HART HOUSE
I.D. NUMBER 0034769
905 N.E. PERRY ST.
PEORIA, IL 61603

                         "A" VIOLATION(S)

The facility shall notify the resident's physician of any accident, injury, or change in a resident's
condition that threatens the health, safety or welfare of a resident.

There shall be written training and habilitation objectives for each resident that are: Stated in
specific behavioral terms that permit the progress of the individual to be assessed.

There shall be evidence of training and rehabilitation services activities designed to meet the
training and rehabilitation objectives set for every resident.

An appropriate, effective and individualized program that manages residents' behaviors shall be
developed and implemented for residents with aggressive or self-abusive behavior.  Adequate,
properly trained and supervised staff shall be available to administer these programs.

There shall be available sufficient, appropriately qualified and training and habilitation
personnel, and necessary supporting staff, to carry out the training and habilitation program. 
Supervision of delivery of training and habilitation services shall be the responsibility of a
person who is a Qualified Mental Retardation Professional.

An owner, licensee, administrator, employee or agent of a facility shall nto abuse or neglect a
resident.  (Section 107 of the Act)

These regulations are not met as evidenced by the following:

Per the facility's incident and accident reports, Z1 was identified as an individual who had
repeatedly aggressed against, R1, R2, R3, R5 and R6 on several occasions with the last assault
occurring on 12/18/98 against R2.  Z1, at that time, made an unprovoked attack on R2 biting off
a large portion of her right ear.  Per the incident reports, Z1 had attacked R1 on 8/16/98 outsident
which resulted in a 10-15 minute beating in which staff was unable to intervene resulting in
multiple bruising of her legs, back, sides and face which required an emergency room visit for
evaluation.  Both incidents occurred during a time when the facility had only one staff member
present for 14 clients.  There are three clients currently on behavior programs and psychotropic
medication.  Of the eight incidents in which Z1 was the identified perpetrator, seven occurred
during the day when only one staff was present.  Z1 has a documented history of aggression
which the facility failed to identify and assess for programmatic purposes.

