summary: Plan of Correction - MHLCS Annual

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PRINTED: 09/19/2019

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
. CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
|
| 346089 Bo WING ee 09/11/2019
a NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
| 91 POPLAR CIRCLE
| BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL SWANNANOA, NC 28778
ir (X4) ID - SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
| TAG REGULATORY OR LSC IDENTIFYING INFORMATION} TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
| =
W 189 STAFF TRAINING PROGRAM W 189

CFR(s): 483.430(e)(1)

| The facility must provide each employee with

] initial and continuing training that enables the

| employee to perform his or her duties effectively,
| efficiently, and competently.

|

|

This STANDARD is not met as evidenced by: il wha
Based on observation, record review and

interviews, the facility failed to ensure staff were

sufficiently trained relative to client positioning at

meals for 1 of 2 sampled clients (#27) in

Beaucatcher. The finding is: RECEIVED
Observations in the group home on 9/10/19 at :
6:25 PM revealed client #27 to participate in the ocT -7 2019

supper meal that included beef casserole, refried

beans and fruit. Continued observation of client

#27 at the supper meal revealed the client to sit in

a wheelchair at the table, to feed herself with staff DHSR on L & ron
assistance when needed and to utilize a swivel Black Mountain

spoon utensil. Continued observation revealed

| client #1 to have excessive food spillage while

self feeding, dropping food into both the

wheelchair and the client's lap.

Review of records for client #1 on 9/11/19
revealed a an occupational therapy (OT)
evaluation dated 7/23/19. Review of the OT
| evaluation revealed client #1 to have a pureed
| diet with thin liquids. Further review of the OT
evaluation revealed client #1 to have a thoracic
cushion in her dining chair due to a diagnosis of
severe kyphoscoliosis. The 7/2019 OT
evaluation further reflected the recommendation
at meals that staff need to ensure client #1 is
transferred from her wheelchair to the wooden
chair for optimal positioning to feed herself

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE. TITLE {X6) DATE

Mili ~” Derek brisena Program Adenitnrs trator 4:30-19

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
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 disclosable 14
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.

FORM CMS-2567(02-99} Previous Versions Obsolete Event ID:0Q2411 Facility (D: 922418 if continuation sheet Page 1 of 10

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

PRINT!
FO

ED: 09/19/2019
RM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION (X3)

DATE SURVEY

TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

W 189 Continued From page 1
successfully.

Interview with the qualified intellectual disabilities
professional (QIDP) on 9/11/19 revealed client #1
should have been transferred to the wooden
dining chair that is used for client #27 at all meals
to support proper positioning of the client while
self feeding.

INDIVIDUAL PROGRAM PLAN

CFR(s): 483.440(c)(4)

W 227

The individual program plan states the specific
objectives necessary to meet the client's needs,
as identified by the comprehensive assessment
required by paragraph (c)(3) of this section.

This STANDARD is not met as evidenced by:
Based on observation, review of records and
interview, the team failed to ensure the individual
service plan (ISP) for 1 of 4 sampled clients (#1)
in Beaucatcher included objective training to
address needs relative to behavior management.
The finding is:

Observation in the group home on 9/11/19 at 8:25
AM revealed client #5 to walk down the hallway of
the group home after the breakfast meal and
attempt to hold onto this surveyor by the pants
and to grab and pull this surveyor's hand
Continued observation from 8:30 AM until 8:45
AM revealed staff C and Y to observe client #1 to
follow this surveyor around the facility, attempting
to grab this surveyor by the pant leg and hand
while providing no redirection of client #1.
Observation further revealed client #1 to walk
close to client #17 in the facility hallway and client

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:0Q2411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
346089 BAWING 09/11/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL
SWANNANOA, NC 28778
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x6)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
DATE

TAG CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

W 189

W 227

Facility ID: 922418

ol

If continuation sheet Page 2 of 10

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

PRINTED: 09/19/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES. (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G089

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

(X3) DATE SURVEY.
COMPLETED

09/11/2019

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

SUMMARY STATEMENT OF DEFICIENCIES.

(X4) ID
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

W 227 Continued From page 2

#17 to state "No, get away from me"
Observation at 8:48 AM revealed Staff Y to
prompt client #1 to a morning routine activity of
changing clothes to which the client complied.

Review of records for client #1 on 9/11/19
revealed an ISP dated 12/4/19. Review of the
ISP revealed current training objectives to
address daily living skills and hygiene. Further
review of the ISP revealed no behavior support
guidelines, objectives or interventions to address
observed behaviors of pulling on others, following
or invading the personal space of others.

Interview with the clinical director and qualified
intellectual disabilities professional (QIDP) on
9/11/19 verified client #1 did not have a behavior
support plan. Further interview with the clinical
director and QIDP confirmed client #1 has a
history of behavior that included pulling on staff
that is usually related to communication.
Additional interview verified client #1 will invade
the personal space of others in an effort to get
attention. Interview with the clinical director and
QIDP confirmed client #1 could be benefit from
training to address identified needs of pulling
behavior and invading the personal space of
others.

PROGRAM IMPLEMENTATION

CFR(s): 483.440(d)(1)

W 249

As soon as the interdisciplinary team has
formulated a client's individual program plan,
each client must receive a continuous active
treatment program consisting of needed
interventions and services in sufficient number
and frequency to support the achievement of the
objectives identified in the individual program

ID PROVIDER'S PLAN OF CORRECTION (x5)

PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
Ww 227
Ww 249 A)

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:0Q2411

Facility ID: 922418 If continuation sheet Page 3 of 10

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

PRINTED: 09/19/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER

34G089

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

(X3) DATE SURVEY
COMPLETED

B WING 09/11/2019

NAME OF PROVIDER OR SUPPLIER.

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE

(4) ID SUMMARY STATEMENT OF DEFICIENCIES.
PREFIX (EACH DEFICIENCY MUST BE PRECEDED 8Y FULL PREFIX
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
——_—

SWANNANOA, NC 28778
ID PROVIDER'S PLAN OF CORRECTION (x5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETION

W 249 Continued From page 3
plan

This STANDARD is not met as evidenced by:
Based on observations, review of records and
staff interviews, the facility failed to ensure
objectives and guidelines listed in the individual
service plans (ISP's) were implemented as
prescribed for 3 of 3 sampled clients in Sunset
(#9, #25 and #29) and 1 of 2 sampled clients in
Beaucatcher (#27). The findings are:

objective was implemented as prescribed for
client #9.

Observations in Sunset on 9/10/19 at 4:35 PM
revealed clients #9, #25 and #29 to be seated at
the dining table for snack. Further observations
at that time revealed staff A in the kitchen
operating a food processor to puree cookies
without the assistance of any clients. Continued
observations at 4:45 PM revealed clients #9, #25
and #29 eating the pureed cookies for the snack
meal.

Observations on 9/10/19 at 5:27 PM revealed
staff V in the kitchen processing dinner food
items without assistance from any clients.
Further observations at 6:00 PM revealed staff Z
processing dinner food items without the
assistance of clients and at that time, clients #9,
#25 and #29 were sitting at the dining table.
Continued observations at 6:10 PM revealed
clients #9, #25 and #29 eating pureed dinner
items consisting of beef and re-fried beans, bean
salad, and mashed potatoes.

A. The facility failed to ensure a meal preparation

W 249

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:0Q2411

Facility ID: 922418 If continuation sheet Page 4 of 10

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

PRINTED: 09/19/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES. (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER

34G089

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A, BUILDING

BING 09/11/2019

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

SUMMARY STATEMENT OF DEFICIENCIES

(x4) ID
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

Review of the record for client #9 on 9/11/19
revealed an ISP dated 3/1/19 which included a
nutrition section, which indicated the client has a
regular, pureed diet. Further review of the ISP
revealed an objective implemented 11/6/18 for
client #9 to initiate pushing down on a switch to
puree meal items 75% of the time for three
consecutive months

Interview with the qualified intellectual disabilities
professional (QIDP) on 9/11/19 confirmed the
food processing objective was current and
confirmed the objective should be trained at all
opportunities.

