Stepping Stone, Inc.

Deficiency cited, re-licensure survey : C 248 Employee, Volunteer, and Student Records

Based on documentation review and interview, the Provider failed to ensure that one (1) of six (6) staff (Staff A) in sample met the educational requirement outlined in the job description of the staff as Person Centered Support Staff (PCS). Findings include: (a) Review of the personnel record of Staff A, Person Centered Support Staff (PCS) and Approved Medication Assistive Personnel (AMAP), revealed no diploma, transcripts, or other official documented evidence of completion of high school or General Educational Development (GED) diploma. There was noted to be a notarized document, dated 9/3/24, in which Staff A affirmed that she had completed school up to the 12th grade. (b) Review of the job description for Person Centered Support Staff, signed by Staff A on 1/31/20, revealed that this position requires a high school diploma or GED. (c) Interview on 12/10/24 at 12:00 p.m. with Staff G, Executive Assistant, confirmed the Provider could not provide documented evidence that Staff A met the minimal educational requirement established in the job description for Person Centered Support Staff of a high school diploma or GED.

Deficiency cited, re-licensure survey : C 247 Employee, Volunteer, and Student Records

Based on documentation review and interview, the Provider failed to conduct annual performance evaluations for three (3) of five (5) staff (Staff A, C, and D) in the sample per the Provider's policy. Findings include: (a) Review of the personnel record of Staff A, Person Centered Support Staff (PCS) and Approved Medication Assistive Personnel (AMAP), hired 1/31/20, revealed no documented evidence of a performance evaluation for the year 2023. (b) Review of the personnel record of Staff C, Licensed Practical Nurse (LPN), hired 6/29/16, revealed no documented evidence of a performance evaluation for the year 2023. (c) Review of the personnel record of Staff D, PCS/AMAP, hired 1/15/20), revealed no documented evidence of a performance evaluation for the year 2023. (d) Review of the Provider's Evaluation Policy 2- 37, dated October 2012 and provided as current, revealed formal performance evaluations will be conducted annually for all employees. (e) Interview on 12/10/24 at 2:15 p.m. with Staff G, Executive Assistant, confirmed Staff A, C, and D did not receive performance evaluations for the year 2023.

Deficiency cited, re-licensure survey : C 319 1

Based on documentation review and interview, the Provider failed to ensure that one (1) of two (2) Approved Medication Assistive Personnel (AMAP) staff (Staff A) in the sample met the educational requirement to administer medications per the Legislative Rule, Delegation of Medication Administration and Health Maintenance Tasks to Approved Medication Assistive Personnel, W.Va. Code R. \'a716-60-1, et seq. Findings include: (a) The Legislative Rule, Delegation of Medication Administration and Health Maintenance Tasks to Approved Medication Assistive Personnel, 64CSR60, effective 07/01/21, states: "6.1. A facility may permit a facility staff member to be trained as an AMAP in a single specific agency only after compliance with the provisions of this rule and when the following criteria are met: ...6.1.3. The facility staff member holds a high school diploma or the equivalent..." (b) Review of the AMAP record of Staff A, Person Centered Support Staff (PCS) and Approved Medication Assistive Personnel (AMAP), revealed an AMAP certification date of 8/13/24 and medication pass observations conducted on 8/18/24 and 10/11/24. (c) Review of the personnel record of Staff A, PCS/AMAP, revealed no documented evidence of a high school diploma or General Educational Development (GED) diploma. (d) Interview on 12/10/24 at 12:00 p.m. with Staff G, Executive Assistant, confirmed that the Provider could not provide documented evidence that Staff A, PCS/AMAP met the minimal educational ...

Deficiency cited, re-licensure survey : C 296 1

Based on observation, documentation review and interview, the Provider failed to check fire extinguishers monthly to ensure they have adequate pounds per square inch for two (2) of two (2) fire extinguishers at the Main Office where consumers, families and staff gather for meetings. Findings include: (a) Observation on 01/11/23 between 3:20 p.m. and 3:40 p.m. at 1636 Nadenbousch Lane, Inwood revealed no initials and dates on the extinguisher tags or documentation indicating monthly checks were completed for the year 2022. Observation revealed a hole had been punched through the extinguisher tags for the month of June 2022. (b) Interview on 01/11/23 at 3:35 p.m. with Staff E, Person Centered Supervisor confirmed the two (2) fire extinguisher tags did not have monthly initials or dates on them indicating they were checked for 2022. Staff E confirmed observing the hole punch on each fire extinguisher for the month of June 2022. (c) Interview on 01/11/23 at 8:22 p.m. with Staff I, Executive Assistant confirmed the fire extinguishers are not checked monthly by the Provider.

Deficiency cited, re-licensure survey : C 115 Basic Rights

Based on observation, documentation, and interview, the Provider implemented a restrictive floor alarm mat without approval from the Human Rights Committee prior to implementation and failed to obtain a written and signed physician's order to reflect this restriction of one (1) of one (1) consumer (Consumer #9) observed during a home visit on 01/12/23. This floor alarm mat was also observed to not function properly on 01/12/23. Findings include: (a) Observation at the home of Consumer #9 on 01/12/23 at approximately 11:04 a.m. revealed a gray soft horizontal mat with an alarm attached to it at the top of the stairs leading into Consumer #9's bedroom. The alarm was on and not working when the surveyor or Consumer #9 stood on the mat. (b) Review of the Human Rights Committee minutes provided by the Provider dated 01/24/22, 04/19/22, and 10/25/22 revealed no documented evidence of a discussion or approval for a floor mat alarm for Consumer #9. (c) Review of a document provided by the Provider's nurse, titled "Human Rights Committee," dated 01/24/22, with Consumer #9's identification number, revealed the document is used by nursing staff in preparation to present nursing restrictive measures to the Human Rights Committee for review. There was no documented evidence of a floor alarm mat on the document to discuss or which was ordered for Consumer #9. (d) Review of a document provided by the Provider's nurse, titled "Human Rights Committee," dated 01/24/23, with Consumer #9's ...

Deficiency cited, re-licensure survey : C 149 Human Rights Committee

Based on documentation review and interview, the Provider failed to have one-third of their Human Rights Committee members as consumers. The Provider had no consumers or designated legal representatives (DLRs) of consumers represented at the Human Rights Committee meetings for the year 2022. This deficient practice has the potential to affect all consumers served by the Provider. Findings include: (a) Review of the Human Rights Committee Meeting minutes dated 01/24/22 revealed one (1) staff with no title in attendance and five (5) community members in attendance with no consumers or DLRs in attendance. (b) Review of the Human Rights Committee Meeting minutes dated 04/19/22 revealed one (1) staff with no title in attendance and five (5) community members in attendance with no consumers or DLRs in attendance. (c) Review of the Human Rights Committee Meeting minutes dated 10/25/22 revealed one (1) staff with no title in attendance and five (5) community members in attendance with no consumers or DLRs in attendance. (d) Review of the Provider's policy titled "Human Rights," dated April 2018 and presented as current, revealed the Human Rights Committee would include "at least one-third consumers and no more than one-third, who are staff..." (e) Interview on 01/10/23 at 4:04 p.m. with Staff J, Owner/Chief Financial Officer confirmed the five (5) community members in attendance at the 01/24/22, 04/19/22 and 10/25/22 meetings were not guardians of any consumers served by the ...

Deficiency cited, re-licensure survey : C 142 Human Rights Committee

Based on documentation review and interview, the Provider failed to document all parties attending each Human Rights Committee meeting. This deficient practice has the potential to affect all consumers served by the Provider. Findings include: (a) During interview on 01/10/23 at 4:03 p.m., Staff J, Owner/Chief Financial Officer stated Staff K, Executive Director and Staff L, Office Manager attended the Human Rights Committee Meetings held in the year 2022 and were not reported as being in attendance. (b) Review of the Human Rights Committee Meeting minutes dated 01/24/22 revealed Staff K, Executive Director and Staff L, Office Manager were not noted on the minutes as being in attendance. (c) Review of the Human Rights Committee minutes dated 04/19/22 revealed Staff K, Executive Director and Staff L, Office Manager were not noted on the minutes as being in attendance. (d) Review of a Human Rights Committee minutes, dated 10/25/22, revealed Staff K, Executive Director and Staff L, Office Manager were not noted on the minutes as being in attendance. (e) Review of the Provider's policy titled "Human Rights, dated April 2018 and presented as current, revealed the Human Rights Committee would "Hold meetings to keep written minutes of all meetings, including names and titles of all members and guests present..."