The facility did not provide aggression management training or behavioral training to the staff at
the facility.  Per interview, training was provided at the workshop and attendance was voluntary. 
Of the staff at the facility, only two had attended a general "behavior management" session.  The
eight incidents of Z1 constitute abuse in that the facility failed to provide sufficient and
competent staff for the management of 14 clients, failed to provide program structure which met
the needs of Z1 for the protection of the other clients resident in the facility, failed to provide
active treatment strategies including assessments, that were proven to be effective and that were
revised when necessary, failed to have monitoring systems in place to protect individuals from
aggression thus placing clients in an unsafe environment which allowed  R1, R2, R3, R5 and R6
to be abused by Z1 in the absence of adequate staff.  The facility failed to provide protective
supervision to R2, especially after knowing that Z1 had in the past, been known to aggress and
that R1 and R2 had been injured as a result of omissions of supervision.  Per the Social History
in the clinical record, Z1 was admitted to the facility on 8/20/97 from home.  Admitting
diagnosis includes moderate mental retardation (IQ of 40 and ICAP score of 1-year, 3-months),
profound hearing loss, congenital microphaly and right hemiplegia.  Z1 is nonverbal and
communicates primarily by sign.  He is ambulatory.  The history continues to state, "He has had
some problems this past year with behaviors when he gets agitated....  Ways to vent irritability
will be explored.... behavior at work has improved."  A social Developmental study dated
10/2/91 indicates that Z1 was placed in a respite situation per mother's request due to behavior
problems in the home where Z1 would "Constantly tease her (his sister) and sometimes hit her." 
It continued on to state residential placement was requested due to "inappropriate sexual
behavior in the home."  According to a Psychological evaluation completed 12/14/95, Z1 was
placed in a residential situation for a while but did not remain and returned home where he
"responded positively to the structured behavioral limits" placed on him by his mother's friend. 
Per interview with E1 and E2 on 12/29/98, Z1 was discharged from his prior placement due to
aggression which they were unaware of at his admission even thought the information was
provided in documentation at the time.  E1 was unaware of this information and stated she was
not present when he was admitted and was not knowledgeable to this fact.  No further
assessment was done nor were any measures taken to address Z1's aggressive behavior on
admission even though aggression was identified.  Per the consultant nurse notes dated 9/5/97,
Z1 "has had one incident of aggressive behavior, please refer to Dr. (Z3) for evaluation for need
of medication for behaviors."  Interview with E1 stated that his behaviors were not severe at this
time, however, the physician was still contacted per the nurse consultant's recommendation.  The
facility medical director, E7, was notified and Paxil was ordered for aggression.  No assessment
or tracking of Z1's behavior was completed in order to determine how often, how severe or how
serious the behavior was.  No behavior program was written and initiated even though
medication use was initiated.  Staff were not provided with interventions or specific directions in
regards to effectively managing Z1's explosive behaviors and toward protecting other clients
from being assaulted.  Z1 remained on the Paxil and on 2/24/98, an ICAP was completed which
identified Z1 as hurtful to others and lists the primary problem as "hitting," occurs "less than
monthly" and is slightly serious; a mild problem."  Also identified is his habit of refusing to obey
which is listed as 1-3 times per month and is slightly serious also.  The IDT was held 3/27/98
which again identified that fact that Z1 is hurtful to others.  This meeting and IPP does not
reflect the medication use of Paxil nor does it contain any programmatic steps toward Z1's
aggression or documentation which would be used to determine justification for medication use. 
Per interview with E1, the facility did not initiate a program but tracked the maldaptive
behaviors and tracked incidents.  However, no documentation was provided when requested.  Per
E1, no program was written as Z1's behavior was "unprovoked" and staff were unable to identify
when it would occur.  Therefore, a program was not written.  E1 and E2 contributed to Z1's
behavior due to inability to communicate and placed him on a communication program which
included a picture book but failed to take preventative measures addressing Z1's aggression and
assaults on peers.  Per a laboratory sheet, on 4/6/98. Z1 was listed as having a diagnosis of
