Initial Comments:
A focused fundamental survey visit was completed on March 26 and 27, 20024. The purpose of this visit was to evaluate compliance with the requirements of 42 CFR, Part 483, Subpart I regulations for Intermediate Care Facilities for Individuals with intellectual disabilities. The census at the time of the visit was six, and the sample consisted of three Individuals.
Plan of Correction:
483.420(a)(2) STANDARD
PROTECTION OF CLIENTS RIGHTS
Name - Component - 00
The facility must ensure the rights of all clients. Therefore the facility must inform each client, parent (if the client is a minor), or legal guardian, of the client's medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment.
Observations:
Based on interview with administrative staff and a review of facility records, the facility failed to inform each client, parent (if the client is a minor), or legal guardian, of the client's medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment for one of three sample individuals receiving behavior modifying medications. This practice is specific to Individual #3.
Findings include:
A review of Individual #3's record on 03/27/2024 between 10:00 AM and 11:00 AM revealed that a 90 Day Physician's order dated 02/05/2024 through 05/05/2024. This physician's order notes that Individual #3 is receiving Escitalopram (Lexapro) 5 mg daily, which was prescribed by his neurologist for the treatment of Depressive Disorder. Further review of the record revealed that there was no documented evidence that the facility sought written informed consent from Individual #3 and/or parent/legal guardian, for the use of Escitalopram and inform all parties of Individual #3's medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment.
Interview with the Clinical Director and Behavior Specialist on 03/27/2024 at approximately 10:40 AM confirmed that the facility did not obtain consent from Individual #3 and/or parent/legal guardian for the use of the above mentioned behavior modifying medication. The Clinical Director stated that he was unaware that Individual #3 was taking this medication.
Plan of Correction:The facility will ensure the rights of all clients.
CE #1
On 3/27/24 consent was obtained from individual #3, the designated contact and the HRC representative to continue the Lexpro 5mg until they meet with the psychiatrist.
CE#2
On or before April 28, 2024, nursing will review the remaining individuals in the facility to ensure that all who are on behavior modifying medications have consent from each individual as well as their designated contacts to do so. Any anomalies upon discovery of the facilities nurse will be reach out to the Clinical Director to initiate consents from individual and designated contact.
CE#3
When a new behavior modifying medication is initiated, it is sent to the individual's primary care physician for review. Once reviewed by PCP the Clinical Director or designee an assessment of the individual will be initiated. The assessment findings are presented to the team along with the psychiatrist for review. If the Psychiatrist and the team agree that there are no symptoms indicating a mental health disorder, the psychiatrist will document a note on the Psychotropic Medication Team Review Form noting that there is no need for medication at this time. If the team and psychiatrist concur that the individual is presenting symptoms consistent with the mental health diagnosis, the psychiatrist will identify the appropriate treatment, based on data gathered from the team and clinical assessment consent is than obtained by the individual and their designated contact and sent to BMRC and HRC for approval. Once approval is obtained nursing will be notified to have the order filled. If the medication recommendation is not going to be followed the reasons why are noted by the in an order by the PCP and the team reconvenes to see if a second opinion may be warranted.
CE#4
On or before April 30, 2024, the facility nurse will do an audit once a month for 3 months of all behavior modifying medications to ensure that consents are in place, thereafter every 90 days during medication review. These audits will be completed and sent to the Associate Executive Director for verification within 7 days of the audit. Any anomalies will be addressed immediately and reported to the Clinical Director for initiation of consent.
CE#5 The Associate Executive Director will be responsible for monitoring the process and reporting any discrepancies and corrective actions taken to the Senior Executive Director at the monthly Director's meetings.
483.450(e)(2) STANDARD
DRUG USAGE
Name - Component - 00
Drugs used for control of inappropriate behavior must be approved by the interdisciplinary team.
Observations:
Based on a review of the record and interview with administrative staff, the facility failed to obtain approval from the interdisciplinary team for the use of a drug used to control inappropriate behaviors for one of one Individual prescribed Escitalopram (Lexapro) for Depressive Disorder. This practice is specific to Individual #3.
