3 sampled clients (#1, #2 and #3)

and 5 additional clients (#4, #5, #6, #7 and #8), the

facility failed to implement the clients' ISP

(Individual Support Plan) training objectives and

educate clients #1 and #3 regarding their

medications when formal and/or informal training

opportunities existed.

Findings include:

1. On 6/16/20 from 4:00 PM to 6:15 PM, an


At 4:45 PM, staff #4 walked to the basement to get

a box of frozen fish and a bag of broccoli to fix for

dinner. Staff #4 turned the oven on to preheat

and opened the boxes of macaroni and cheese.

Client #2 came in from the back yard and staff #4

prompted him to wash his hands to help with

dinner. Client #2 washed his hands then went to

do something else. At 5:00 PM, client #1 was

sorting coins at the kitchen table, client #5 was

working on a puzzle, client #3 was taking a

shower, client #4 was talking to the RM

(Residential Manager), client #6 was reading the

newspaper and clients #7 and #8 were sitting

outside in the swing. Staff did not prompt the

clients to assist with dinner preparation. At 5:20

PM, staff #4 poured the macaroni noodles into a

pan and stirred the noodles. Staff #4 stated to

client #6, "[Client #6], I'd let you help, but I don't

want you to get burnt". Staff #4 poured the

broccoli into the boiling water then got cans of

peaches out of the cabinets. At 5:25 PM, staff #4

stirred the broccoli and noodles then checked the

fish in the oven. At 5:50 PM, staff #3 poured the

macaroni and cheese and peaches into serving


B St, Richmond


06/23/2020


15G457



failed to implement clients’ ISP

training objectives and educate

clients regarding their

medications when formal

and/or informal training

opportunities existed.





practice?

·All staff will be retrained on

client ISPs and training objectives.

·HSC/Nurse will review client

medication administration goals

and update as needed.




observations


monthly IDT






07/23/2020 12:00:00AM





07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

bowls. At 5:55 PM, staff #3 and #4 carried the

food to the table and staff #4 gave everyone a

slice of cheese for their fish sandwich. The clients

served themselves their food. Staff did not

prompt or encourage clients #1, #2, #3, #4, #5, #6,

#7 and #8 to assist with meal preparation.


reviewed. Client #1's 4/2/20 ISP indicated client #1

had an objective to increase his ability to

participate in meeting his ADL (activities of daily

living) skills.



had an objective to increase his ADL skills.



had an objective to increase his participation in

daily/weekly household tasks.

On 6/22/20 at 2:45 PM, a focused review of client

#4's record was conducted. Client #4's 4/2/20 ISP

indicated client #4 had an objective to increase his

ADL skills.



indicated client #5 had an objective to increase

her participation in ADL skills.




participation in meeting his ADL needs.














observations


monthly IDT














observations


monthly IDT
















07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

domestic skills at the group home.




ADL skills.

On 6/16/20 at 5:10 PM, staff #4 was interviewed.

Staff #4 stated, "The clients like to cook." Staff #4

indicated the clients should be prompted and

encouraged to help prepare the meals.

On 6/16/20 at 5:20 PM, client #6 was interviewed

and he indicated he liked to cook.

On 6/17/20 at 9:00 AM, the RM was interviewed.

The RM indicated the clients should be prompted

and encouraged to assist with preparing the

meals. The RM indicated all of the clients were

capable of helping.





The CEO indicated the clients should be in the

kitchen with staff helping prepare the meals. The

CEO indicated all of the clients were capable of

doing something to assist with preparing the

meals. The QIDP indicated the staff needed to be

retrained.

2. On 6/16/20 at 5:45 PM, an observation of client

#1's medication administration was conducted.

Staff #4 administered client #1's medication and

did not explain to client #1 what she was going to

do, how to take the medication, the name of the

medication, the reason for the medication use and

the side effects.




observations


monthly IDT



implemented?

·7/23/2020





07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

On 6/17/20 at 6:15 AM and 7:10 AM, observations

of client #3's medication administration was

conducted. Staff #1 administered client #3's

medication and did not explain to client #3 what

he was going to do, how to take the medication,

the name of the medication, the reason for the

medication use and the side effects.

On 6/17/20 at 6:40 AM, an observation of client

#1's medication administration was conducted.

Staff #1 administered client #1's medication and

did not explain to client #1 what he was going to

do, how to take the medication, the name of the

medication, the reason for the medication use and

the side effects.



had an objective to increase his ability to

participate in meeting his ADL skills.




daily/weekly household tasks (medications-

identify AM medication packet).