Deficiency cited, re-licensure survey : C 463 Abuse, Neglect, and Critical Incidents

Based on documentation review and interview, the Provider failed to complete thorough internal investigations using the current Reporting and Investigation Guidelines for Incidents, set forth by the Secretary for six (6) of six (6) internal investigations reviewed involving five (5) consumers (Consumer #3, #4, #9, #12, and #13). Of these six (6), the Provider failed to complete several requirements in the internal investigative phase to include but not limited to: at least two (2) staff members to conduct investigations which forms an investigative committee; failed to interview the victim and alleged perpetrator with at least one (1) other committee member present; failed to make an Adult Protective Services report as mandatory reporters; failed to initial or sign the final internal investigative report; failed to make a consensus decision regarding substantiation or lack thereof; or the investigative report did not include a section detailing the action taken by the Chief Executive Officer or designee along with their signature; or the guardian was not informed of the internal investigation. This deficient practice has the potential to affect all consumers served by the Provider. Findings include: (a) Review of a Confidential Investigation Report, signed by Staff I, Executive Assistant, dated 02/17/22, with an incident report dated 02/11/22 for Consumer #12, revealed only one (1) committee member, Staff I, completed the internal investigation and completed interviews with ...

Deficiency cited, re-licensure survey : C 483 Quality Assurance

Based on documentation review and interview, the Provider failed to follow their own policies and procedures to monitor appropriateness of consumer services monthly, ensure services are effective and required information is obtained. This deficient practice has the potential to affect all consumers served by the Provider. Findings include: (a) Documentation review revealed no documented evidence of the implementation of a quality assurance program. (b) Review of the Provider's policy titled "Quality Assurance Reviews," dated January 2018 and presented as current, revealed "Quality Assurance will review at least 10% of all Staff, Family, and Respite Provider files every month to ensure that they are complete, and up to date with all required information for each file." (c) Interview on 01/11/23 at 11:03 a.m. with Staff J, Owner/Chief Financial Officer confirmed review of the monthly reports were not completed per the Provider's policy and had no documented evidence of when quality assurance was completed in the year 2022.

Deficiency cited, re-licensure survey : C 162 Transportation

Based on observation and interview, the provider failed to include first aid kits in all four (4) company vehicles used for consumer transportation which has the potential of affecting all consumers served by the provider. Findings include: (a) Observation on 08/24/21 at 10:41 a.m. of the provider's vans revealed no evidence of first aid kits in the four (4) vehicles owned and operated by the provider. (b) Interview on 08/24/21 at 10:43 a.m. with Staff A, Executive Director, confirmed none of the four (4) provider vehicles have first aid kits.

Deficiency cited, re-licensure survey : C 159 64-11-5.9.a.1. Human Rights Committee

Based on documentation review and interview, the Center failed to maintain a human rights committee to hold meetings and keep written minutes of all meetings, including the names and titles of all members and guests present and members absent. Consumers affected: all consumers served by the Center. Findings include: (a) Review of the Human Rights Committee Meetings dated 1/30/18, 7/26/17, 10/26/17 and 4/20/17 revealed that "Members Present" listed names, but their titles (staff, consumer/consumer advocate, community member, presenter, guest) were omitted. (b) Review of the Human Rights Committee minutes for 1/30/18, 7/26/17, 10/26/17 and 4/20/17 revealed that members absent were not included. (c) The Center's Policy, "2-5 Human Rights", January 2013, states: "Hold meetings to keep written minutes of all meetings, including names and titles of all members and guest present, and guest absent." (d) Interview on 3/26/18 at 2:20 p.m. with Staff M, Executive Director, confirmed that in the human rights committee meeting minutes, the members listed only their names and not their titles, and that the absent members were omitted. (e) The failure of the Center to maintain a human rights committee to hold meetings and keep written minutes of all meetings, including the names and titles of all members and guests present and members absent does not meet the intent of the regulation that the Center shall maintain a human rights committee to hold meetings and keep written minutes of all ...

Deficiency cited, re-licensure survey : C 339 64-11-8.1.a.11. Basic Rights

Based on documentation review and interview, the Center failed to ensure that a consumer shall have rights including, but not limited to the right to confidentiality of records, as provided in this rule. Consumers affected: all consumers served by the Center. Findings include: (a) Review of the Human Rights Committee meeting minutes dated 1/30/18, 7/26/17, 10/26/17 and 4/20/17 revealed that the meetings on all four (4) dates were held at a restaurant, potentially compromising the consumer's right to confidentiality. (b) Review of the Human Rights Committee meeting minutes dated 1/30/18, 7/26/17, 10/26/17 and 4/20/17 revealed the consumers' names were listed without the protection of concealment in a public circumstance. (c) Interview on 3/26/18 at 2:25 p.m. with Staff M, Executive Director, confirmed the Human Rights Committee meets at a restaurant. She stated, "We usually meet in a private room, but I can't say that happens all the time. When wait staff come in and out we try to stop talking about the consumer, but I can't say for sure." (d) The failure of the Center to ensure the right to confidentiality of records does not meet the intent of the regulation that a consumer shall have rights including, but not limited to the right to confidentiality of records, as provided in this rule.

Deficiency cited, re-licensure survey : C 143 64-11-5.6.b. Personnel

Based on interview and personnel record review, the center failed to ensure that contracted providers did not have convictions of consumer or child abuse or neglect for six (6) of six (6) contracted employees in the sample. This deficient practice has the potential to affect all consumers served by the Center. Staff identifiers: (a) The following contracted employees records did not have evidence that a criminal background check had been done: (i) Staff E, Nurse, hired 10/06. (ii) Staff F, Community Residential Habilitation Provider, hired 12/06. (iii) Staff G, Community Residential Habilitation Provider, hired 4/06. (iv) Staff H, Respite Provider, hired 7/02. (v) Staff I, Respite Provider, hired 6/04. (vi) Staff J, Community Residential Habilitation Provider, hired 7/06. (b) During interview on 5/22/07 at 3:00 p.m., the Center's office manager stated that the Center does not complete criminal background checks on contracted staff. (c) Prior the the exit interview on 5/23/07 at 2:30 p.m., the Center's Office Manager presented evidence that National Criminal Records Reports were completed on five (5) of the six (6) contracted staff reviewed (Staff F, G, H, I and J). These background checks were initiated via an Internet service after the personal record review which was conducted in the morning and early afternoon hours of 5/22/07.

Deficiency cited, re-licensure survey : C 152 64-11-5.7.a. Staff Training

Based on interview and personnel record review, the Center failed to ensure that contracted employees are trained in consumer rights and the use of emergency procedures for five (5) of six (6) contracted employees in the sample. This deficient practice has the potential to affect all consumers served by the Center. Findings include: (a) The following four (4) contracted employees had no evidence that they had been trained in emergency procedures such as crisis intervention and restraints: (i) Staff E, Nurse, hired 10/06. (ii) Staff F, Community Residential Habilitation Provider, hired 12/06. (iii) Staff I, Respite Provider, hired 6/04. (iv) Staff J, Community Residential Habilitation Provider, hired 7/06. (b) One (1) contracted employee, Staff E - hired 10/06, had no evidence that she had been trained in consumer rights. (c) During an interview on 5/22/07 at 3:00 p.m., the Center's Office Manager stated that the Center had ceased to require contracted respite staff and contracted nursing staff to complete training in consumer rights and the use of emergency procedures, such as crisis intervention and restraints. (d) During an interview on 5/22/07 at 3:00 p.m., the Center's Office Manager stated that the Center does not require contracted Residential Habilitation staff to complete training in the use of emergency procedures, such as crisis intervention and restraints.

Deficiency cited, re-licensure survey : C 112 64-11-5.4.b. Financial

Based on interview and record review, the Center had not completed an audit since opening. Findings include: (a) The Center has been in operation since July 2001. (b) The last audit (financial statement) was completed 6/20/04 and covered the 2003 calendar year. (c) On 1/1/04, the Center became a partnership with a former employee becoming co-owner. (d) On 8/13/04, the Center auditor sent a letter outlining concerns which needed to be addressed, including bank reconciliation, credit card transactions, commingling of Center and personal accounts, and invoice approvals. (e) As of 5/23/05, the Center did not have an audit for the 2004 calendar year.

Deficiency cited, re-licensure survey : C 262 64-11-7.5.b.3. Consumer Discharge

Based on interview and record review, one (1) of one (1) discharged consumer's records did not contain a summary of consumer progress toward Individual Program Plan (IPP) goals, contrary to Center policy and this rule. Consumer affected: #4. Findings include: (a) Center policy 2 -15 stated that the discharge summary should contain a "final evaluation summary of individual's progress toward treatment goals." (b) Review of the discharge summary for Consumer #4 failed to find this information contained therein. (c) Interview with the qualified mental retardation professional (QMRP) for Consumer #4 at 12:05 p.m. on 5/23/05 revealed that she did not include it on the discharge summary, because it was not asked for on the form.

Deficiency cited, re-licensure survey : C 102 64-11-5.2.a. Governing Body

(1) Based on interview and record review, the governing body has failed to assure that Center policies/procedures and plans of correction were followed. Findings include: (a) Cross refer to C112 [\'a764-11-5.4.b.] - The Center failed to implement its own plan of correction for the previous survey regarding the lack of an annual audit. (b) Cross refer to C159 [\'a764-11-5.9.a.1.] and C166 [\'a764-11-5.9.c.] - The make-up of the human rights committee was not in compliance with Section 5.9 of the rules. (c) Cross refer to C172 [\'a764-11-5.11.a.] - The Center did not adhere to its own policy regarding quality assurance. (d) Cross refer to C230 [\'a764-11-7.2.a.] - The Center did not adhere to its own admission criteria or procedures.