B. The facility failed to ensure a meal preparation
guideline was implemented as prescribed for
client #25.

Observations in Sunset on 9/10/19 at 4:35 PM
revealed clients #9, #25 and #29 to be seated at
the dining table for snack. Further observations
at that time revealed staff A in the kitchen
operating a food processor to puree cookies
without the assistance of any clients. Continued
observations at 4:45 PM revealed clients #9, #25
and #29 eating the pureed cookies for the snack
meal.

Observations on 9/10/19 at 5:27 PM revealed
staff V in the kitchen processing dinner food
items without assistance from any clients
Further observations at 6:00 PM revealed staff Z
processing dinner food items without the
assistance of clients and at that time, clients #9,
#25 and #29 were sitting at the dining table.
Continued observations at 6:10 PM revealed
clients #9, #25 and #29 eating pureed dinner
items consisting of beef and re-fried beans, bean

FORM CMS-2567(02-39) Previous Versions Obsolete

Event ID:0Q2411

ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

W 249 Continued From page 4 W 249

Facility ID: 922418 If continuation sheet Page 5 of 10

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

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

PRINTED: 09/19/2019

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY
COMPLETED

AND PLAN OF CORRECTION

A. BUILDING

B. WING

34G089

09/11/2019 |

[aie OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PROVIDER'S PLAN OF CORRECTION (x5),

COMPLETION
DATE

salad, and mashed potatoes.

Review of the record for client #25 on 9/11/19
revealed an ISP dated 11/11/18 which included a
nutrition section, which indicated the client has a
regular pureed diet. Further review of the ISP
revealed a current meal preparation guideline for
the client to puree her food items:

Interview with the QIDP on 9/11/19 confirmed the
food processing guideline was current and
confirmed the guideline should be followed at all
opportunities.

C. The facility failed to ensure a meal preparation
guideline was implemented as prescribed for
client #29.

Observations in Sunset on 9/10/19 at 4:35 PM
revealed clients #9, #25 and #29 to be seated at
the dining table for snack. Further observations
at that time revealed staff A in the kitchen
operating a food processor to puree cookies
without the assistance of any clients. Continued
observations at 4:45 PM revealed clients #9, #25
and #29 eating the pureed cookies for the snack
meal.

Cbservations on 9/10/19 at 5:27 PM revealed
staff V in the kitchen processing dinner food
items without assistance from any clients
Further observations at 6:00 PM revealed staff Z
processing dinner food items without the
assistance of clients and at that time, clients #9,
#25 and #29 were sitting at the dining table
Continued observations at 6:10 PM revealed
clients #9, #25 and #29 eating pureed dinner
items consisting of beef and re-fried beans, bean
salad, and mashed potatoes.

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES, ID
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
W 249 Continued From page 5 W 249

___|

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:0Q2411 Facility ID: 922418

If continuation sheet Page 6 of 10

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

PRINTED: 09/19/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G089

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION
COMPLETED

A. BUILDING

EWING 09/41/2019

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

SUMMARY STATEMENT OF DEFICIENCIES

(x4) 1D
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

Review of the record for client #29 on 9/11/19
revealed an ISP dated 4/11/19 which included a
nutrition section, which indicated the client has a
1200 calorie, low fat, pureed diet. Further review
of the ISP revealed a current meal preparation
guideline for the client to push the button on the
food processor to help puree her food

Interview with the QIDP on 9/11/19 confirmed the
food processing guideline was current and
confirmed the guideline should be followed at all
opportunities.

D. The facility failed to ensure meal guidelines
were implemented as prescribed for client #27.

Observations in the group home on 9/10/19 at
6:25 PM revealed client #27 to participate in the
supper meal that included beef casserole, refried
beans and fruit. Continued observation of client
#27 at the supper meal revealed the client to sit in
a wheelchair at the table, to self feed with staff
assistance when needed and to utilize a swivel
spoon utensil. Continued observation revealed
client #1 to have excessive food spillage while
self feeding, dropping food into the wheelchair
and onto the client's lap. At no time during
observation of the supper meal was it observed
for staff to offer client #27 additional food to
replace spillage.

Observation in the group home on 9/11/19 of
client #27 during the breakfast meal revealed the
client to sit in a wooden chair, to eat her complete
breakfast meal with hand over hand staff
assistance and to utilize a swivel spoon utensil. It
was not observed during the breakfast meal for
client #27 to have the opportunity to self feed

Event ID:0Q2411

FORM CMS-2567 (02-99) Previous Versions Obsolete

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

W 249 Continued From page 6 W 249

Facility 1D: 922418 If continuation sheet Page 7 of 10

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

PRINTED: 09/19/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G089

(X2) MULTIPLE CONSTRUCTION
A BUILDING

(X3) DATE SURVEY
COMPLETED

B. WING 09/11/2019

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

[ (x4) ID
PREFIX
TAG

W 249 Continued From page 7
during any part of the meal

Review of records for client #27 on 9/11/19
revealed mealtime guidelines dated 8/28/19.
Review of the 8/28/19 meal guidelines revealed a
schedule frequency for all snacks and meals.
Continued review of meal guidelines for client #27
revealed a teaching method that indicated 1) Staff
will encourage client #27 to feed herself as much
as possible. 2) Staff may assist the client in
feeding herself by gently putting pressure on the
underside of her dominant elbow (to reduce
severity of tremors). 3) If the client spills any of
her food, please replace the food spilled with
more food. 4) After client #27 has been eating 30
minutes, staff may then provide the client with
hand over hand assistance to finish her meal.

Interview with the QIDP on 9/11/19 verified the
meal guidelines for client #27 remain current.
Continued interview with the QIDP revealed
additional food should have been offered to the
client to address spillage during meals. The
QIDP further confirmed staff should not begin
hand over hand assisting client #27 with eating
unless the client has been eating 30 minutes and
is continuing to take a long time to finish her
meal

SPACE AND EQUIPMENT

CFR(s): 483.470(g)(2)

W 436

The facility must furnish, maintain in good repair,
and teach clients to use and to make informed
choices about the use of dentures, eyeglasses,
hearing and other communications aids, braces,
and other devices identified by the
interdisciplinary team as needed by the client

ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 249
W 436 yn

=

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:0Q2411

Facility |D: 922418 if continuation sheet Page 8 of 10

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

PRINTED: 09/19/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

This STANDARD is not met as evidenced by:
Based on observation and interview, the facility
failed to maintain in good repair, a wheelchair for
1 of 2 sampled clients (#2) in Pisgah. The finding
is:

Observation in the group home 9/10/19 revealed
client #2 sitting in a wheelchair at the dinner table.
Observation of client #2's wheelchair revealed a
spoke with a sharp edge to protrude outward
from the client's tire . Further observation
revealed client #2 conversing with the qualified
intellectual disabilities professional (QIDP)
pointing at the spoke stating it needed to be
repaired. The QIDP was observed to respond to
client #2 during conversation with "| know" and
further explained a special tool was needed to
complete the repair.

Observation in the group home on 9/11/19 at 9:05
AM revealed while loading on the van, client #2
informed and pointed out to the internal physical
therapy staff that the spoke on her wheelchair
needed to be repaired. Further observation
revealed the internal PT staff to respond to client
#2 with acknowledgement and the need to
contact the wheelchair company to come out and
take a look at the wheelchair.