On 6/22/20 at 4:00 PM, the CEO, QIDP, RN and the

SSC were interviewed. The RN indicated the staff

were all trained on Core A and Core B and the

clients should be educated about their

medications each time medication is administered.

9-3-4(a)

483.440(f)(3)(iii)

PROGRAM MONITORING & CHANGE

The committee should review, monitor and

make suggestions to the facility about its

practices and programs as they relate to drug

W 0264

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07/17/2020PRINTED:

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OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

usage, physical restraints, time-out rooms,

application of painful or noxious stimuli,

control of inappropriate behavior, protection of

client rights and funds, and any other areas

that the committee believes need to be

addressed.

Based on observation, record review, and


and 4 additional clients (#4, #5, #6 and #8), the

facility failed to ensure the HRC (Human Rights

Committee) approved the restrictive practice of

locking laundry supplies and hygiene items in the

hall closet.

Findings include:

On 6/16/20 from 4:00 PM to 6:15 PM and on

6/17/20 from 5:55 AM to 7:55 AM observations

were conducted at the group home. On 6/16/20 at

4:00 PM, client #4 asked staff #4 to unlock the hall

closet so he could start his laundry. At 4:10 PM,

client #4 asked staff #4 to unlock the closet again.

At 4:15 PM, staff #4 unlocked the closet so client

#4 could start his laundry. Throughout the

observations the hall closet door with the hygiene

products and laundry detergent remained locked.

This affected clients #1, #2, #3, #4, #5, #6 and #8.


reviewed. There was no documentation in the

record indicating HRC approval had been

obtained for locking the hygiene products and

laundry detergent in the hall closet.







B St, Richmond


06/23/2020


15G457



failed to ensure the HRC

approved the restrictive

practice of locking laundry

supplies and hygiene items in

the hall closet.





practice?

·McSherr has obtained HRC

approval for the restrictive practice

of locking laundry supplies and

hygiene items in the hall closet.

·McSherr has obtained guardian




·Team will review client

restrictive practices through

monthly IDT




07/23/2020 12:00:00AM





07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00







#4's record was conducted. There was no

documentation in the record indicating HRC

approval had been obtained for locking the

hygiene products and laundry detergent in the

hall closet.






hall closet.






hall closet.






hall closet.


Manager) was interviewed. The RM stated the

closet was locked due to client #7 "licking his

deodorant and eating toothpaste multiple times

several years ago". The RM indicated the laundry

products and the hygiene baskets were locked in















monthly IDT
















monthly IDT














07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

the closet to prevent client #7 from ingesting

non-food items. The RM indicated the cleaning

supplies were not locked and client #7 hasn't

attempted to do anything since those items were

locked. The RM stated, "We probably need to

look at that again".





The QIDP stated the closet was locked due to

client #7 ingesting toothpaste and licking his

deodorant "several years ago". The QIDP

indicated the HRC was meeting this week and

they were going to recommend to discontinue the

restriction.

9-3-4(a)








monthly IDT



implemented?

·7/23/2020

483.460(a)(3)(iv)

PHYSICIAN SERVICES

The facility must provide or obtain annual

physical examinations of each client that at a

minimum includes tuberculosis control,

appropriate to the facility's population, and in

accordance with the recommendations of the

American College of Chest Physicians or the

section on diseases of the chest of the

American Academy of Pediatrics, or both.

W 0327

Bldg. 00

Based on record review and interview for 1 of 3

sampled clients (#3), the facility failed to ensure

client #3 had an annual TB (tuberculosis)

screening completed.

Findings include:


reviewed. The record did not include

documentation of a TB screening being completed


B St, Richmond


06/23/2020


15G457



07/23/2020 12:00:00AM





07/17/2020PRINTED:

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OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

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TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

since 2/1/19.



Professional), RN (Registered Nurse) and then

SSC (Social Services Coordinator) were

interviewed. The RN indicated TB tests should be

completed on an annual basis. The RN indicated

the RM (Residential Manager) was responsible for

scheduling medical appointments and she had not

scheduled the screening.

9-3-6(a)

failed to ensure client had an

annual TB screening





practice?

·HSC/Nurse will be retrained on

maintaining all client TBs

·McSherr nurse will ensure all

clients receive annual TB

screening.

·HSC/nurse will monitor through

tracking.












screening.


tracking.










screening.





07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00


tracking.











screening.


tracking.



implemented?

7/23/2020

483.460(k)(2)

DRUG ADMINISTRATION

The system for drug administration must

assure that all drugs, including those that are

self-administered, are administered without

error.