Deficiency cited, re-licensure survey : C 112 64-11-5.4.b. Financial

Based on interview and record review, the Center had not completed an audit since opening. Findings include: (a) The Center has been in operation since July 2001. (b) Interview with the accountant for one of the owners on 5/18/04 at 2:50 p.m. revealed that he had been asked to complete an audit in response to the previous survey. He had questions concerning the timeline for submission. (c) The Center was cited for this deficiency during the last survey and stated that an independent audit would be completed by 11/30/03, and annually thereafter. (d) Review of Center records failed to find any audit subsequent to 11/30/03.

Deficiency cited, re-licensure survey : C 143 64-11-5.6.b. Personnel

Based on record review, two (2) of ten (10) employee files reviewed did not have evidence of a criminal background check relevant to these specific staff (Staff C and J). Findings include: (a) Staff C, hired on 1/7/04 as a direct care staff, had all her previous work experience and lived in Maryland. Her criminal background check was done in West Virginia. (b) Staff J, hired on 9/10/03, had immediately, previous work experience in Maine. Her criminal background check was completed in West Virginia on 3/9/04.

Deficiency cited, re-licensure survey : C 159 64-11-5.9.a.1. Human Rights Committee

(2) Based on record review, there was no evidence that the human rights committee issued an annual report of its activities and recommendations to the governing body. Findings include: (a) There was no evidence of any human rights committee annual reports. (b) The Center has been in operation since July 2001.

Deficiency cited, re-licensure survey : C 166 64-11-5.9.c. Human Rights Committee

Based on interview and record review, the human rights committee was not composed of one third consumers and only one third staff. Findings include: (a) Review of the human rights committee minutes from 11/7/01 through 5/ll/04 revealed that the only "consumer" on the three (3) person committee became the co-owner of the Center on 1/1/04. (b) Interview with this co-owner on 5/20/04 at 11:00 a.m. revealed that the Center was established as a Limited Liability Corporation in 2002, but did not begin to operate as one until 1/1/04. This change was deemed non- reviewable for a Certificate of Need on 5/19/03 by the Health Care Authority. They did not change until January 2004, although she had contributed funds towards the Center prior to that time. She stated that they were in the process of finding another member. (c) The remaining two (2) members of the human rights committee were the contracted psychologist and his wife.

Deficiency cited, re-licensure survey : C 172 64-11-5.11.a. Quality Assurance

Based on interview and record review, the Center's quality assurance system was not functioning or comprehensive. Findings include: (a) Center policy 2-7, Quality Assurance, stated: "A review of services received by all individuals receiving services from SSC will be completed by the QMRP twice annually, 1 January and in July." (b) The Center's Plan of Correction for the 8/21/03 Office of Health Facility Licensure and Certification (OHFLAC) licensure survey stated that this would be done quarterly, beginning by 11/30/03. (c) Interview with the co-owner of the Center on 5/20/04 at 10:22 a.m. revealed that while there had been individual record reviews since the last survey, there had been no reports generated since because they had not implemented this for a year. (d) There was no evidence of human rights committee reports, which could have been included in the analysis.

Deficiency cited, re-licensure survey : C 215 64-11-6.8.b.7. Consumer Records

Based on record review, one (1) of three (3) consumers in the sample with guardians or surrogates/powers of attorney did not have verification of such in his record (Consumer #1). Findings include: (a) Consumer #1 has, according to his 3/11/04 Individual Program Plan (IPP), a medical power of attorney. There was no evidence in the record that the persons named were actually his powers of attorney, and they had not been required to sign his release of information for medical issues.

Deficiency cited, re-licensure survey : C 230 64-11-7.2.a. Assessment and Planning

Based on interview and record review, the Center did not establish a formal intake process that assesses each consumer for admission and admits only those who meet criteria. Findings include: (a) Consumer #1's only admissions data consisted of a waiver application. There was no admissions criteria or decision in evidence. Only a Needs Summary (DD-14), a psychological and a social history were in the record. The Center staff could not easily identify when he was admitted to the program. (b) Consumer #3's only admissions data consisted of a waiver application. There was no admissions criteria or decision in evidence. There was a Needs Summary (DD-14). There was a 4/22/03 psychological update and a 4/8/03 social history in the record. The Center staff could not easily identify when he was admitted to the program. (c) Consumer #4 had an annual Individual Program Plan (IPP) on 4/3/03, his date of entry according to a list provided by the Office Manager. The next treatment plan in the record was another "annual" on 9/24/03, labeled "Annual/Initial". (d) Consumer #6 had an annual IPP on 3/13/03, her date of entry according to a list provided by the Office Manager. The next IPP in the record was another "annual" on 9/24/03, labeled "Annual/Initial". (e) Interview with the Service Coordinator for Consumer #6 on 5/18/04 at 1:45 p.m. revealed that the first IPP was for the waiver packet, but no services were provided until 9/24/03 when the packet was approved. (f) Center Policy 2-2 ...

Deficiency cited, re-licensure survey : C 242 64-11-7.3.c. Treatment Plan

Based on interview and record review, the Center did not implement activities to meet consumers needs as identified in the treatment plans for five (5) of six (6) consumers in the sample (Consumer #1, #2, #3, #4 and #6) and one (1) consumer (Consumer #8) with behavioral needs. Findings include: (a) All consumers admitted since 3/02 in the sample had treatment plans developed upon admission that reflected services to be offered when and if the Waiver packet was approved (Consumer #1, #2, #3, #4 and #6). (b) Interview with the Service Coordinator for Consumer #6 on 5/18/04 at 1:45 p.m. revealed that the first Individual Program Plan (IPP) was written for the Waiver packet and was not implemented at all, but served as an example of services which would be provided if the Waiver packet was approved. Prior to Waiver approval, only case management services were provided. (c) None of these consumers received the services stated in the "Waiver Packet" treatment plans, although these plans outlined extensive day habilitation and residential habilitation services and training. (d) None of the "Waiver Packet" treatment plans stated that the services described therein were not to be provided until the packet was approved. (e) Due to the difficulty in establishing the actual date of entry for the consumer into services, it was impossible to determine the exact period of time for these consumers when services were identified as needed by the Interdisciplinary team (IDT), but were not ...

Deficiency cited, re-licensure survey : C 285 64-11-7.7.a. Critical Incidents and Crisis Management

Based on record review, the Center's system for tracking incidents did not include sufficient data needed to identify trends or areas of potential consumer jeopardy. Findings include: (a) There was no evidence of any system to track incidents other than by individual consumers prior to January 2004. (b) The system did not track medication errors or analyze medication error data at all. (c) The system did not have any mechanism to track time of day or the individual staff involved in the incident. (d) The Center did not have evidence that it identified incidents of possible immediate jeopardy for consumers or investigated them at all. (i) On 2/22/04, Consumer #8 and #5 did not receive their evening medications until 10:43 p.m. The medications were scheduled for 8:00 p.m. There was no evidence that the Licensed Practical Nurse (LPN) who "overslept", was retrained, disciplined, or addressed in any way other than that she was told to go ahead and administer the medications. The medications not administered were not identified. (ii) There was no evidence of an internal investigation of this event. While there was some additional data in the 'explanation' section of the tracking sheet, there was no evidence that these events were investigated. The person doing the 'explanation', when this was done, or what sources provided the explanation were not documented.

Deficiency cited, re-licensure survey : C 346 64-11-8.1.a.18. Basic Rights

Based on interview and record review, the Center did not assure that consumers have the have the right to referral to other providers. Findings include: (a) Interview with the Office Manager on 5/18/04 at 10:00 a.m. revealed that there were no agreements or memoranda of understanding with outside agencies because the Center did not provide any services to a consumer unless all needed services were provided to the consumer. She thought this was a policy. (b) This was confirmed during interview with the co-owner of the Center on 5/20/04 at 10:38 a.m. She referred to this as a "one stop shop". She stated that they needed to do service coordination in order to balance the other money they receive for other services. She specifically referred to Consumer #9, who had received day program services from another agency and was told this could not continue if the family wanted services from the Center. She stated: "We tell them before they come on board. Otherwise, it eats in to our profit." (c) Center policy 2-26, Relationship to Families stated: "The relationship between Stepping Stones Cottages and the individual being served and their family is that of Provider of Service of Record. SSC, LLC will provide service coordination, QMPR evaluation and training, billing for services, and any other service agreed upon by the two parties. (d) Center policy 2-3, Intake, stated: "...to transition the individual to SSC's services. All required waiver services will be provided to the newly ...