Interview with the internal PT staff on 9/11/19
revealed the staff to be responsible for repairs
and maintenance of adaptive equipment.
Interview with group home staff on 9/11/19
revealed client #2's wheelchair had been in need
of repair due to the protruding spoke for almost
two weeks. Further interview with the QIDP on
9/11/19 revealed she was made aware of the

AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED
34G089 B. WING 09/11/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL
SWANNANOA, NC 28778
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION 0x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 436 Continued From page 8 W 436

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:0Q2411

Facility |D: 922418 If continuation sheet Page 9 of 10

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

PRINTED: 09/19/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY
COMPLETED

condition of client #2's wheelchair by the PT staff
on 9/5/19 or 9/6/19. The QIDP also revealed that
she was not made aware PT personnel had to
contact the wheelchair company to complete the
repairs. The QIDP further verified the exposed
spoke to be a safety issue

A. BUILDING
34G089 B. WING — 09/11/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL
u SWANNANOA, NC 28778
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE Dare
DEFICIENCY)
W 436 Continued From page 9 W 436

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:0Q2411

Facility |D; 922418 If continuation sheet Page 10 of 10

RECEIVED
Blue West Opportunities — Swannanoa Site 7
ocl -7 2019
Plan of Correction — Survey 9/11/19

DHSR NHL & C
Black Mountain / WRO

W189
The facility must provide each employee with the initial and continuing training that
enables the employee to perform his or her duties effectively, efficiently, and
competently.

Specific example: positioning a client at meals

The Motoric Specialist, William Joseph and Lisa Duncan, CDM, CFPP will complete
retraining of meal time routine for client #27. Training will include adaptive equipment
needs, meal consistency and positioning for meals.

Regular clinical assessment will occur ongoing, at least monthly in each group home,
and will provide staff with the opportunity for retraining as needed, in order to ensure
continued compliance with the expectation that the facility must provide each employee
with the initial and continuing training that enables the employee to perform his or her
duties effectively, efficiently, and competently.

Responsible Persons: William Joseph, Motoric Specialist; Lisa Duncan, Clinical
Support Specialist; Christine Willingham, QIDP

Mechanism to ensure compliance: Clinical Assessment

Frequency of Mechanism: Formally, at least monthly in each group home; informally,
at least weekly in each group home

W227

The individual program plan states the specitic objectives necessary to meet the client’s
needs, as identified by the comprehensive assessment needs. Objectives are
developed for those needs which are considered to be most likely to improve the client’s
ability to independently function in his/her daily life, as determined by the assessment.
There is a clear link between the specific objectives and the functional assessment data
and recommendations.

William R. McCuller, Ph.D., Licensed Psychologist, HSP-P; and Javarous Wilson,

Behavior Analyst, and Christine Willingham, QIDP will create a new behavior support
plan for client AJ addressing behaviors disruptive to habilitation.

After receiving consent from the guardian and HRC, Javarous Wilson will hands-on train
those people working with AJ about the behavior support plan and continue to monitor
the progress.

Christine Willingham, QIDP and Javarous Wilson will round to assess effectiveness and
active implementation of BSPs.

Responsible Persons: Javarous Wilson, Behavior Specialist; Dr. William McCuller,
Psychologist; Christine Willingham, QIDP

Mechanism to ensure compliance: Clinical Assessment

Frequency of Mechanism: Formally, at least monthly in each group home; informally,
at least weekly in each group home

W249

As soon as the interdisciplinary team has formulated a client's individual program plan,
each client must receive a continuous active treatment Program consisting of needed
interventions and services in sufficient number and frequency to support the
achievement of the objectives identified in the individual program.

Specific example: a) The facility failed to ensure a meal preparation objective was
implemented for clients. b) S.C.'s meal time guidelines were not followed and no food
was replaced for spillage.

The assistant QIDP, Stephanie Handy and Lisa Duncan CDM, CFPP will complete
retraining of meal time routines for clients #25, #27, #9 and #29, including adaptive
equipment needs, meal consistency, positioning for meals, and training needs.

In addition, weight monitoring will continue to ensure S.C.'s caloric needs are met, as
evidenced by staying in her ideal weight range. (80 to 94 pounds)

Regular clinical assessment will occur ongoing, at least monthly in each group home,
and will provide staff with the opportunity for retraining as needed, in order to ensure
continued compliance with the expectation that as soon as the interdisciplinary team
has formulated a client's individual program plan, each client must receive a continuous
active treatment program consisting of needed interventions and services in sufficient
number and frequency to support the achievement of the objectives identified in the
individual program.

Responsible Persons: Stephanie Handy, QIDP Assistant; Lisa Duncan, Clinical
Support Specialist; Christine Willingham, QIDP

Mechanism to ensure compliance: Clinical Assessment

Frequency of Mechanism: Formally, at least monthly in each group home; informally,
at least weekly in each group home

W436

The facility must furnish, maintain in good repair and teach clients to use and to make
informed choices about the use of dentures, eyeglasses, hearing and other
communications aids, braces, and other devices identified by the interdisciplinary team
as needed by the client.

Specific example: This STANDARD is not met as evidenced by: based on observation
and interview, the facility failed to maintain in good repair, a wheelchair for 1 of 2
sampled clients (#2) in Pisgah.

Program Administrator will train facility staff responsible for coordinating supports and
assessing needs for changes in supports regarding the facility's protocols for IDT
process. The training will include review of expectations for assessment, notification and
documentation.

The Motoric Specialist, William Joseph and Christine Willingham, QIDP will train all staff
on the process for reporting and maintaining all resident devises, as follows:

Process for reporting repairs needed and maintaining resident equipment

All staff are instructed to access Therap and Scomm their Supervisor, Motoric Specialist
and QIDP with any broken or in need of repair equipment as soon as found. If anyone
believes that there is an immediate danger to residents of staff, then report via walkie-
talkie or call On-Site Supervisor immediately.

Regular assessments in the group homes and chart reviews, and any follow-up thereby
identified, wili be conducted by ithe Program Administrator and QIDP, in order to ensure
continued compliance with the expectation that the facility must furnish, maintain in
good repair and teach clients to use and to make informed choices about the use of
dentures, eyeglasses, hearing and other communications aids, braces, and other
devices identified by the interdisciplinary team as needed by the client.

Responsible Persons: Derek Briscoe, Program Administrator; William Joseph, Motoric
Specialist; Christine Willingham, QIDP

Mechanism to ensure compliance: Clinical Assessment

Frequency of Mechanism: Formally, at least monthly in each group home; informally,
at least weekly in each group home

document_type: Plan of Correction


state: NC

summary: Statement of Deficiency - MHLCS Complaint

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 03/11/2019

FORM APPROVED

OMB NO. 0938-0391

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

(X3) DATE SURVEY

COMPLETED

c
03/07/2019

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000 | INITIAL COMMENTS Ww 000
No deficiencies were cited as a result of a
complaint survey conducted on 3/7/19 for Intake
#NC00148025.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

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 disclosable 14

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.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 1JBE11

Facility ID: 922418

If continuation sheet Page 1 of 1

inspection_type: MHLCS Complaint

document_type: Statement of Deficiency


summary: Plan of Correction - MHLCS Follow-up

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

PRINTED: 12/06/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

R
12/06/2018

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

ID PROVIDER'S PLAN OF CORRECTION (x5)

PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

W 000 | INITIAL COMMENTS

Arevisit was conducted on 12/6/18, for all
previous deficiencies cited during the
recertification survey on 9/19-20/18 and the
complaint survey #NC00144614 on 11/1/18. All
deficiencies have been corrected, and no new
noncompliance was found. The facility is in
compliance with all regulations surveyed.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

W 000

TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
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 disclosable 14
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.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:TV2G12

Facility ID: 922418 If continuation sheet Page 1 of 1

inspection_type: MHLCS Follow-up


summary: Plan of Correction - MHLCS Complaint

raw_content:
PRINTED: 11/09/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
Cc

346089 B.WING_ 41/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

BLUE RIDGE HOMES-SWANNANOA

INITIAL COMMENTS

Intake #NC00144614 I Qty
STAFF TREATMENT OF CLIENTS
CFR(s): 483.420(d)(1)

The facility must develop and implement written
policies and procedures that prohibit
mistreatment, neglect or abuse of the client.