W 0369

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interview for 1 of 3 sampled clients (#3), the

facility failed to ensure staff administered client

#3's medications as ordered by the physician.

Findings include:

1. On 6/17/20 from 5:55 AM to 7:55 AM an


At 6:15 AM, client #3's 6:00 AM medication was

administered. Staff #1 administered client #3's


B St, Richmond


06/23/2020


15G457



failed to ensure staff

07/23/2020 12:00:00AM





07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

Levothyroxine (for hypothyroidism/low thyroid

hormone) 75 mcg (micrograms) tab (tablet). After

client #3's medication was administered client #3

went to the dining room and sat down at the table

for breakfast. Client #3 started eating a breakfast

burrito at 6:25 AM.


reviewed. Client #3's 2/5/20 PO (Physician's

Order) signed by the physician indicated client #3

was prescribed Levothyroxine 75 mcg tab, take

one tablet by mouth daily at 5:00 AM. The June

2020 MAR (Medication Administration Record)

indicated client #3 was prescribed Levothyroxine

75 mcg tab, take one tablet by mouth daily at 5:00

AM.





The RN indicated the Levothyroxine should be

administered at 5:00 AM because it was ordered

to be taken on an empty stomach. The RN

indicated client #3 should not eat for 30 minutes

to one hour after the medication is administered.

2. On 6/17/20 at 7:10 AM an observation of client

#3's 7:00 AM medication was conducted. Staff #1

did not administer client #3's Miralax (for

constipation) and Debrox (for ear wax buildup) ear

drops.


reviewed. Client #3's 2/5/20 PO (Physician's

Order) signed by the physician indicated client #3

was prescribed Miralax 17 G (grams) daily at 8:00

AM and Debrox 6.5% OT (otic/ear) SOL (solution)

in both ears daily at 8:00 AM.

administered client

medications as ordered by the

physician.





practice?

·Staff will be retrained on correct

times to administer medications

per the MAR

·All medications will be

administered as ordered by the

prescribing physician




observations


monthly IDT










per the MAR







observations


monthly IDT





07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00


SSC were interviewed. The RN indicated

medications should be administered as prescribed

by the physician.

9-3-6(a)








per the MAR







observations


monthly IDT









per the MAR







observations


monthly IDT







07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

implemented?

7/23/2020

483.470(l)(1)

INFECTION CONTROL

There must be an active program for the

prevention, control, and investigation of

infection and communicable diseases.

W 0455

Bldg. 00




facility failed to complete a health screening prior

to the surveyor entering the group home to assist

with preventing the spread of Covid-19

(Coronavirus Disease/respiratory illness) during a

pandemic.

Findings include:

On 6/16/20 from 4:00 PM to 6:15 PM and on

6/17/20 from 5:55 AM to 7:55 AM, observations

were conducted at the group home. The surveyor

was not screened (temperature and symptoms

checklist) for Covid-19 upon entry to the group

home during the observations. This affected

clients #1, #2, #3, #4, #5, #6, #7 and #8.

On 6/23/20 at 9:00 AM, the undated article

"Guidance for Group Homes for Individuals with

Disabilities" was reviewed from the website

www.cdc.gov. The article indicated: "...Screen

and advise residents, staff, and essential

volunteers. GH (group home)administrators may

want to consider screening residents, workers,

and essential volunteers for signs and symptoms

of COVID-19.

Screening includes actively taking each person's

temperature using a no-touch thermometer, and

asking whether or not the person is experiencing


B St, Richmond


06/23/2020


15G457



failed to complete a health

screening prior to the surveyor

entering the group home to

assist with preventing the

spread of COVID-19.





practice?

·A health screening sheet has

been put into place and all visitors

are screened upon arrival at the

group home.

·Staff have been trained on

implementation of the screening

process.




observations

07/23/2020 12:00:00AM





07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

symptoms such as shortness of breath or has a

cough...."


Manager) was interviewed. The RM indicated

visitation at the group home was suspended and

they haven't had a visitor since the beginning of

March 2020. The RM indicated staff are required

to take their temperature prior to clocking in for

their shift. The RM indicated visitors should be

screened prior to entering the group home.





The CEO indicated the group home stopped all

visitation the middle of March 2020 so they didn't

have a screening process for visitors in place.

The CEO indicated visitors should be screened

prior to entering the group home to assist with

preventing the spread of Covid-19. The CEO

stated she would have a process in place

"immediately".

9-3-7(a)


monthly IDT











group home.



process.




observations


monthly IDT









group home.



process.




observations





07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00


monthly IDT










group home.



process.




observations


monthly IDT



implemented?