Deficiency cited, survey : C 112 64-11-5.4.b. Financial

Based on interview and record review, the Center has not had an Annual Independent Audit. Findings include: (a) An independent audit was not provided to the surveyor, when it was requested. (b) Interview with the Executive Director on 8/19/03 at 2:30 p.m. revealed that the Center had never had an independent audit. She stated that an accountant did their taxes, but there was no other auditing mechanism. (c) The Center has been in operation since July 2001.

Deficiency cited, survey : C 152 64-11-5.7.a. Staff Training

Based on interview and record review, the Center has failed to assure that five (5) of six (6) personnel whose records were reviewed had basic training in emergency behavior management including passive restraint (Staff A, B, C, E and F). Findings include: (a) Staff A, hired as a Community Living Mentor I on 12/30/02, had no evidence of current training in behavior management, including passive restraint. Her CPI training expired on 4/18/03. (b) Staff B, hired as a Community Living Mentor I on 12/30/02, had no evidence of current training in behavior management, including passive restraint. Her CPI training expired on 4/18/03. (c) Staff C, hired as a Community Living Mentor I on 4/20/03, had no evidence of training in behavior management, including passive restraint. (d) Staff E, hired as a Community Living Mentor I on 6/4/03, had no evidence of training in behavior management, including passive restraint. (e) Staff F, hired as a Community Living Mentor I on 7/16/03, had no evidence of training in behavior management, including passive restraint. (f) Interview with the Executive Director on 8/21/03 at 11:30 a.m. confirmed that none of these staff had this training. She stated that since the Center did not use restraint as a behavioral intervention, she did not think that they needed it.

Deficiency cited, survey : C 172 64-11-5.11.a. Quality Assurance

Based on interview and record review, the Center's quality assurance system is not comprehensive. Findings include: (a) The systems analysis procedure consisted of individual record review, primarily for utilization review. It was not designed to identify trends in more than one file. There was no system to compare/contrast findings between files, nor was there evidence of analysis of treatment plan reviews. (b) Interview with the Executive Director on 8/21/03 at 11:30 a.m. confirmed this.

Deficiency cited, survey : C 241 64-11-7.3.b. Treatment Plan

(1) Based on record review, treatment plans were not developed within seven (7) days or completed within thirty (30) days of entry to the Center's programs for five (5) of six (6) consumers in the sample (Consumer #1, #2, #3, #4 and #5). Findings include: (a) Consumer #1 was admitted to the Center's programs after 8/22/02. The Center did not do any annual review at that time. Instead, a 5/30/02 six (6) month review by the former service provider was located in the file along with another update, 8/22/02, by the former service provider also. There was no treatment planning done by the Center until 11/26/02. (b) Consumer #2 was admitted to the Center's programs on 12/30/02. An annual Individual Program Plan (IPP) was conducted by the former provider of services on 11/13/02. This annual was included in the record at the Center, but there was no other annual IPP in evidence. The receiving Center did not do a new treatment plan reflecting its services and objectives, or the change in placement. There was no additional treatment planning for this consumer until 3/24/03, when a ninety (90) day review was held. (c) Consumer #3 was admitted to the Center's programs on 2/02. A six (6) month review was conducted by the Center on 6/27/02. Subsequent updates were conducted on 3/10/03 and 6/26/03. An 'annual' was held on 12/19/02, ten (10) months after she entered the program. (d) Consumer #4 was admitted to the Center's programs on 3/24/02. An annual IPP was conducted by the former ...

Deficiency cited, survey : C 246 64-11-7.3.e.2.B. Treatment Plan

(2) Based on record review, Individual Program Plans (IPPs) were not completed by the Center for one (1) of six (6) consumers in the sample (Consumer #2). Findings include: (a) Consumer #2's 11/13/02 annual review was not done by the Center. This consumer has not had an annual review as of 8/21/03. (3) Based on record review, there are no projected completion dates for Individual Program Plan (IPP) objectives for six (6) of six (6) consumers IPPs reviewed (Consumer #1 through #6). Findings include: (a) Consumer #1's 11/26/02 annual IPP objectives do not include projected completion dates. Instead, the date of the next update, 11/03, is indicated for all nine (9) objectives. (b) Consumer #2's 11/13/02 annual IPP objectives do not include projected completion dates. Instead, the date of the next update, 5/03, is indicated for all ten (10) objectives. (c) Consumer #3's 12/19/02 annual IPP objectives do not include projected completion dates. Instead, the date of the next update, 12/03, is indicated for all nine (9) objectives. (d) Consumer #4's 3/6/03 annual IPP objectives do not include projected completion dates. Instead, the date of the next annual review, 2/04, is indicated for all ten (10) objectives. (e) Consumer #5's 7/17/03 annual IPP objectives do not include projected completion dates. Instead, the date of the next review, 12/03, is indicated for all eleven (11) objectives. (f) Consumer #6's 3/27/03 annual IPP objectives do not include projected completion dates. ...

Deficiency cited, survey : C 252 64-11-7.3.g.4. Treatment Plan

Based on record review, the rationale for medications was not included on the treatment plans of four (4) of six (6) consumers in the sample (Consumer #1, #2, #4 and #6). All consumers in the sample were on one (1) or more medications. Findings include: (a) Consumer #1's annual Individual Program Plan (IPP) 11/26/02 did not contain the rationale for her medications. Only the medication names and dosage were listed. (b) Neither Consumer #2's annual IPP 11/30/02, nor her 5/29/03 and 3/24/03 updates contained the rationale for her medications. Only the medication names and dosage were listed. (c) Neither Consumer #4's annual IPP 3/6/03, nor his 5/2/03 update contained the rationale for his medications. Only the medication names and dosage were listed on the annual. Medications were not listed at all on the update. (d) Neither Consumer #6's annual IPP 3/27/03, nor his 6/3/03 update contained the rationale for his medications. Only the medication names and dosage were listed.

Deficiency cited, survey : C 254 64-11-7.4.a. Treatment Plan Review

(2) Based on record review, periodic review were not completed as determined by the interdisciplinary team (IDT) for one (1) of six (6) consumers in the sample (Consumer #3). Findings include: (a) Consumer #3 had a update (6 month review) on 6/27/02. She did not have another review until 12/19/02, even though the 6/27/02 review stated that "an informal 90 day meeting will be held in September unless problems or issues reflect a need for a full team." There was no evidence that this meeting was held.

Deficiency cited, survey : C 285 64-11-7.7.a. Critical Incidents and Crisis Management

Based on record review, the Center's system for tracking critical incidents did not include sufficient data needed to identify trends or areas of potential consumer jeopardy. Findings include: (a) The tracking system only tracked the date/time of occurrence, the name of the consumer, the staff, and the general type of occurrence. It did not identify any location of the incident, the outcome of the incident, antecedents if present.

Deficiency cited, survey : C 153 64-11-5.7.b. Staff Training

Based on record review, the Center failed to ensure that staff that have direct contact with consumers have current training/certification in cardiopulmonary resuscitation (CPR) in four (4) out of five (5) personnel files reviewed. Staff affected include: #1 through #4. Findings include: (a) Staff #1 through #4 each had CPR training that expired on 9/25/02 and the facility could not provide evidence at the time of exit that they had been recertified (either a training roster or current cards to indicate that training had occurred).

Deficiency cited, survey : C 245 64-11-7.3.e.2.A. Treatment Plan

Based on record review, the Center failed to ensure that treatment plans contain specific goals that identify a change in mental health status or a change in adaptive behavior for four (4) of six (6) consumer files reviewed. Consumers affected include: #1, #3, #5 and #6. Findings include: (a) Consumer #1's treatment plan dated 7/29/02 includes a "therapy treatment goal" that is written as a component objective, i.e., "...will attend counseling and discuss his aggressive behaviors by 7/30/02." (b) Consumer #3's treatment plan dated 8/30/02 includes a "therapy treatment goal" to "seek out counseling and develop goals for counseling by 9/15/02". This is not an outcome or result (i.e., change in adaptive behavior or mental health status). (c) Consumer #5's treatment plan dated 7/29/02 notes a staff-oriented service goal as opposed to one that is consumer-centered, i.e., "...will have counseling set up that he can participate in by 4/1/02." (d) Consumer #6's treatment plan dated 8/30/02 put the consumer into the role of service coordinator. It notes that the consumer will "...obtain a counselor and set up three goals to work on in his counseling sessions by 9/30/02."