This STANDARD is not met as evidenced by:
The facility failed to ensure its procedures to
manage the behaviors of 4 of 1 sampled clients
(#16) did not result in the neglect of other clients
in the home as evidenced by observation,
interview and record verification. The finding is:

Review of client #16's individual program plan
(IPP) dated 5/18/18 revealed a behavior support
plan (BSP) updated 9/28/18 to address the
client's disruptive behavior. Review of the BSP
revealed client #16's disruptive behaviors are
identified as non-compliance, intrusive seeking
behavior, inappropriate aggressive contact,
verbal aggression, PICA, physical aggression,
property destruction, absent without leave
(AWOL), verbally threatening self-injurious
behavior, making untrue statements, invading the
privacy of other clients' rooms and entering the
bedroom of another client without permission or
approval.

Further review of the BSP, substantiated by
interview with administrative staff, revealed the
BSP was updated on 9/28/18 and included
monitoring with the use of a silent alarm to be
placed on client #16's door to alert staff when he
leaves his room at night to keep client #16 from

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

° Derek CUS bok Chivcal ie Zc for- 1-19-(8%

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
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 disclosable 14
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.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B9FW11 Facility 1D: 822418 If continuation sheet Page 1 of 3

Blue West Opportunities ~ Swannanoa Site
Plan of Correction

Complaint Survey 11/1/18

W 149 STAFF TREATMENT OF CLIENTS

The facility must develop and implement written policies that prohibit mistreatment, neglect or
abuse of the client.

Immediately upon exit of the surveyors on 11/1/18, staff were instructed and trained to increase
supervision of Client #16 until the silent alarm system called for in Client #16’s behavior support
plan is implemented. An additional staff member was instructed to remain in Hawksbill each 3
shift, pending the alarm installation, and instructed to complete 15 minutes bedchecks.

The silent alarm was installed on 11/13/18, and staff were trained on its use. Nightly, the alarm
will be tested prior to its use, in order to ensure its effectiveness in preventing the mistreatment,
neglect or abuse of clients who reside in Hawksbill group home.

Regular clinical assessment and any follow-up thereby identified will be conducted by the clinical
team, in order to ensure continued compliance with the expectation that the facility must
develop and implement written policies that prohibit mistreatment, neglect or abuse of the
client.

Responsible persons: Site Director, QIDP


raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 11/09/2018

FORM APPROVED

OMB NO. 0938-0391

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

(x4) ID
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X3) DATE SURVEY

COMPLETED

c
11/01/2018

(8)
COMPLETION
DATE

W 000

W 149

INITIAL COMMENTS

Intake #NC00144614
STAFF TREATMENT OF CLIENTS

W 000

W 149

CFR(s): 483.420(d)(1)

The facility must develop and implement written
policies and procedures that prohibit
mistreatment, neglect or abuse of the client.

This STANDARD is not met as evidenced by:
The facility failed to ensure its procedures to
manage the behaviors of 1 of 1 sampled clients
(#16) did not result in the neglect of other clients
in the home as evidenced by observation,
interview and record verification. The finding is:

Review of client #16's individual program plan
(IPP) dated 5/18/18 revealed a behavior support
plan (BSP) updated 9/28/18 to address the
client's disruptive behavior. Review of the BSP
revealed client #16's disruptive behaviors are
identified as non-compliance, intrusive seeking
behavior, inappropriate aggressive contact,
verbal aggression, PICA, physical aggression,
property destruction, absent without leave
(AWOL), verbally threatening self-injurious
behavior, making untrue statements, invading the
privacy of other clients' rooms and entering the
bedroom of another client without permission or
approval.

Further review of the BSP, substantiated by
interview with administrative staff, revealed the
BSP was updated on 9/28/18 and included
monitoring with the use of a silent alarm to be
placed on client #16's door to alert staff when he
leaves his room at night to keep client #16 from

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
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 disclosable 14
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.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: B9FW11 Facility ID: 922418 If continuation sheet Page 1 of 3

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 11/09/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
11/01/2018

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

going into others personal bedrooms. Further
interview with administrative staff revealed the
BSP update and silent alarm were a response to
client #16's recent behaviors of entering other
clients' bedrooms.

Review of client #16's behavior log revealed the
client was noted on 9/25/18 to be seen exiting
client #29's bedroom by staff. Further review of
the behavior log revealed once again on 9/28/18
client #16 was observed entering client #31's
bedroom at 8:27 PM without permission and was
caught at 10:50 PM going into client #29's
bedroom after he was laying down to go to sleep.

Continued review of the behavior log revealed
after the BSP revision of 9/28/18, revealed other
incidents continued to occur including 10/1/18
when client #16 stole staff's drink located in client
#31's bedroom, 10/2/18 when client #16 was
caught going through client #7's dresser and
10/11/18 when staff saw client #16 go into client
#29's bedroom. Information included in the
10/11/18 entry revealed when staff got to the
doorway, client #16 was exiting and client #29
stated client #16 had hit him.

Interview with staff in Hawksbill and
administrative staff revealed other than the
revision to the BSP to include the use of the silent
alarm and the need to keep better track of client
#16, no other changes have been made in the
home. Staffing patterns and numbers are still
noted to be the same as well as the level of
supervision provided for client #16. Subsequent
interviews with administrative staff revealed that
as of the 11/1/18 survey the silent alarm has not
been installed as the facility is waiting for the
alarm company to schedule a time.

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 149 | Continued From page 1 W 149

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: B9FW11

Facility ID: 922418 If continuation sheet Page 2 of 3

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

34G089

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

PRINTED: 11/09/2018

FORM APPROVED

OMB NO. 0938-0391

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

(X3) DATE SURVEY

COMPLETED

c
11/01/2018

The facility recognized the need for increased
supervision to assure client #16 did not exit his
bedroom to enter others rooms and developed a
plan. However, the facility did not implement
alternative methods to appropriately monitor
client #16 such as increasing staff or supervision
until the alarm system could be installed. As a
result, the facility ended up neglecting the needs
of the other clients in the home.

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 149 Continued From page 2 W 149

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: B9FW11

Facility ID: 922418

If continuation sheet Page 3 of 3


summary: Statement of Deficiency - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

(x4) ID
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

ID
PREFIX
TAG

PRINTED: 09/26/2018

FORM APPROVED

OMB NO. 0938-0391

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X3) DATE SURVEY

COMPLETED

09/20/2018

(8)

COMPLETION
DATE

W 104

GOVERNING BODY

CFR(s): 483.410(a)(1)

The governing body must exercise general policy,
budget, and operating direction over the facility.

This STANDARD is not met as evidenced by:
Governing body and Management failed to
provide adequate operating direction over the
facility by failing to develop a specific policy and
training regarding bed bugs and other potential
pests. The finding is:

Afternoon observations at the group home on
9/19/18 at 4:00 PM, substantiated by interview
with staff, revealed several of the homes to have
client clothing bagged up due to bed bugs being
found on site. Interview with the Site Manager
revealed that bed bugs were found only in Pisgah
on 9/18/18 in the living room area. Further
interview revealed the contracted pest control
service was contacted and had been on-site that
morning to search for additional bugs and to
spray the living room in Pisgah. Continued
interview with the Site Manager revealed that it
was reported to her that bed bugs were not found
in any other location in Pisgah although it was
unclear if the pest control company searched the
other 3 homes on site.