7/23/2020

483.480(d)(4)

DINING AREAS AND SERVICE

The facility must assure that each client eats

in a manner consistent with his or her

developmental level.

W 0488

Bldg. 00




facility failed to ensure the clients were involved

in all aspects of the meal preparation based on

their skill level and to ensure the clients had

napkins while eating meals.


B St, Richmond


06/23/2020


15G457

07/23/2020 12:00:00AM





07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

Findings include:

1. On 6/16/20 from 4:00 PM to 6:15 PM, an


At 4:45 PM, staff #4 walked to the basement to get

a box of frozen fish and a bag of broccoli to fix for

dinner. Staff #4 turned the oven on to preheat

and opened the boxes of macaroni and cheese.

Client #2 came in from the back yard and staff #4

prompted him to wash his hands to help with

dinner. Client #2 washed his hands then went to

do something else. At 5:00 PM, client #1 was

sorting coins at the kitchen table, client #5 was

working on a puzzle, client #3 was taking a

shower, client #4 was talking to the RM

(Residential Manager), client #6 was reading the

newspaper and clients #7 and #8 were sitting

outside in the swing. Staff did not prompt the

clients to assist with dinner preparation. At 5:20

PM, staff #4 poured the macaroni noodles into a

pan and stirred the noodles. Staff #4 stated to

client #6, "[Client #6], I'd let you help, but I don't

want you to get burnt". Staff #4 poured the

broccoli into the boiling water then got cans of

peaches out of the cabinets. At 5:25 PM, staff #4

stirred the broccoli and noodles then checked the

fish in the oven. At 5:50 PM, staff #3 poured the

macaroni and cheese and peaches into serving

bowls. At 5:55 PM, staff #3 and #4 carried the

food to the table and staff #4 gave everyone a

slice of cheese for their fish sandwich. The clients

served themselves their food. Staff did not

prompt or encourage clients #1, #2, #3, #4, #5, #6,

#7 and #8 to assist with meal preparation.


reviewed. Client #1's 4/2/20 ISP (Individual

Support Plan) indicated client #1 had an objective

to increase his ability to participate in meeting his



failed to ensure the clients

were involved in all aspects of

the meal preparation based on

their skill level and to ensure

the clients had napkins while

eating meals.





practice?

·Staff will be retrained on client

ADLs and client involvement

during meal preparation.

·Staff will ensure clients have

napkins during each meal.




observations


monthly IDT



















07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

ADL (activities of daily living) skills.



had an objective to increase his ADL skills.




daily/weekly household tasks.




ADL skills.



indicated client #5 had an objective to increase

her participation in ADL skills.




participation in meeting his ADL needs.




domestic skills at the group home.




ADL skills.

On 6/16/20 at 5:10 PM, staff #4 was interviewed.

Staff #4 stated, "The clients like to cook". Staff #4

indicated the clients should be prompted and

encouraged to help prepare the meals.


observations


monthly IDT














observations


monthly IDT















observations


monthly IDT





07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

On 6/16/20 at 5:20 PM, client #6 was interviewed

and he indicated he liked to cook.


The RM indicated the clients should be prompted

and encouraged to assist with preparing the

meals. The RM indicated all of the clients were

capable of helping.





The CEO indicated the clients should be in the

kitchen with staff helping prepare the meals. The

CEO indicated all of the clients were capable of

doing something to assist with preparing the

meals. The QIDP indicated the staff needed to be

retrained.

2. On 6/16/20 from 4:00 PM to 6:15 PM, an


Client #3 ate dinner from 5:55 PM to 6:15 PM. At

6:10 PM, client #3 had ketchup all over his fingers.

Client #3 did not have a napkin so he licked the

ketchup off of his fingers. Staff did not prompt

him to get a napkin.


The RM indicated the clients should have napkins

to wipe their hands on while eating meals.


SSC were interviewed. The CEO, QIDP and the

SSC indicated staff should prompt and encourage

the clients to use napkins. The CEO indicated

staff should ensure each client has a napkin prior

to eating.



implemented?

7/23/2020





07/17/2020PRINTED:

FORM APPROVED

OMB NO. 0938-039




A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED


(X4) ID

PREFIX

TAG




PREFIX

TAG



DEFICIENCY)

(X5)

COMPLETION


RICHMOND, IN 47374

15G457 06/23/2020

MCSHERR INC - B ST

4412 S B ST

00

9-3-8(a)


w 0000 · 2020. 7. 17. · 4412 s b st 00 observation was conducted at the group home. at 6:15 am,...

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