Deficiency cited, survey : C 246 64-11-7.3.e.2.B. Treatment Plan

Based on record review, the Center failed to ensure that the treatment plans contain specific, measurable, outcome-based objectives (at least one per identified goal) for six (6) of six (6) consumer files reviewed. Consumers affected include: #1, #2, #3, #4, #5 and #6. Findings include: (a) Consumer #1's treatment plan dated 4/26/02 notes only services and "component objectives" under the therapy treatment goal (to discuss his aggressive behaviors), i.e., "...will report to his counselor three (3) anger management techniques he can use by 7/30/02." (b) Consumer #2's treatment plan dated 8/30/02 notes broad unmeasurable statements as the therapy objectives, i.e., "...will develop the skills he needs to enhance his self esteem with the aide of his counselor." (c) Consumer #3's treatment plan dated 9/30/02 includes objectives that the identified behavior (i.e. "problems") is not specific enough to be measured, i.e., "...will have one or fewer incidents of problems a month while visiting his grandmother by 12/1/02." (c) Consumer #4's treatment plan (review) dated 8/26/02 notes objectives that are not measurable. They are stated more like goals and lack criteria needed for measurement, i.e., "...will decrease his daily levels of anxiety by developing positive coping mechanisms with the aid of staff by 7/1/02." (d) Consumer #5's treatment plan dated 7/29/02 notes only component objectives. Outcome based objectives for therapy were never identified, i.e., "...will attend all ...

Deficiency cited, survey : C 252 64-11-7.3.g.4. Treatment Plan

Based on record review, the Center failed to ensure that treatment plan reviews include a rationale for continuation (or changes) of medication regimens in three (3) of three (3) cases in which medications were prescribed to address behavior or mental health issues. Consumers affected include: #1, #2, and #5. Findings include: (a) Consumer #1's initial treatment plan dated 4/26/02 does not list any medications at all. The section was left blank. The 7/29/02 treatment plan (review) lists Trazadone 50 mg (milligram) q (every) hs (hour of sleep) and Adderal XR 10 mg (for ADHD and anxiety). The plan does not discuss the rationale for the addition of these medications, nor does it identify specific symptomatology that is to be tracked to ensure the effectiveness of the regimen. (b) Consumer #2's treatment plan (review) dated 8/30/02 lists the medications but does not address specific symptomatology or provide a rationale for its continued use. The medications in question include: Depakote 1000 mg q 8:30 p.m., Concerta 36 mg q 7:00 a.m., Paxil 30 mg q 7:00 a.m., Wellbutrin 150 mg q 7:00 a.m., and Cyprophetadine 4 mg q 8:30 p.m.. (c) Consumer #5's 7/29/02 treatment plan (review) lists Trazadone 50 mg q hs and Adderal XR 30 mg (for ADHD and anxiety). The plan does not discuss the rationale for continued use of these medications, nor does it identify or discuss specific symptomatology to ensure the effectiveness of the regimen.

Deficiency cited, survey : C 258 64-11-7.4.c. Treatment Plan Review

Based on record review, the Center failed to ensure that the treatment plan and reviews are signed by the the consumer or legal representative for three (3) of six (6) consumer files reviewed. Consumers affected include: #3, #4, and #5. Findings include: (a) Consumer #3's treatment plan dated 8/30/02 does not include the signature of the legal representative. There was no rationale documented as to why the signature was not obtained or documentation to show that the facility made good faith attempts to obtain the signature/participation of the guardian. (b) Consumer #4's treatment plan review dated 8/26/02 does not include the signature of the legal representative. There was no rationale documented as to why the signature was not obtained or documentation to show that the facility made good faith attempts to obtain the signature/participation of the guardian. (c) Consumer #5's treatment plan dated 7/29/02 does not include the signature of the legal representative. There was no rationale documented as to why the signature was not obtained or documentation to show that the facility made good faith attempts to obtain the signature/participation of the guardian.

Deficiency cited, survey : C 150 64-11-5.6.d.6. Personnel

Based on record review and staff interview, the Center does not maintain a personnel record that includes: employee performance evaluations for all staff in three (3) of three (3) personnel records reviewed who have been employed over a year (Staff # 2, #4 and #8). Findings include: (a) Interview with the Executive Director on 12/5/01 in the afternoon revealed that evaluations are completed annually for each employee. (b) Review of personnel records revealed employee evaluations were lacking for: Staff #8 - hired 5/5/00; Staff #4 - hired 4/18/00; and Staff #2 - hired 5/12/99 (employee evaluation was dated 5/15/00).

Deficiency cited, survey : C 152 64-11-5.7.a. Staff Training

(1) Based on personnel record review, review of written staff schedules, and staff interview, the Center has not ensured that direct care staff shall begin orientation and training on the use of emergency procedures, such as crisis intervention and restraints, for three (3) of three (3) house parent staffs who were hired after 4/14/01 (the date of the last survey) (Staff #10, #13 and #17). Findings include: (a) Review of the house parents personnel records revealed lack of training on the use of emergency procedures, such as crisis intervention and restraints for: Staff #10 - hired 7/12:00/01; Staff #13 - hired 10/26/01; and Staff #17 hired 6/2/01. (b) Review of the written staff schedules revealed that Staff #10 and #17 were scheduled together at the facility, without any other staff, for nine ( 9) shifts in October, November and December. These staff, #10 and #17, are still without training on the use of emergency procedures, such as crisis intervention and restraints. Dates and shifts scheduled to work together: October: 8th - 12:00 midnight to 8:00 a.m..; 15th - 12:00 midnight to 8:00 a.m.; 22nd - 12:00 midnight to 8:00 a.m.; 29th - 12:00 midnight to 8:00 a.m.. (4 shifts); and November: 5th -12:00 midnight to 8:00 a.m..; 12th - 12:00 midnight to 8:00 a.m.; 19th - 12:00 midnight to 8:00 a.m.; 26th - 12:00 midnight to 8:00 a.m.. (4 shifts); and December: 3rd -12:00 midnight to 8:00 a.m. (1 shift). (c) During an interview on 12/5/01 in the morning, the Assistant Director ...

Deficiency cited, survey : C 153 64-11-5.7.b. Staff Training

Based on personnel record review and staff interview, the Center has not ensured that direct care staff are trained in first aid, infectious disease control, cardiopulmonary resuscitation and Heimlich's maneuver for three (3) of three (3) house parent staff who were hired after 4/14/01 (the date of the last survey) (Staff #10, #13 and #17). Findings include: (a) Review of the house parents personnel records revealed lack of training in first aid, infectious disease control, and cardiopulmonary resuscitation and Heimlich's maneuver for: Staff #10 - hired 7/12/01; Staff #13 - hired 10/26/01; and Staff #17 - hired 6/2/01. (b) During an interview on 12/5/01 in the morning, the Assistant Director reviewed the files and did not find any record of training for first aid, infectious disease control, and cardiopulmonary resuscitation and Heimlich's maneuver for the above mentioned staff.

Deficiency cited, survey : C 160 64-11-5.9.a.2. Human Rights Committee

Based on document review and interview, the Center did not ensure that the human rights committee reported its activities and recommendations to the governing body or a standing committee of the governing body at least annually. Findings include: (a) The minutes of the human rights committee dated 11/30/01 did not include that the committee reported anything to the board or a committee of the board. There were no other human rights committee meetings for the year 2001 and there were none for the year 2000. (b) The Executive Director stated on 12/5/01 in the afternoon, that the human rights committee has not made a report to the board or a committee of the board this year.

Deficiency cited, survey : C 167 64-11-5.9.d. Human Rights Committee

Based on record review and interview, the Center has not ensured that members of the human rights committee have training in confidentiality in order to review client records. Findings include: (a) Review of the human rights committee policy (no date) presented by the Assistant Director on 12/5/01 revealed nothing about the committee having training in confidentiality in order to review client records. The assistant director stated that policy has been in effect since he was hired, which was in 1997. (b) Review of the minutes of the human rights committee meeting of 11/30/01 revealed nothing about training in confidentiality. There was no human rights committee meeting in 2000 and the 11/30/01 meeting was the only one for 2001.

Deficiency cited, survey : C 168 64-11-5.10.a.1. Transportation Services

Based on staff interview, the Center does not have written procedures for proper maintenance of vehicles. Findings include: (a) Interview with the Executive Director on 12/6/01 at 8:00 a.m. revealed there were no written procedures for proper maintenance of vehicles.

Deficiency cited, survey : C 169 64-11-5.10.a.2. Transportation Services

Based on staff interview, the Center does not have written procedures for adequate passenger supervision. Findings include: (a) Interview with the Executive Director on 12/6/01 at 8:00 a.m. revealed there were no written procedures for adequate passenger supervision.

Deficiency cited, survey : C 170 64-11-5.10.a.3. Transportation Services

Based on staff interview, the Center does not have written procedures for appropriate passenger restraining systems. Findings include: (a) Interview with the Executive Director on 12/6/01 at 8:00 a.m. revealed there were no written procedures for appropriate passenger restraining systems.