Continued observations at 5:00 PM in Pisgah
revealed the living room open for use by the
clients. Subsequent interviews with the Site
Manager revealed she did not know what the pest
control company sprayed but was told by
maintenance staff that the pest control company
said it should be fine for clients 30 minutes after
spraying. Interviews with the qualified intellectual

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

W 104

TITLE

(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
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 disclosable 14
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.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:TV2G11

Facility ID: 922418

If continuation sheet Page 1 of 9

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(x4) ID
PREFIX
TAG

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

ID
PREFIX
TAG

PRINTED: 09/26/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

09/20/2018

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(8)
COMPLETION
DATE

W 104 | Continued From page 1

disabilities professional (QIDP), the Site Manager
and the Clinical Services Director revealed no
knowledge of the plan to assure the beg bugs in
Pisgah were eliminated other than the pest
control company was coming back out to the
group home next week.

Review of the facility's 7/1/17 Pest Control Policy
revealed any observations of pests should be
reported to facility maintenance staff for further
observation. If needed, facility maintenance will
contact appropriate vendor and site management
will be instructed regarding recommended
procedures as instructed by the pest control
vendor. The only other part of the policy noted
that follow-up inspection from the vendor will
occur based on their recommendations.

Although the facility has a general policy
regarding calling the pest control vendor and
following their recommendations, the facility per
interview with he QIDP and Clinical Services
Director does not have a policy specific to bed
bugs or other pests that may affect the clients in
the home. For example, the policy does not
contain information about how to assure clients
and their belongings are cared for if bed bugs are
found in clients' homes. In addition, the policy
does not address best practice to assure bed
bugs are not spread or ways the facility will
handle a bed bug or other pest infestation other
than follow the pest company recommendations.
In that the facility failed to develop a more
detailed policy regarding pest control that
included the needs and safety of the clients,
Management failed to provide operating direction
over the client as required.

W 137 | PROTECTION OF CLIENTS RIGHTS

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:TV2G11

W 104

W 137

Facility ID: 922418 If continuation sheet Page 2 of 9

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 09/26/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

09/20/2018
STREET ADDRESS, CITY, STATE, ZIP CODE

91 POPLAR CIRCLE
SWANNANOA, NC 28778

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 137 | Continued From page 2 W 137

CFR(s): 483.420(a)(12)

The facility must ensure the rights of all clients.
Therefore, the facility must ensure that clients
have the right to retain and use appropriate
personal possessions and clothing.

This STANDARD is not met as evidenced by:
The facility failed to assure 3 of 5 sampled clients
residing in Beaucatcher and Hawksbill (#8, #21
and #31) were provided with clean appropriate
clothing in good repair as evidenced by
observation and interview. The findings are:

A. Afternoon observations in Beaucatcher on
9/19/18 at 4:42 PM revealed staff assisting client
#8 from his bedroom to an activity in the dining
room. Further observations revealed the client to
be wearing shorts with excessive food debris and
stains on them. In addition, continued
observations revealed the shorts were on the
client backwards with his pants front zipper and
side pockets located in the back.

Interview with the clinical services director
revealed the client is very picky about what he
wears and will often not be happy until he finds
the right clothes that suit him even if the clothes
are dirty. Further interview revealed the group
home needs to do a better job of assuring the
client only wears clean clothing by washing his
clothes more often or buying more than one item
of preferred clothing to assure the client has a
choice but can wear clean clothing.

B. The facility failed to ensure 2 of 8 clients
residing in Hawksbill had clothing that fit properly
and in that was in good repair.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:TV2G11

Facility ID: 922418 If continuation sheet Page 3 of 9

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(x4) ID
PREFIX
TAG

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

ID
PREFIX
TAG

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

PRINTED: 09/26/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

09/20/2018

(8)
COMPLETION
DATE

W 137 | Continued From page 3

1. Observations in Hawksbill on 9/19/18 at 5:35
PM revealed client #31 to be walking outside in
the driveway of the facility with staff when his
pants were noted to fall down to around his
ankles in full view of any passerby. Staff were
observed to assist the client in pulling the pants
back up. It was noted the client did have a belt
on. However, the pants and belt were either too
big for the client or staff failed to ensure the client
had dressed properly before leaving the facility.
Interview with the clinical services director
revealed he was aware of some of client #31's
clothing being a little big for him.

2. Observations in Hawksbill on 9/19/18 from
3:45 PM until 6:10 PM revealed client #21 to be
wearing sweat pants with the knee out of the left
pant leg and with food stains on the pants. It was
noted the client to be both inside and outside of
the facility and visible to any passerby. Continued
observations, substantiated by interview with
staff, revealed the client had worn the pants all
day. Further interview with staff revealed he had
not noticed the knee of the pants being torn out.
Interview with the clinical services director,
verified the clients pants knee was torn out and
should have been changed. Therefore, the facility
failed to ensure client #21 was dressed in clothing
in good repair.

INDIVIDUAL PROGRAM PLAN

CFR(s): 483.440(c)(2)

W 207

Appropriate facility staff must participate in
interdisciplinary team meetings.

This STANDARD is not met as evidenced by:

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:TV2G11

W 137

W 207

Facility ID: 922418

If continuation sheet Page 4 of 9

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 09/26/2018

FORM APPROVED

OMB NO. 0938-0391

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

(X3) DATE SURVEY

COMPLETED

09/20/2018

The facility failed to show evidence appropriate
staff were involved and the team process
occurred in the implementation of the use of
alarms for 1 of 3 sampled clients residing in
Hawksbill (#31) and 1 of 2 sampled clients
residing in Sunset (#24) as evidenced by
observations, interviews and review of records.
The findings are:

A. The facility failed to show evidence of the team
process in the decision to implement the use of
an alarm for client #31 who resides in Hawksbill.

Observations in Hawksbill on 9/19/18,
substantiated by interview with the clinical
services director, revealed client #31 has an
alarm he wears attached to his shirt when sitting
in a chair in his personal bedroom. Continued
interview with the clinical services director
revealed the alarm is to alert staff when the client
attempts to get out of his chair. Further interview
revealed the client has an unsteady gait and has
fallen in the past and needs staff assistance and
a walker when ambulating.

Review of the records, verified by interview with
the clinical services director, revealed no written
consent from the guardians or the human rights
committee was available in the record for review.
Continued review of the records, verified by
interviews with the clinical services director,
revealed no evidence was available in the records
to show what staff participated and the team
process in deciding to implement the use of the
alarm to alert staff when client #31 attempted to
get out of his chair.

B. The facility failed to show evidence of a team
process in the decision to implement the use of a

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:TV2G11

Facility ID: 922418

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 207 | Continued From page 4 W 207

If continuation sheet Page 5 of 9

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 09/26/2018

FORM APPROVED

OMB NO. 0938-0391

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

(x4) ID
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X3) DATE SURVEY

COMPLETED

09/20/2018

(8)

COMPLETION
DATE

W 207

W 263

FORM CMS-2567(02-99) Previous Versions Obsolete

Continued From page 5

wheelchair alarm for client #24 who resides in
Sunset.

Observations in Sunset during the 9/19-20/18
survey revealed an alarm attached to the
wheelchair of client #24. Interview with staff,
substantiated by further observations, revealed
an alarm sounds to alert staff when the client
unfastens the wheelchair seatbelt and attempts to
stand up due to the client's history of injuries from
falling. Client #24 was observed at supper and
breakfast assisting staff in pureeing her food and
the alarm sounded when staff assisted the client
to stand from her wheelchair in the kitchen.

Review of client #24's individual support plan
(ISP) dated 2/20/18 revealed no mention of the
use of a wheelchair alarm. Further review of client
#24's record revealed no team meetings or
consultant recommendations regarding the use of
the alarm. Interview with staff and the clinical
services director revealed no one was sure how
long the intervention had been used but a
guardian consent for the wheelchair alarm was
obtained 8/10/18. The facility failed to show
evidence of a team process regarding the use,
benefit and restrictive aspect of the client's
wheelchair alarm.