"aggressive behavior."  The facility still failed to track, monitor Z1's behavior and take
appropriate measures to assure the other clients safety from Z1's aggressive attacks.  Per the
clinical record, the Paxil, which was ordered to help control his anxiety and help manage his
aggression, was discontinued due to staffs' reports that no "dangerous aggressive-type
behaviors" had occurred.  This information is not present in the IPP.  This information was
confirmed by E1 who agreed that Z1 did not have a program present in regards to his aggressive
behaviors at the time.  Nor did the IPP contain the medication use or discontinuation.  Per the
incident reprots provided by the facility, on 7/2/98, Z! "Was agitating female resident (R1) and
tried to keep her from going to her room.  Staff intervened and he let resident alone."  Z1 then
went to his room , and staff heard Z1 and his roommate arguing and found Z1 hitting R5 in the
eye.  The incident report states under "action" which was taken Z1 "was told to calm down and
brought him to sit in the living room."  Again, Z1 had no program structured to meet his
identified needs and the facility failed to provide monitoring and active treatment strategies to
prevent reoccurrence of Z1's aggression.  No report was written on the incident involving Z1 and
R1.  Per interview with E1 and E2, Z1 often teased R1 because he was "attracted to her" and she
rejected him.  Per interview with E3, Z1 daily aggravated R1 and would continually make faces
at her.  E1 and 2 indicated Z1 wanted to develop a relationship with R1 but R1 wasn't interested
and this rejection angered him.  Asked if a sexuality or a social relationship assessment was
completed on Z1, they replied no.  Therefore, Z1 was provided no training on developing social
relationships and sexuality which was an identified need area which triggered aggressive acts
toward females.  Per the incident reports, on 8/16/98, another altercation occurred between Z1
and R1.  Per the report filled out by E5, the incident occurred at 10 a.m. when R1 was sitting in
the backyard of the facility.  The report states the only staff on duty was in the restroom at the
time and "when came out heard consumer yelling and screaming.  When staff went to the door,
Z1 was hitting and kicking R1.  When staff tried to go closer to help consumer, Z1 leaped out at
staff.  When staff told R1 to run to the front, every time she tried Z1 ran after her throwing her
down to the ground and repeating to hit and kick her."  The report continues to state, "Finally he
let (r1) consumer go, then staff grabbed (R1) and consumer and walked around to the front.  As
we reached the porch, Z1 came out of the house and pinned R1 in the chair and started hitting
her.  Staff hurried and grabbed R1 and ran into the house."  Per interview on 1/6/99, E5
described the assault as lasting at least 10-15 minutes in length and stated she was alone with the
14 clients at the time.  She confirmed that she was inside when it started and stated a neighbor
witnessed the assault occurring first and called the police before coming over.  E5 stated there
were other neighbors outside with Z1 and R1 but all were unable to help due to Z1 threatening
them when they approached.  (Z1 was described by E1 and E2 as being approximately 5-foot, 10
inches tall and weighing 210 pounds.  R1 is relatively short in stature and slightly obese).  Per
interview with E5, she first called Emergency Response Service (ERS) and was told to call the
police who arrived approximately 15 later after Z1 was already calm.  The incident report states
that police arrived and "tried talking to the consumer (Z1)."  Per the incident report, R1 suffered
multiple bruises over her back, sides, legs and arms and had a black eye.  R1 was taken to the
emergency room for evaluation.  Per interview with E1, the facility did not initiate any
interventions following the assault because it was unprovoked and stated that the cause could not
be determined.  Therefore, the facility failed to take preventative measures to ensure the safety of
R1 and the other clients residing at the facility.  Per the report, type of assault was checked
"assault" and "abuse/neglect" with abuse/neglect circled with "omit" written next to it.  Per the
incident reports, the next day on 8/17/98 at 9:05 a.m., Z1 assaulted another peer R6.  The report
states "consumer was going to linen closet.  According to victim and another consumer in living
room area, Z1 hit victim in her left side for no apparent reason.  Staff was not in immediate
area...."  Action taken by staff states "victim was redirected to her room."  No action or
intervention was implemented toward managing Z1's aggression in order to prevent future abuse
of peers.  At 9:08 a.m., 3 minutes later, Z1 hit R5 while he was laying on his bed in his room.