Deficiency cited, survey : C 204 64-11-6.6.n.2. Physical Environment - Residential Facilities

Based on review of handwritten Center menus and staff interview, the Center has not ensured that the food services are planned with the regularly documented assistance of a dietitian. Findings include: (a) Review of the daily handwritten menus during tour on 12/3/01 revealed lack of evidence of any assistance with a dietician. In addition, the only written menus posted were for 12/3/01 and 11/28/01. (b) The Executive Director stated during an interview on 12/4/01 in the afternoon, that the Center has been seeking the input of a dietician; however, the menus are not currently planned with the assistance of a dietician. REPEAT

Deficiency cited, survey : C 246 64-11-7.3.e.2.B. Treatment Plan

(1) Based on record review and interview, the Center has not ensured that the treatment plan includes measurable objectives in two (2) of two (2) active records reviewed (Consumer #5 and #7). Findings include: (a) Consumer #5's 9/16/01 treatment plan contains objectives that are methods, such as "will attend counseling once a week at school for the next six months" and "will take his Lamictal 100 mg. one tablet in the morning and one at bedtime as long as the doctor recommends it." Record review and interview with the case manager on 12/6/01 at 8:10 a.m. revealed consumer compliance was not a problem for either objective. (b) Consumer #7's 10/21/01 treatment plan contains objectives that are methods, such as "will attend counseling at every week for the next three (3) months..." and " will take his Clariton at bedtime as needed as long as the doctor recommends it." Record review and interview with the case manager on 12/6/01 at 8:10 a.m. revealed consumer compliance was not a problem for either objective.

Deficiency cited, survey : C 104 64-11-5-2.c. Governing Body

Based on record review and staff interview, the administrator has not managed the Center and implemented policy. Findings include: (a) There has been no functioning human rights committee at the Center since January 2000. (Also see C159 - \'a764-11-5.9.a.1.) (b) The Center had no policy or procedures for medication errors, including reporting these to the physician. Additionally, there was no system of review for medication errors. There was no system to ensure medications ordered by the physician are promptly filled. Consumers did not receive medications as ordered by the prescribing physician. (Also see C297 - \'a764- 11-7.10.b.3. and C298 - \'a764-11-7.10.b.4.) (c) Employee records reviewed of employees hired after 1/5/00 were without a job application and any evidence of training in consumer rights; one-half of the records reviewed of employees hired after 1/5/00 were without evidence of training in crisis intervention and restraints; the record of one staff (house parent) hired 8/00 was without evidence of any reference checks; and all records reviewed of employees hired after 8/00 lack training regarding their responsibilities in supervising the medication administration for consumers who self administer medications. Also see C145 - \'a764-11-5.6.d.1., C147 - \'a764-11- 5.6.d.3., C152 - \'a764-11-5.7.a. and C154 - \'a764-11-5.7.c. (d) The director was not able to provide a written policy or procedure regarding the orientation and initial training of new employees ...

Deficiency cited, survey : C 145 64-11-5.6.d.1. Personnel

Based on record review and staff interview, the Center has not maintained a personnel record that includes the job application in four (4) of four (4) records reviewed of staff hired after 1/5/00 (Staff #1, #2, #4 and #6). Findings include: (a) Review of the house parents personnel records revealed no job applications for: Staff #1 - hired 9/9/00; Staff #2 - hired 8/24/00; Staff #4 - hired 1/11/00; and Staff #6 - hired 8/18/00. Yet, on the outside of each file is a checklist that includes "job application". The two (2) files of employees, #3 and #5, hired in 1998 and 1999 respectively, contain job applications. (b) During an interview on 4/5/01, in the morning, the director reviewed the files and did not find any job applications.

Deficiency cited, survey : C 146 64-11-5.6.d.2. Personnel

Based on record review and staff interview, the Center has not maintained a personnel record that includes emergency contacts in six (6) of six (6) staff records reviewed (Staff #1, #2, #3, #4, #5 and #6). Findings include: (a) Review of staff personnel records revealed lack of information regarding emergency contacts for: Staff #1 - hired 9/9/00; Staff #2 - hired 8/24/00; Staff #3 - hired 3/10/98; Staff #4 - hired 1/11/00; Staff #5 - hired 5/11/99; and Staff #6 - hired 8/18/00. (b) During an interview on 4/5/01, in the morning, the director reviewed some files and did not find any information about emergency contacts.

Deficiency cited, survey : C 147 64-11-5.6.d.3. Personnel

Based on record review and staff interview, the Center has not maintained a personnel record that includes references for the house parents hired after 8/1/00 in one (1) of three (3) records reviewed. Findings include: (a) Review of staff personnel records revealed a lack of any reference checks for Staff #2 - hired 8/24/00. (b) During an interview on 4/5/01, in the morning, the director reviewed the file and did not find any information regarding reference checks. The director indicated that the employee had listed references on her resume; however, there was no indication that the references had been checked.

Deficiency cited, survey : C 152 64-11-5.7.a. Staff Training

Based on record review and staff interview, the Center has not ensured that professional and direct care staff shall begin orientation and training on consumer rights and the use of emergency procedures, such as crisis intervention and restraints, for four (4) of the four (4) house parent staff records reviewed who were hired after 1/5/00. Findings include: (a) Review of the house parents personnel records revealed lack of orientation and training on consumer rights for: Staff #1 - hired 9/9/00; Staff #2 - hired 8/24/00; Staff #4 - hired 1/11/00; and Staff #6 - hired 8/18/00. (b) Review of the house parents personnel records revealed lack of training on the use of emergency procedures, such as crisis intervention and restraints for: Staff #2 - hired 8/24/00; and Staff #6 - hired 8/18/00. (c) During an interview on 4/5/01, in the morning, the director reviewed the files and did not find any record of consumer rights training or training on the use of emergency procedures, such as crisis intervention and restraints for the above mentioned staff.

Deficiency cited, survey : C 154 64-11-5.7.c. Staff Training

Based on record review and staff interview, the Center has not ensured that employees providing services to consumers are trained regarding their responsibilities in supervising the medication administration for consumers who self administer medications for three (3) of the three (3) house parent staff records reviewed who were hired after 8/18/00. Findings include: (a) Review of the house parents personnel records revealed lack of orientation and training regarding medications for: Staff #1 - hired 9/9/00; Staff #2 - hired 8/24/00; and Staff #6 - hired 8/18/00. (b) During an interview on 4/5/01, in the morning, the director reviewed the files and did not find any record of orientation or training regarding medication use for the above mentioned staff. The director stated on 4/5/01, in the morning, that consumers self administer their own medications, staff observe and then both parties initial the medication records. The medications and current months records are kept in a locked box in the staff office; he opened the locked medication box for surveyor review. (c) However, staff do not ensure medications are administered for consumer's in compliance with their physician's order; they sometimes withhold medications without a physician's order; there were dates that medications were not documented as being given and there was no documentation regarding the omission. Also see C297 - \'a764-11-7.10.b.3. (d) Staff do not ensure that medication errors, as defined by this rule ...

Deficiency cited, survey : C 159 64-11-5.9.a.1. Human Rights Committee

Based on staff interview, the Center has not maintained a human rights committee to hold meetings and and keep written minutes of all meetings. Findings include: (a) The director was not able to provide any documentation of human rights committee meetings during the survey. He stated on 4/4/01, in the morning, that there had been no human rights committee meetings since he started at the Center (January 2000). 64-11-6.6.n.2. Physical Environment -

Deficiency cited, survey : C 204 Residential Facilities

Based on record review, handwritten Center menus and staff interview, the Center has not ensured that the food services are planned with the regularly documented assistance of a dietitian. Findings include: (a) Consumer #7 had been to the emergency room on 2/3/01 and to the physician's office on 2/14/01 because of constipation. Review of the daily handwritten menus lacks evidence of any assistance with a dietician. (b) The financial officer stated on the morning of 4/6/01 that the Center receives reimbursement for the foods and there is no dietician review associated with the reimbursement. The director could not show any evidence that the food services are planned with regularly documented assistance of a dietitian; he stated that he was unaware of this regulation during discussion the morning of 4/6/01.

Deficiency cited, survey : C 240 64-11-7.3.a. Treatment Plan

Based on record review, the Center has not assured that the consumer shall have a written treatment plan that considers the consumer's needs in one (1) of two (2) active consumer records reviewed. The consumer identifier is #7. Findings include: (a) Record review of Consumer #7 revealed an emergency room (ER) visit on 2/3/01 with staff progress notes dated 2/3/01 documenting the reason: "constipation and cramping of the stomach". The progress notes document upon return from the ER: "...drank the medicine for his constipation. He then went to bed.". The report of the ER follow up visit of 2/4/01 contains instructions that include: drink plenty of fluids and increase the bran in his diet. On 2/14/01, during a physician visit, the documentation notes a problem with constipation and instructions that include: increase vegetables, fruit and liquid in the diet. (b) The current treatment plan dated 3/12/01 does not address the need for his diet to include an increase in bran, vegetables, fruit and liquids.