PROGRAM MONITORING & CHANGE

CFR(s): 483.440(f)(3)(ii)

The committee should insure that these programs
are conducted only with the written informed

consent of the client, parents (if the client is a
minor) or legal guardian.

This STANDARD is not met as evidenced by:

Event ID:TV2G11

W 207

W 263

Facility ID: 922418

If continuation sheet Page 6 of 9

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(x4) ID
PREFIX
TAG

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

ID
PREFIX
TAG

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

PRINTED: 09/26/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

09/20/2018

(8)
COMPLETION
DATE

W 263 | Continued From page 6

The specially constituted committee, designated
as the human rights committee (HRC), failed to
ensure written informed consent was obtained for
the restriction of client rights relative to the use of
an alarm for 1 of 3 sampled clients (#31) residing
in Hawksbill as evidenced by observations,
interviews and review of records. The finding is:

Observations in Hawksbill on 9/19/18,
substantiated by interview with the clinical
services director, revealed client #31 has an
alarm he wears attached to his shirt when sitting
in a chair in his personal bedroom. Continued
interview with the clinical services director
revealed the alarm is to alert staff when the client
attempts to get out of his chair. Further interview
revealed the client has an unsteady gait and has
fallen in the past and needs staff assistance and
a walker when ambulating.

Review of the records, verified by interview with
the clinical services director, revealed no written
consent from the guardians was available in the
record for review. Therefore, the facility failed to
show evidence written consent was given for the
use of the alarm for client #31 while in personal
bedroom.

PROGRAM MONITORING & CHANGE

CFR(s): 483.440(f)(3)(iii)

W 264

The committee should review, monitor and make
suggestions to the facility about its practices and
programs as they relate to drug 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.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:TV2G11

W 263

W 264

Facility ID: 922418

If continuation sheet Page 7 of 9

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(x4) ID
PREFIX
TAG

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

ID
PREFIX
TAG

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

PRINTED: 09/26/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

09/20/2018

(8)
COMPLETION
DATE

W 264 | Continued From page 7

This STANDARD is not met as evidenced by:
The facility failed to show evidence the specially
constituted committee referred to as the human
rights committee (HRC) reviewed and approved
the use of alarms for 1 of 3 sampled clients (#31)
residing in Hawksbill as evidenced by
observations, interviews and review of records.
The finding is:

Observations in Hawksbill on 9/19/18,
substantiated by interview with the clinical
services director, revealed client #31 has an
alarm he wears attached to his shirt when sitting
in a chair in his personal bedroom. Continued
interview with the clinical services director
revealed the alarm is to alert staff when the client
attempts to get out of his chair. Further interview
revealed the client has an unsteady gait and has
fallen in the past and needs staff assistance and
a walker when ambulating.

Review of the records for client #31, verified by
interview with the clinical services director,
revealed no written consent from the HRC was
available in the record for review. Therefore, the
facility failed to show evidence HRC had
approved the use of the alarm for client #31 while
in personal bedroom.

DRUG USAGE

CFR(s): 483.450(e)(2)

W 312

Drugs used for control of inappropriate behavior
must be used only as an integral part of the
client's individual program plan that is directed
specifically towards the reduction of and eventual

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:TV2G11

W 264

W 312

Facility ID: 922418

If continuation sheet Page 8 of 9

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PRINTED: 09/26/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

09/20/2018

elimination of the behaviors for which the drugs
are employed.

This STANDARD is not met as evidenced by:
The team failed to ensure 1 of 2 sampled clients
(#14) residing in Pisgah the use of medications to
control inappropriate behaviors were used only as
an integral part of the individual support plan
(ISP) and is directed specifically toward the
reduction of and the eventual elimination of the
behavior for which it is employed as evidenced by
interview and review of records. The finding is:

Review of the records for client #14 revealed
physician's orders dated 8/31/18 prescribing
Citalopram (Celexa) 40 mg take by mouth
everyday at 8:00 AM for depression. Continued
review of the records for client #14 revealed an
ISP dated 10/9/17 which included a behavior
support plan (BSP) to reduce the rate of
behaviors disruptive to habilitation to zero
episodes per month for 6 consecutive months.

Further review of the BSP revealed target
behaviors were defined as non-compliance,
verbal disruption, physical aggression, tantrum
behaviors, inappropriate sexual behaviors,
stealing, bossing others and self-injurious
behaviors. Additional review of the BSP, verified
by interview with the clinical services director,
revealed the BSP failed to identify depression as
a target behavior for which Citalopram (Celexa) is
given. Therefore, there is no method of
measuring the effectiveness of the medication in
the reduction of the behaviors for which it is
given.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:TV2G11

Facility ID: 922418

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 312 Continued From page 8 W 312

If continuation sheet Page 9 of 9

inspection_type: MHLCS Annual


summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 09/26/2018

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
Hachad
See AA 34G089 8. WING 09/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
BLUE RIDGE HOMES-SWANNANOA
SWANNANOA, NC 28778
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES \ D PROVIDER'S PLAN OF CORRECTION : 8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX | (EACH CORRECTIVE ACTION SHOULD BE ‘COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG | CROSS-REFERENCED TO THE APPROPRIATE ; DATE
1 L DEFICIENCY) ;
W104 GOVERNING BODY W104) eS o9 iL Gel
CFR(s): 483.410(a)(1) | ! aac |
i ! t
The governing body must exercise general policy, | :
budget, and operating direction over the facility. '

This STANDARD is not met as evidenced by: |
Governing body and Management failed to '
provide adequate operating direction over the
facility by failing to develop a specific policy and |
training regarding bed bugs and other potential |
pests. The finding is: i

Afternoon observations at the group home on

9/19/18 at 4:00 PM, substantiated by interview

with staff, revealed several of the homes to have i
client clothing bagged up due to bed bugs being |
found on site. Interview with the Site Manager |
revealed that bed bugs were found only in Pisgah
‘on 9/18/18 in the living room area. Further
interview revealed the contracted pest control
service was contacted and had been on-site that
morning to search for additional bugs and to
spray the living room in Pisgah. Continued
interview with the Site Manager revealed that it
was reported to her that bed bugs were not found
in any other location in Pisgah although it was
unclear if the pest control company searched the !
other 3 homes on site. i 1

|
| 1
| |
|

Continued observations at 5:00 PM in Pisgah i
revealed the living room open for use by the |
clients. Subsequent interviews with the Site i
Manager revealed she did not know what the pest i
control company sprayed but was told by |
maintenance staff that the pest control company |
said it should be fine for clients 30 minutes after i
spraying. Interviews with the qualified intellectual |

LABORATORY DIRECTOR'S OR PROYIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE.

) tbh rrghrtne, CDP __ oly 13g
Any deficiency statement ending with an asterisk (*) denotes dy ficiency whick the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disciosable 90 days

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 disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved pian of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:Tv2G11 Facility ID: 922418 If continuation sheet Page 1 of 9

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

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
34G089

NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

PRINTED: 09/26/2018

(x4) 1D
PREFIX |
TAG

W 104

SUMMARY STATEMENT OF DEFICIENCIES.
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 1

disabilities professional (QIDP), the Site Manager
and the Clinical Services Director revealed no

. knowledge of the plan to assure the beg bugs in

Pisgah were eliminated other than the pest

; control company was coming back out to the

group home next week.

Review of the facility's 7/1/17 Pest Control Policy
revealed any observations of pests should be
reported to facility maintenance staff for further
observation. If needed, facility maintenance will
contact appropriate vendor and site management
will be instructed regarding recommended
procedures as instructed by the pest control
vendor. The only other part of the policy noted

- that follow-up inspection from the vendor will

occur based on their recommendations.