Again, no staff was present and no interventions were initiated to prevent additional assaults.
Actions following this assault states, "victim was removed from room for about a 30 minute
period" but provided no training or interventions to Z1. Per review of time sheets, only one staff
was present during this altercation also. The facility failed to provide adequate supervision of Z1
after the first altercation and failed to provide any active treatment strategies that would
effectively protect peers from Z1's repeated aggressive assaults. Case notes dated 8/25/98 state
an emergency IDT meeting was scheduled to discuss continued appropriate placement for Z1. It
continues on to state CISA was contacted to attend due to possible need of transfer to another
appropriate placement. The note continues to state "...Emergency IDT meeting also necessary to
prevent further incidents of aggressive behavior." However, no active treatment strategies were
initiated as the result of this special meeting and no additional measures were taken to prevent
further occurrence. Case note dated 8/98 states "Dr. (Z5) will see him on 9/14...facility is to call
if any more emergency situations occur..." Additional information from case notes states, R1 and
Z1 were talked to regarding friendships. After the assault on 8/16/98, E5 indicated that Z1 would
wait for R1 to come off her bedroom wing so staff needed to be 1:1 with her as she was "deathly
afraid" of him. She also stated he would wait for her to come to breakfast in much the same way.
Interview with E3, E5 and E6 indicate Z1 can be very intimidating because of his size. On
9/27/98 at 9 p.m., Z1 assaulted R6 after she was asked to shut off the TV by staff. Incident
reports states she was punched in the stomach by Z1. Action taken consisted of  "directing Z1 to
his room, Police were called. ERS doctors were called more than once none responded but
police." Again, only one staff was present in the facility at the time of the incident. At 9:05 p.m.,
5 minutes after the first attack, Z1 reportedly became "agitated that the TV was shut off by a
peer," did not understand why due to his hearing/speech impairment and went to his room
followed by E3 where he walked over to R5 and "began to hit him over and over." This assault
occurred in the presence of staff and no interventions were provided to prevent this action.
Actions state "R5 was directed to come and stand next to staff out in hallway and wait for
police." Again, no active treatment strategies were initiated in regards to Z1's aggressive
behavior. Per interview, Z1 saw Z5 on 9/28/98 and Neurotin 100mg i tid was ordered for
aggression. Z5 provided a behavior program for Z1 which included no crisis intervention for
when the aggression occurred. Methodology states "when staff notices any signs of agitation,
staff immediately assumes 1:1 to try to explain why he can't have things his way...use
communication book and physical prompts - verbal praise for restraining self and listening to
staff - staff will also try 'redirection techniques' as early in sequence as possible to
distract/redirect him into, for example, turning off TV and going to bed." There is no adaptive
component or training included within this program and previous redirection and intervention
with 1:1 had not been successful due to staff being unable to physically manage him. The
program did not include intervention to use when staff were unable to redirect. The program also
stated staff was to provide "verbal praise" and verbal cues - light physical ones if he'll tolerate."
Per clinical record and interview, Z1 is profoundly deaf and primarily uses sign which his is not
real proficient in and dies not read lips. The facility failed to provide active treatment strategies
which proved to be effective in managing Z1's aggression. Per the incident reports, on 10/10/98
at 12:05 p.m., R3 "was choked by another male client (Z1). Staff was coming out of laundry
room and heard a loud noise. Upon entering hallway, staff saw victim pinned against wall and
Z1 choking him. Victim was being choked to the point where it was difficult for him to talk. One
staff separated parties, victim fell to the floor." Injured area of R3 was described as "fingerprints
on his neck." Action was reported as staff redirected Z1 to his room and R3 to dining room area.
The next day, at 11 a.m. on 10/11/98, R3 was again attacked by Z1. Incident report states, "when
entered the dining room, staff saw Z1 on top of victim on the floor in the living room, staff ran
over and separated both parties. R3 expressed to staff that Z1 had choked him." Staff told R3 to
go in dining room and Z1 stayed in living room area. Staff called police, E1. Police contacted
ERS and they removed him from the house. No active treatment strategies were implemented in
regards to this repeated aggressive behavior.