Deficiency cited, survey : C 252 64-11-7.3.g.4. Treatment Plan

Based on record review and staff interview, the Center has not ensured that the treatment plan provides for the review of drug dosages and types and explains the rationale for changes or continuation of psychotropic drugs regimens for one (1) of one (1) consumers where medications are used. The consumer identifier is #2. Findings include: (a) Record review for Consumer #2 revealed treatment plans dated 10/13/00, 1/10/01 and 3/21/01. The consumer was taking Depakote (dosage varied from 250 mg TID to currently 500 mg BID) and Adderall (dosage varied from 30 mg TID to currently 20 mg 8:00 a.m. and 12:00 noon and 10 mg at 4:00 p.m.); yet a review of these drug dosages and types and a rationale for of the psychotropic drugs regimens, including changes, are not on his treatment plan. Additionally, the medication administration records (MARs) have conflicting reasons for the rationale of the medication Depakote. On the 10/4 -7/00 record, the reason is documented by staff as "depression", on the 3/18-21/01 record, the reason is documented by staff as"seizures". (b) The case manager acknowledged on 4/5/01, in the afternoon, that the treatment plan for Consumer #2 did not contain the required information about the psychotropic drugs and that there are conflicting reasons given for the use of the medication Depakote.

Deficiency cited, survey : C 254 64-11-7.4.a. Treatment Plan Review

Based on record review of treatment plans and staff interview, the Center has not ensured that treatment plan reviews summarize the amount of treatment or training provided, documents progress towards the objectives, or indicates problems that impeded progress for two (2) of two (2) treatment plan reviews of consumers currently residing in the Center. The consumer identifiers are #1 and #7. Findings include: (a) Record review of Consumer #1's record revealed a treatment plan dated 1/10/01 that has goals and/or objectives of: acquiring knowledge of community/recreational resources, along with how to use them; and he will get off probation, he will not increase his probationary period by acting inappropriately or using drugs. However, the treatment plan summary (review) dated 1/10/01 does not summarize the amount of treatment or training provided, note progress toward the objectives or document the problems or barriers that impede progress. (b) Record review of Consumer #7's record revealed a treatment plan dated 3/12/01 that documents as a problem (health/medical) that he hasn't met the medical assessments for placement, yet the treatment plan summary/review does not note the problems or barriers that impede progress or what the unmet medical assessments are. (c) Discussion of the records and lack of treatment plan reviews containing the required content occurred with the director on 4/6/01 in the morning. He stated he was aware of problems with the treatment plans.

Deficiency cited, survey : C 297 64-11-7.10.b.3. Medication Services

Based on consumer record review, review of the Center's medication policy, and staff interview, the Center has not ensured that the process for administering medications includes that all medications are administered in compliance with the physician's orders for two (2) of two (2) consumers in the sample with daily medications. The consumer identifiers are #2 and #7. Findings include: (a) The director stated on 4/5/01, in the morning, that consumers self administer their own medications, staff observe and then both parties initial the medication records. The medications and current months' records are kept in a locked box in the staff office; he opened the locked the medication box for surveyor review. (b) Record review of Consumer #2's medication administration record (MAR) for April 2001 documents the physician ordered "Adderall 10 mg at 4 p.m." However, there was no documentation that the 4:00 p.m. doses on 4/01/01 or 4/02/01 were given or documentation regarding the omission. Staff #7 stated on 4/05/01 in the afternoon that she did not give the consumer his afternoon medication on 4/2/01 because she returned with the other consumers to the Center after 5:00 p.m. Yet, Consumer #2 was at the Center on 4/2/01, at 4:00 p.m., and staff at the Center did not ensure that the consumer received his medication. Staff #7 stated she had been told that if the time frame is more than one hour after the time not to give the medication; she also stated that no one called the physician ...

Deficiency cited, survey : C 298 64-11-7.10.b.4. Medication Services

(1) Based on consumer record review, review of the Center's medication policy in the policy and procedure manual and staff interview, the Center has not ensured that medication errors, as defined by this rule are reported immediately in accordance with written procedures, including properly recording it in the consumer's record and notifying the physician who prescribed the drug for two (2) of two (2) consumers in the sample with daily medications. The consumer identifier are #2 and #7. Mediation errors (defined by this rule, \'a764-11-3.26 include: the failure to administer a drug ordered by a physician. Findings include: (a) The director stated on 4/5/01, in the morning, that consumers self administer their own medications, staff observe and both parties initial the medication records. The medications and current months records are kept in a locked box in the staff office; he opened the locked medication box for surveyor review. (b) Review of the Center's medication policy, last revised 6/99, in the policy and procedure manual revealed nothing about medication errors or reporting the errors to the physician. During discussions regarding medications the morning of 4/6/01, the director stated that there is no policy regarding medication errors or reporting these errors to the prescribing or attending physician, nor is there a systemic review of the medication errors for trends or patterns. (c) Record review of Consumer #2' medication administration record (MAR) for April ...

Deficiency cited, survey : C 351 64-11-8.1.a.23. Basic Rights

Based on review of the Resident's Rights given to consumers and staff interview, the Center has failed to update the consumers rights to include rights that are required in the current West Virginia Legislative Rules for Licensure of Behavioral Health Centers, 664CSR11, effective 7/1/00. Findings include: (a) Review of the current printed Resident's Rights information, contained in the Facility Policies and Procedures manual provided by the director of the Center, occurred on 4/05/01. The printed information has the following Consumer Rights (in the current licensure regulations, in effect since 7/1/00) omitted from the document. Some of the omitted phrases or rights include: (i) \'a764-11-8.1.a.1. - "The right to treatment and services that...result in a positive outcome to the maximum extent possible"; (ii) \'a764-11-8.1.a.10. - "The right to human treatment environment in which personal dignity and self-esteem are promoted"; (iii) \'a764-11-8.1.a.13. - "The right to assert grievances, [wording has changed to include] orally or in writing..."; (iv) \'a764-11-8.1.a.19. - "The right to be free from physical, [wording has changed to include] verbal,...psychological abuse or punishment"; (v) \'a764-11-8.2.a.20. - "The right to be free from unnecessary...medication"; and (vi) \'a764-11-8.1.a.24.B. - "The right to unimpeded access to his or her attorney or religious advisor." (b) Interview with the director on 4/6/01, in the morning, revealed that the Resident's Rights has not ...

Deficiency cited, initial licensure survey : C 168 64-11-5.10.a.1. Transportation Services

Based on interview and record review, the Center does not have written procedures for the maintenance of center vehicles. Findings include: (a) There was no mention in policy/procedure manual of vehicle maintenance. (b) This was confirmed during interview with the executive director on 4/3/01, at 11:00 a.m.

Deficiency cited, initial licensure survey : C 169 64-11-5.10.a.2. Transportation Services

Based on interview and record review, the Center does not have written procedures for adequate passenger supervision. Findings include: (a) There was no mention in policy/procedure manual of passenger supervision including maximum number of consumers in the vehicles, or the staff: consumer ratio(s). (b) This was confirmed during interview with the executive director on 4/3/01, at 11:00 a.m.

Deficiency cited, initial licensure survey : C 228 64-11-7.1.b. Program Description

Based on interview and record review, the Center does not have procedures outlining outside services providers' responsibilities. Findings include: (a) There was no mention in the policy/procedure manual of the responsibilities of outside service providers. The manual does not identify these service providers or their function relative to the Center. (b) This was confirmed during interview with the executive director on 4/3/01, at 11:00 a.m.

Deficiency cited, initial licensure survey : C 266 64-11-7.6.b.1. Behavior Intervention

Based on interview and record review, the Center does not have written procedures for behavioral interventions. Findings include: (a) There was no mention in policy/procedure manual of behavioral interventions except as related to the review by the human rights committee. (b) There was no reference to functional analysis prior to behavioral interventions, or procedures to develop behavioral plans. (c) This was confirmed during interview with the executive director on 4/3/01, at 11:00 a.m.

Deficiency cited, survey : C 118 64-11-5.4.h. Financial

Based on record review and staff interview, the center failed to obtain a bond to protect the funds of eleven (11) of eighteen (18) consumers who have funds that exceeds $500.00 in total value. Findings include: (a) Review of the center's consumer fund balance sheet for the month of October 2000 and interview with the resident coordinator on 11/30/00, at approximately 7:00 p.m., indicate several consumers, #2, #4, #5, #6 and #7, have summer employment wages and weekly allowance money in the amount of approximately $814.24. This fund is kept in custody of the center for safekeeping. Additionally, several other consumers, #1, #8, #11, #13 and #14, have weekly allowance money in the approximate amount of $198.00 which is also in the custody of the center. However, the center has not obtained any kind of Bond to protect these consumers' funds that exceed $1,012.00 in value.

Deficiency cited, survey : C 152 64-11-5.7.a. Staff Training

Based on personnel record review and staff interview, the center failed to ensure that each staff receives training in consumer rights beginning on the first day of employment for three (3) of the four (4) child care workers' personnel records reviewed. Findings include: (a) Staff G, H and I's personnel records indicate that each of these employees did not receive training in consumer's rights, although they have been employed since 2/1/00, 8/14/00 and 9/25/00, respectively. (b) Interviews with the resident coordinator during 11/29-30/00, indicated that the above three (3) staff, G, H and I, have received training in the center's Policy Procedure Manual. Upon further questioning, the resident coordinator handed a two (2) page "Resident Rights" section to the surveyor indicating that staff have received this training. However, the two (2) page section of the Resident Rights were merely the Behavioral Health Centers Licensure regulations, \'a764-11-8.1.a.1. through \'a764-11-8.2.d, repeated. The center did not have a record of the substance of the Resident Rights training, date, or the name of the presenter who might have provided the training to these staff to prevent potential abuse and neglect of the consumers.