Although the facility has a general policy
regarding calling the pest control vendor and
following their recommendations, the facility per

’ interview with he QIDP and Clinical Services

Director does not have a policy specific to bed
bugs or other pests that may affect the clients in
the home. For example, the policy does not
contain information about how to assure clients
and their belongings are cared for if bed bugs are
found in clients' homes. In addition, the policy
does not address best practice to assure bed
bugs are not spread or ways the facility will
handle a bed bug or other pest infestation other

. than follow the pest company recommendations.

W 137

In that the facility failed to develop a more

: detailed policy regarding pest control that

included the needs and safety of the clients,
Management failed to provide operating direction
over the client as required.

PROTECTION OF CLIENTS RIGHTS

FORM APPROVED
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING COMPLETED
B. WING ~_ 09/20/2018
STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778
1D i PROVIDER'S PLAN OF CORRECTION 5)
PREFIX | (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG i CROSS-REFERENCED TO THE APPROPRIATE OATE
i DEFICIENCY)
L
W 104 |
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W 137;

|

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: TV2G11

Facility iD: 922418

If continuation sheet Page 2 of 9

PRINTED: 09/26/2018
DEPARTMENT. OF HEALTH AND HUMAN SERVICES FORM APPROVED.

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

346089 B. WING ________. 09/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE

E HOMES-SWANNAN!
BLUE RIDGE S-SWANNANOA SWANNANOA, NC 28778

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES wo | PROVIDER'S PLAN OF CORRECTION xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX | {EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) mas | CROSS-REFERENCED TO THE APPROPRIATE DATE
| DEFICIENCY) :
W137 i | :
Continued From page 2 W137, ifs El x

The facility must ensure the rights of all clients.
Therefore, the facility must ensure that clients
have the right to retain and use appropriate
personal possessions and clothing.

|
CFR(s): 483.420(a)(12) |

This STANDARD is not met as evidenced by:
The facility failed to assure 3 of 5 sampled clients
residing in Beaucatcher and Hawksbill (#8, #21
and #31) were provided with clean appropriate
clothing in good repair as evidenced by
observation and interview. The findings are:

A. Afternoon observations in Beaucatcher on
9/19/18 at 4:42 PM revealed staff assisting client
#8 from his bedroom to an activity in the dining
room. Further observations revealed the client to
be wearing shorts with excessive food debris and
stains on them. In addition, continued
observations revealed the shorts were on the
client backwards with his pants front zipper and
side pockets located in the back.

Interview with the clinical services director
revealed the client is very picky about what he
wears and will often not be happy until he finds
the right clothes that suit him even if the clothes
are dirty. Further interview revealed the group
home needs to do a better job of assuring the i
client only wears clean clothing by washing his | :
clothes more often or buying more than one item
of preferred clothing to assure the client has a
choice but can wear clean clothing.

B. The facility failed to ensure 2 of 8 clients i
residing in Hawksbill had clothing that fit properly :
and in that was in good repair. | |

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:TV2G11 Facility ID: 922418 if continuation sheet Page 3 of 9

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

PRINTED: 09/26/2018
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G089

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

(X38) DATE SURVEY
COMPLETED

09/20/2018

NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(x4) 1D
PREFIX
TAG}

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

ID PROVIDER'S PLAN OF CORRECTION.
PREFIX | (EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
| DEFICIENCY)

(x8)
COMPLETION
DATE

:
W 137 , Continued From page 3
i

; 1. Observations in Hawksbill on 9/19/18 at 5:35

, PM revealed client #31 to be walking outside in
the driveway of the facility with staff when his
pants were noted to fall down to around his

‘ankles in full view of any passerby. Staff were

' observed to assist the client in pulling the pants

. back up. It was noted the client did have a belt

' on. However, the pants and belt were either too
big for the client or staff failed to ensure the client
had dressed properly before leaving the facility.
Interview with the clinical services director
revealed he was aware of some of client #31's

‘clothing being a little big for him.

‘2. Observations in Hawksbill on 9/19/18 from
3:45 PM until 6:10 PM revealed client #21 to be
wearing sweat pants with the knee out of the left
pant leg and with food stains on the pants. It was
noted the client to be both inside and outside of

. the facility and visible to any passerby. Continued

- observations, substantiated by interview with
staff, revealed the client had worn the pants all

: day. Further interview with staff revealed he had
not noticed the knee of the pants being torn out.

. Interview with the clinical services director,
verified the clients pants knee was torn out and
should have been changed. Therefore, the facility
failed to ensure client #21 was dressed in clothing

: In good repair.

INDIVIDUAL PROGRAM PLAN
CFR(s): 483.440(c)(2)

W207

Appropriate facility staff must participate in
interdisciplinary team meetings.

. This STANDARD is not met as evidenced by:

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TV2G11

w207:
i
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Facility 1D: 922418 If continuation sheet Page 4 of 9 |
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PRINTED: 09/26/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
346089 B. WING 09/20/2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE

BLUE RIDGE HOMES-SWANNANOA
E RIDGE HOMES-SWANNANO, SWANNANOA, NC 28778

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES mo | PROVIDER'S PLAN OF CORRECTION ar)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY) i
W 207 Continued From page 4

The facility failed to show evidence appropriate
staff were involved and the team process
occurred in the implementation of the use of
alarms for 1 of 3 sampled clients residing in
Hawksbill (#31) and 1 of 2 sampled clients
residing in Sunset (#24) as evidenced by ! i ‘
observations, interviews and review of records. | | :
The findings are: j |

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war Uf te
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A. The facility failed to show evidence of the team
process in the decision to implement the use of
an alarm for client #31 who resides in Hawksbill.

Observations in Hawksbill on 9/19/18,
substantiated by interview with the clinical
services director, revealed client #31 has an
alarm he wears attached to his shirt when sitting
in a chair in his personal bedroom. Continued
interview with the clinical services director
revealed the alarm is to alert staff when the client
attempts to get out of his chair. Further interview
revealed the client has an unsteady gait and has
fallen in the past and needs staff assistance and
a walker when ambulating.

Review of the records, verified by interview with

the clinical services director, revealed no written
consent from the guardians or the human rights

committee was available in the record for review.
Continued review of the records, verified by i
interviews with the clinical services director, H
revealed no evidence was available in the records ‘ : 1
to show what staff participated and the team L t
process in deciding to implement the use of the H
alarm to alert staff when client #31 attempted to }
get out of his chair. j

B. The facility failed to show evidence of a team
process in the decision to implement the use of a

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:TV2G11 Facility ID: 922418 if continuation sheet Page 5 of 9

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

STATEMENT OF DEFICIENCIES: (X41) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

(X4) ID : SUMMARY STATEMENT OF DEFICIENCIES
PREFIX : (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

W 207 : Continued From page 5

: wheelchair alarm for client #24 who resides in

| Sunset.

; Observations in Sunset during the 9/19-20/18
survey revealed an alarm attached to the
wheelchair of client #24. Interview with staff,

: substantiated by further observations, revealed

an alarm sounds to alert staff when the client

| unfastens the wheelchair seatbelt and attempts to
stand up due to the client's history of injuries from

, falling. Client #24 was observed at supper and
breakfast assisting staff in pureeing her food and
the alarm sounded when staff assisted the client
to stand from her wheelchair in the kitchen.

: Review of client #24's individual support plan
(ISP) dated 2/20/18 revealed no mention of the

" use of a wheelchair alarm. Further review of client
#24's record revealed no team meetings or

* consultant recommendations regarding the use of

» the alarm. Interview with staff and the clinical
services director revealed no one was sure how
long the intervention had been used but a

: guardian consent for the wheelchair alarm was

- obtained 8/10/18, The facility failed to show
evidence of a team process regarding the use,
benefit and restrictive aspect of the client's
wheelchair alarm.

W263. PROGRAM MONITORING & CHANGE

. CFR(s): 483.440(f)(3)(ii)

The committee should insure that these programs
are conducted only with the written informed
consent of the client, parents (if the client is a

! minor) or legal guardian.