On 10/13/98, Z1's Neurotin 100mg was increased to 2 caps in a.m., 2 caps in afternoon and 3
caps in the evening. No revisions were made the IPP to reflect the drug use for aggression. On
10/29/98, Z1 again aggressed R1. Incident reports states he went into female hallway to give her
a hug good night and "all of a sudden Z1 had this mean look come over his face, began choking
R1 with all the force he had... ." Staff intervened and separated the two clients. No action was
taken. Per the month of 12/98, Z1 had three incidents occur at workshop that involved a female.
One 12/8/98, Z1 "approached another female client...walked up to her and hit her in the
back...the female client did nothing to provoke this attack, nor was there any warning sign to
predict this was going to happen." Action taken was discussion with him and explanation why it
was inappropriate and that it was "not to happen again." The next day, 12/9/98 at 10:15 a.m., Z1
"again hit the female client today. He hit her on her arm. It appears Z1 thinks this girl is his
girlfriend. When she does not pay attention to Z1, this makes him angry. As a result, he strikes
out at this female. The attack may be immediate or it may be hours after the fact." Again, the
incident was discussed with him but no preventative measures were taken nor any active
treatment strategies implemented to ensure the safety of others. Another attack occurred on
12/16/98 while waiting for the bus ride home. Staff intervened and the next day, a meeting was
held between Z1 and the female. The facility again failed to actively address Z1's aggression. Per
the facilities incident reports, on 12/18/98 at 5:27 p.m., E6 reported that R2 "was in the furnace
room, this writer got the consumer out of the closet and went with her into the common area. R2
sat down on the couch. This writer went into the kitchen and heard screaming...returned to the
dining area where R2 and another consumer were standing. She (R2) had her hand on her right
ear and was crying...E6 looked at her hear and saw a piece of it laying on her shoulder and blood
on her neck the male consumer was standing next to her." E6 stated she ran out and got E1 from
her car and "attempted to call for help the phone was not working." Per interview and confirmed
by time sheets, E6 was the only staff present and E1 had just left the building to go to her car
when E6 ran out to get her leaving the 15 clients alone in the house after the attack. E6, E1 and
E2 were uncertain as to why the pone did not work at that time. Per E1 and E6, E1 returned to
the facility and transproted R2 to the emergency room. Per interview, E1 stated Z1 was calmly
sitting in a chair watching television when she entered the facility. She stated the police were
called because she was unsure of who bit off R2's ear and he couln't communicate whether he
did or not. Interview with E6 revealed that Z1 had blood on his lips and in his mouth
immediately after the incident occurred when E1 reentered the facility. The police arrived
approx. 1 hour after the incident occurred. E1 did not take the severed piece of ear with her. Per
interview, the police took the ear with them in the car for an hour before finally arriving at the
hospital, too late for the physician to reattach it. According to the hospital report, R2's ear
"reveals a large portion of the right ear, approximately 4cm bitten off. Cartilage is visible.
Bleeding is controlled at this time." It also stated, "Sample did not arrive here for over 2 hours
after being bitten off and was not refrigerated or place on ice." Repair to ear consisted of
suturing the severed edge. R2's guardian was notified and chose not to press charges for the
assault. Z1 was removed from the facility per the police who took him to ERS. There the aunt
came and took him home. Z1 was discharged as of 12/18/98. R2 was described as as 66 year old
female with Downs syndrome who has the typically sweet, pleasant personality. Per observation
of 1/6/99, R2 is a relatively small person who would be unable to defend herself against Z1.
Interview with staff confirmed R2's inability to defend herself against an assault. Interview with
E1, E2, E3, E5 and E6 revealed that all agree one staff person is not enough to manage 15
clients. Per interview, E1 and E2 stated they were aware the facility was short staffed indicating
that attempts to hire more staff had been unsuccessful. Per the facility's policy entitled "Policy
on suspected abuse and neglect," abuse is defined as "The infliction of physical pain,
punishment, injury, unreasonable confinement." The policy states that the facility will assist
individuals to "live a life free of abuse and/or neglect." The facility failed to prevent Z1 from
repeatedly abusing his peers. The facility's policy on behavior management and aggression
managment was requested from the facility but they were unable to provide one. Per interview
with E1 and E2, management training is provided at the workshop but review of the training
sheets revealed only two staff had attended a session within the past year. E1 and E2 stated the
facility does not train it's own employees toward specific programs. Incident reports revealed
that the facility called the police or ERS whenever Z1 had a behavior. Per E1, ERS is a
community response service that responds to crisis situations as they occur. E1 stated they come
and talk with Z1. The police were also called on various occasions. Again, they talk with Z1
regarding his actions. Both agencies arrive after the incident occurs and provide no intervention
during the assaults themselves. Nor do they provide any information or interventions to use
when the attacks are actually occurring. Communications training was also requested since E1
and E2 both contributed Z1's aggression to the inability to communicate. E2 stated no
communication had been done at the workshop or facility within the last two years. The facility
failed to provide adequately trained competent staff to supervise the clients at the facility. Per E1
and E2, Z1 attacked because he was unable to communicate so programming was done toward
increasing communications. However, no assessment was done to verify that lack of
communication was the cause of his aggression since the majority of the assaults occurred
"unprovoked" and were not attributed to lack of understanding. E1 indicated that soon after
admission, it would take staff up to 15 minutes at times to "calm him down." When asked what
typ0e of behavior Z1 exhibited at that time, she replied he would get agitated and would pace
and hit the walls but indicated his behavior "wasn't a big problem at the time" therefore a
program wasn't written even though medication was initiated per the nurse consultants request.
E1 stated she was not present when Z1 was admitted and was therefore unaware that he had
behavior problems. She was unaware that the admission papers, social history and psychological
evals present on his current clinical record all identified his prior aggressive behavior and one
identified it as being severe enough to warrant discharge from a previous placement. Per
interview, E1 stated she did not participate in writing Z1's behavior program 10/98 and stated a
program was not initiated when Z1 was placed on Paxil for aggression because it was just to
calm him down. Confirmed per E2, no active treatment strategies were initiated prior to Z1 being
placed on medication and no revisions were made when the medication was increased. E1, 2 and
3 also stated that the behavior which occurred between Z1 and R1 was due to Z1 being attracted
to her and had a similar situation occur at workshop. No social relationship or sexuality
assessment was done thus no active treatment strategies were implemented to meet this identified
need. The social history present on the chart identified that his mother was concerned about
"inappropriate sexual behavior" while at home prior to his placement at the facility. Again, E1
was unaware of this fact and did not initiate any assessment of his social behavior to determine if
a deficit existed in this area or not. The facility failed to take corrective actions to ensure the
safety of the clients residing at the facility especially after knowing that Z1, had in the past,
injured clients in the absence of staff thus the facility failed to ensure that clients residing in the
facility were not subjected to physical abuse by Z1 who posed a continual serious and immediate
threat to his peers