Deficiency cited, survey : C 153 64-11-5.7.b. Staff Training

Based on record review and staff interview, the center failed to ensure that each staff receives training in first aid, infectious disease control, cardiopulmonary resuscitation (CPR) and Heimlich's maneuver procedures for four (4) of the four (4) staff personnel records reviewed. Findings include: (a) Staff D, H and I's personnel record did not contain current certification of first aid training. (b) Staff D, H and I's personnel record did not contain any records of training in infectious disease control. (c) Staff D, H and I's personnel record did not contain current certification or record of their training in CPR and Heimlich's maneuver. (d) Interview with the resident coordinator on 11/29-30/00, verified that the above records were not in the staff personnel records and no other verification was provided at the time of this review.

Deficiency cited, survey : C 157 64-11-5.8.a.1. Requirements for Residential Staff

Based on record review and staff interview, the center failed to ensure that onsite direct care staff have immediate access to relevant information in consumers' medical records in case of medical or other emergency during the evening shift from 8:00 p.m. to 8:00 a.m. Findings include: (a) Review of the consumer's medical records from 11/28-30/00 and interview with the resident coordinator during this time period, determined that all eighteen (18) consumers' records are kept in the locked main office located in a separate building from 8:00 p.m. through 8:00 a.m. The office staff leaves the facility by 7:00- 8:00 p.m., and the direct staff do not have access to the locked main office after 8:00 p.m. (b) Fourteen (14) consumers share the converted barn building and four (4) consumers share two (2) small trailers on the property with the direct staff. The locked medicine room behind the locked kitchen door in the barn building contains only one (1) combined chart of the medication administration records for all eighteen (18) consumers. The child care workers from 8:00 p.m. through 8:00 a.m., therefore, do not have access to any of the medical/psychological or psychiatric or any other relevant information in case of an emergency during this 12 hour shift.

Deficiency cited, survey : C 186 64-11-6.4.b. Structures, Grounds, Equipment

(2) Based on observation and staff interview, the center failed to maintain a clean and sanitary condition in the food storage area and in the laundry room. Findings include: (a) During observation of the center on 11/28/00, a overflowing garbage bag was observed to be laying at the front of the locked food storage room and two (2) or three (3) cats were around. Also, the floor of the food storage room was soiled and dirty. (b) The locked laundry room behind the barn was in complete disarray with boxes of Christmas items cluttering the floor, piles of washed clothes, bedding on one (1) table, several piles of dirty clothes on the floor. A cat jumped on the pile of washed clothes, as soon as the staff opened the laundry door. (b) Interview with the attending staff during this observation period on 11/28/00, indicated that each consumer is assisted/supervised to wash and put away their clothes properly one (1) time a week. However, looking at the piles of dirty clothes stored in the five (5) upstairs bedrooms and the piles of washed/unwashed clothes in the laundry room, it was evident that staff supervision is lacking to maintain the center in a neat and sanitary condition.

Deficiency cited, survey : C 194 64-11-6.6.e. Physical Environment - Residential Facilities

Based on observation and interview, it was determined that the center does not provide a homelike environment for the consumers in the barn building. Findings include: (a) During the tour of the barn building on 11/28/00, it was observed that the eight (8) consumers' bedrooms on the second floor had very little or no personal items in them. The staff indicated that most of the consumers do not bring any personal items, not even family pictures. Therefore, they do not have personalized rooms.

Deficiency cited, survey : C 198 64-11-6.6.i. Physical Environment - Residential Facilities

Based on observation, it was determined that the center does not have sufficient solid waste storage containers to contain the solid waste in safe and sanitary manner. Findings include: (a) During observation on 11/28/00, at approximately 1:00 p.m., the center's solid garbage container was observed to be open and overflowing with several garbage bags. Cats were also observed to be running around the garbage dump area in the back of the kitchen and dinning room. Another full garbage bag was sitting in front of the food storage room.

Deficiency cited, survey : C 202 64-11-6.6.m. Physical Environment - Residential Facilities

Based on observation and interview, the center failed to ensure that each consumer is served their food in a sanitary manner. Findings include: (a) During observation on 11/28/00, around 6:00 p.m., each consumer's milk was poured in a small paper cup and left on a tray in the dinning area for approximately one-half hour prior to the consumers eating their dinner. (b) During this same observation period, sixteen (16) consumers were observed to be crowded at two (2) medium sized dinning tables that was not wiped prior to eating dinner. Each consumer received their dinner on a pre-poured dinner plate from the cook in the kitchen. Most consumers put their cornbread on the bare table top, then used one (1) single knife to scoop margarine from one single big container, and then applied to their soiled cornbread. (c) None of the consumers were provided with a dinner knife to cut their pork chops and each stabbed at their pork chops with their fork and bite it. Some consumers put down their fork on the soiled table top, then used the same fork to eat their desert of Jello and whipped cream. (d) Two (2) consumers could not be seated at the first setting, so they waited to eat their dinner after one (1) dinning table emptied. One (1) consumer was assigned to take all eight (8) consumers' soiled dishes to the kitchen area and throw the soiled food in the garbage. However, he was not instructed to wipe the table, nor did the staff wipe the soiled table, and the two (2) remaining ...

Deficiency cited, survey : C 217 64-11-6.8.b.9. Consumer Records

Based on observation and interview, the center failed to ensure that a signed and dated physician's order by the center's physician, or a copy of the prescription, was available in the consumer's record for four (4) of four (4) consumers in the sample. Findings include: (a) Consumer #1's medication administration records (MARs) reviewed for the month of November 2000, indicate he received "DDAVP Nasal Spray, 1 spray to each nostril" for bedwetting treatment. However, a physician's order was not available in the record at the time of the review on 11/30/00. (b) Consumer #2's MARs reviewed for the month of November 2000, indicate has been receiving "1 -5 mg. tablet Vasotec" for his heart condition and "2 tbs. Zithromax 250 mg. on day one, then 1 tb. for 4 days" from 11/27/00. However, a physician's order was not available in the record at the time of review on 11/30/00. (c) Consumer #3's MARs reviewed for the month of November 2000, indicate he has been receiving "1 - 600 mg. tablet Neurontin at 8:30 a.m., 4:00 p.m. and 8:30 p.m.", "1/2 -0.1 mg. Clonidine at 8:30 a.m. and 1 - 0.1 mg. Clonidine at 9:00 p.m.", "2 - 150 mg. tablet Wellbutrin at 9:00 a.m. and 1 -150 mg. tablet Wellbutrin SR at 3:45 p.m." However, neither a physician's order nor a copy of the prescription orders was available in the record at the time of review. (d) Consumer #4 is an insulin dependent diabetic and his MARs for the month of November 2000, indicate he self injects "25 units of Humulin U" and "1 unit ...

Deficiency cited, survey : C 252 64-11-7.3.g.4. Treatment Plan

Based on records review and staff interview, the center failed to ensure that the treatment plan provides for the review of drug dosages, types and explains the rationale for changes or continuation of psychotropic drugs for one (1) of one (1) consumers who is receiving such drugs reviewed in the sample. Findings include: (a) The medication administration records (MARs) reviewed for the month of November 2000, indicate Consumer #3 is receiving three (3) different medications - Neurontin, Clonidine and Wellbutrin to control his aggressive behavioral problems. (b) The psychological evaluation and diagnostic impression dated 11/15/00, states Consumer #3's diagnosis as follows: "Attention Deficit Hyperactivity disorder; Oppositional Defiant disorder; Physical and sexual abuse victim; and learning disorder in math, reading and writing." (c) However, Consumer #3's treatment plan dated 5/26/00 does not contain a description of the above medications, dosage or the purpose for the continuation of each medication to control his diagnostic conditions.

Deficiency cited, survey : C 294 64-11-7.10.a. Medication Services

Based on observation and interview, the center failed to provide a clean, sanitary method of drug storage as per the professional nursing standards. Findings include: (a) During the drug storage observation on 11/30/00, at approximately 6:00 p.m., it was observed that one (1) of the counselors was trying to clean the drug storage/filing cabinet to accommodate the monthly supply of drugs that arrived that day. The top filing cabinet contained many old and new topical medications for two (2) different consumers. The same file compartment also contained the insulin - Humalog and Humulin bottles of Consumer #4. The drug compartment also contained the Bio-Hazard container that contained the used needles and acu-check-pricks of Consumer #4. (b) Interview with the counselor at this time period indicated that she was unaware that external topical and internal/oral medications are not supposed to be stored together. She was also not aware that a Bio-hazard container with used needles and blood/covered acu-checks should be stored in a separate location and in the medication storage area.