This STANDARD is not met as evidenced by:

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:Tv2G611

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PRINTED: 09/26/2018
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING COMPLETED

BWING J _______. 09/20/2018
STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE

| CROSS-REFERENCED TO THE APPROPRIATE
| DEFICIENCY)
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W263)
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Facility ID: 922418 lf continuation sheet Page 6 of 9

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION,

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089

NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

(X4) 1D
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

PRINTED: 09/26/2018
FORM APPROVED
OMB NO, 0938-0391

W 263

W 264

L

Continued From page 6

The specially constituted committee, designated
as the human rights committee (HRC), failed to
ensure written informed consent was obtained for
the restriction of client rights relative to the use of
an alarm for 1 of 3 sampled clients (#31) residing
in Hawksbill as evidenced by observations,
interviews and review of records. The finding is:

Observations in Hawksbill on 9/19/18,
substantiated by interview with the clinical
services director, revealed client #31 has an
alarm he wears attached to his shirt when sitting
in a chair in his personal bedroom. Continued
interview with the clinical services director
revealed the alarm is to alert staff when the client
attempts to get out of his chair. Further interview
revealed the client has an unsteady gait and has
fallen in the past and needs staff assistance and
a walker when ambulating.

Review of the records, verified by interview with
the clinical services director, revealed no written
consent from the guardians was available in the
record for review. Therefore, the facility failed to
show evidence written consent was given for the
use of the alarm for client #31 while in personal
bedroom.

PROGRAM MONITORING & CHANGE

CFR(s): 483.440(f)(3)(iii)

The committee should review, monitor and make
suggestions to the facility about its practices and
programs as they relate to drug 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.

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

(X3) DATE SURVEY
COMPLETED

B. WING 09/20/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

91 POPLAR CIRCLE
SWANNANOA, NC 28778
ID | PROVIDER'S PLAN OF CORRECTION x8)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

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W 264; i

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:TV2611

Facility ID: 922418. if continuation sheet Page 7 of 9

FORM CMS-2567(02-99) Previous Versions Obsolete

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

STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

346089

NAME OF PROVIDER OR SUPPLIER

BLUE RIDGE HOMES-SWANNANOA

i SUMMARY STATEMENT OF DEFICIENCIES
i (EACH DEFICIENCY MUST BE PRECEDED BY FULL.
REGULATORY OR LSC IDENTIFYING INFORMATION)

W 264 Continued From page 7

' This STANDARD is not met as evidenced by:

| The facility failed to show evidence the specially

: constituted committee referred to as the human

| rights committee (HRC) reviewed and approved
the use of alarms for 1 of 3 sampled clients (#31)

residing in Hawksbill as evidenced by
observations, interviews and review of records.
The finding is:

Observations in Hawksbill on 9/19/18,
| substantiated by interview with the clinical
‘ services director, revealed client #31 has an
“alarm he wears attached to his shirt when sitting
: ina chair in his personal bedroom. Continued
interview with the clinical services director
revealed the alarm is to alert staff when the client
: attempts to get out of his chair. Further interview
* revealed the client has an unsteady gait and has
fallen in the past and needs staff assistance and
a walker when ambulating.

Review of the records for client #31, verified by
interview with the clinical services director,

: revealed no written consent from the HRC was

| available in the record for review. Therefore, the
facility failed to show evidence HRC had
approved the use of the alarm for client #31 while
in personal bedroom.
DRUG USAGE

: CFR(s): 483.450(e)(2)

: Drugs used for control of inappropriate behavior

' must be used only as an integral part of the

: client's individual program plan that is directed

| Specifically towards the reduction of and eventual

Event ID:TV2G11

PRINTED: 09/26/2018
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

A. BUILDING

8. WING

COMPLETED

09/20/2018

STREET ADDRESS, CITY, STATE, ZIP CODE.
91 POPLAR CIRCLE
SWANNANOA, NC 28778

|

PROVIDER'S PLAN OF CORRECTION (xs)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Facility 1D: 922418 If continuation sheet Page 8 of 9

PRINTED: 09/26/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY,
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

B. WING

34G089

09/20/2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE

SWANNANOA, NC 28778

BLUE RIDGE HOMES-SWANNANOA

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

iD | PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETION
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

elimination of the behaviors for which the drugs
are employed.

This STANDARD is not met as evidenced by:
The team failed to ensure 1 of 2 sampled clients
(#14) residing in Pisgah the use of medications to
control inappropriate behaviors were used only as
an integral part of the individual support plan
(ISP) and is directed specifically toward the '
reduction of and the eventual elimination of the i
behavior for which it is employed as evidenced by
interview and review of records. The finding is:

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W312. Continued From page 8 ws12 ING

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Review of the records for client #14 revealed
physician's orders dated 8/31/18 prescribing
Citalopram (Celexa) 40 mg take by mouth |
everyday at 8:00 AM for depression. Continued | |
review of the records for client #14 revealed an | i

ISP dated 10/9/17 which included a behavior | { :
support plan (BSP) to reduce the rate of i | i
behaviors disruptive to habilitation to zero | '
episodes per month for 6 consecutive months. | i

Further review of the BSP revealed target '

behaviors were defined as non-compliance, |

verbal disruption, physical aggression, tantrum {

behaviors, inappropriate sexual behaviors, | |

stealing, bossing others and self-injurious |

behaviors. Additional review of the BSP, verified | '

by interview with the clinical services director, ! i

revealed the BSP failed to identify depression as ! i

a target behavior for which Citalopram (Celexa) is |

given. Therefore, there is no method of \

measuring the effectiveness of the medication in i

the reduction of the behaviors for which it is |
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given. | :
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L a
FORM CMS-2667(02-99) Previous Versions Obsolete Event ID: Tv2Git Facility 1D: 922418 If continuation sheet Page 9 of 9

Regular clinical assessment and any follow-up thereby identified will be conducted by the clinical
team, and regular chart reviews and assessment reviews will be conducted by the Director of
Clinical Services, in order to ensure continued compliance with the expectation that apprayirtas
facility staff must participate in interdisciplinary team meetings

Responsible persons: Clinical Services Director, QIDP

W 263 PROGRAM MONITORING & CHANGE

The committee should insure that these programs are conducted only with the written informed
consent of the client, parents (if the client is a minor) or legal guardian.

The clinical team will receive training regarding the process by which informed consents are
obtained.

Also, consents for the use of the alarms for the clients cited in the survey will be obtained.

Regular chart reviews and any follow-up thereby identified, will be conducted by the Director of
Clinical Services and QIDP in order to ensure continued compliance with the expectation that the
committee should insure that these programs are conducted only with the written informed
consent of the client, parents (if the client is a minor) or legal guardian.

Responsible persons: Clinical Services Director, QIDP

W 312 DRUG USAGE CFR(s): 483.450(e)(2)

Drugs used for control of inappropriate behavior must be used only as an integral part of the
client's individual program plan that is directed specifically towards the reduction of and eventual
elimination of the behaviors for which the drugs are employed.

The IDT will meet to discuss client #14’s strengths and needs regarding behavior support for Axis
| diagnosis of depression. Any followup thereby identified will be conducted.

The Behavior Specialist will consult with the Psychiatrist and the Licensed Psychologist at least
quarterly to assure that any prescribed psychotropic medications are documented as lowest
therapeutic dose(s) and addressed in the Behavior Support Plan as correlating with relevant
diagnoses.

Regular chart reviews and any follow-up thereby identified, will be conducted by the Director of
Clinical Services, QIDP or Assistant QIDP in order to ensure continued compliance with the
expectation that quarterly any BSP updates include medications that correspond to target
behaviors.

. (o}
Received

Responsible persons: Clinical Services Director, QIDP, Behavior Specialist, Psychiatrist,
Psychologist :