Findings include:
1. A review of Individual #3's record on 03/27/2024 between 10:00 AM and 11:00 AM, revealed a physician's 90 day order, dated 02/05/2024 through 05/05/2024. This physician order notes that Individual #3 is prescribed Escitalopram (Lexapro) 5 mg tablet daily.
Continued review of this physician's order revealed that this medication was started on 11/11/2021.
Subsequent review of the record for Individual #3 revealed a document titled "Tele-Consultation Referral and Report, dated 01/14/2022. This document indicates that the Health Care Coordinator consulted with the psychiatrist regarding the use of Escitalopram (Lexapro) for Individual #3. The Psychiatrist's evaluation and recommendations are to "Continue to collect baseline behavior data. No evidence at this time of SAD (Seasonal Affective Disorder). Do not start Lexapro."
In a review of a document titled Annual Clinical Assessment, dated 01/20/22.
This assessment noted the following information:
"On 11/11/2021, [Individual #3's] neurologist recommended prescribing Lexapro for Seasonal Affective Disorder (SAD). Using a modification of the Patient Health Questionaire and guidelines from the Diagnostic Manual-Intellectual Disability (DM-ID-2), the Clinical Director completed an informal screening to rule out SAD. Based on the assessment, there has been no changes in his behavior, as the fall approached. In addition, based on the screening, there has been no change in his interest, sleep, energy, appetite, movement, mood or demonstration behaviors of concern. The only expressed concern was demonstrating an increase in non-complaint behaviors, over the summer."
During a consultation between the Clinical Director and the psychiatrist to dicuss the results of the screening, date of consultation unknow, the psychiatrist concurred with the evaluation of the Clinical Director that [Individual #3] does not appear to have SAD. Baseline data was collected between 11/22/21-12/22/21 to explore [Indvidual #3's] non-complaint behaviors. During that time period, there were no documented episodes of non-complaint behaviors.
2. A review of Individual #3's medication administration record (MAR) for March 2024 revealed that Individual #3 continues to receive the medication of Escitalopram 5 mg daily, which started on 11/11/2021. However, in further review there was no evidence that the Interdisciplinary team meet to discuss the use of Escitalopram (Lexapro) relative to
the target behavior/symptoms associated with the use of this medication, the risks and benefits of the medication, and concurrent approval for the use of the drug as being consistent with the active treatment program.
Interview with the Clinical Director, Behavior Specialist, Qualified Intellectual Disabilities Professional on 03/27/2024 at approximately 11:40 AM, revealed that all interviewees stated that they where unaware that this medication of Lexapro was initiated 11/11/2021 by the neurologist. these interviewees also confirmed that the interdisciplinary team did not meet to evaluate the use this medication relative to previous assessments in 11/2021 regarding the need for this medication for Individual #3.
Plan of Correction:
The facility will ensure that all drugs that are used for control of inappropriate behavior are approved by the interdisciplinary team.
CE#1
On 3/27/24 the interdisciplinary team (IDT) met for individual #3 to address his current medication regimen that also entails the use of a prescribed behavior modifying medication. The team came to the consensus that at this time individual #3 should continue to receive the prescribed behavior modifying medication as ordered until consulting with the psychiatrist to determine a plan of action moving forward. The team initiated the verbal consents needed to continue with HRC approval. As per recommendation of the team a follow up appointment will also be scheduled with neurology. The team meeting was documented with recommendations and sent to the team. The meeting was documented on a mini-IDT and was sent to the Associate Executive Director for verification.
CE#2
On or before 4/26/24 the interdisciplinary team will meet for the remaining individuals in the facility to review each of their medications to ensure that if they are prescribed any behavior modifying medications the team continues to agree that the medication remains appropriate at this time. If they are prescribed a medication that contradicts the recommendation of the psychiatrist and/or the team the team will reconsult psychiatry and initiate the baseline to obtain information on target symptoms to present to the psychiatrist. The meeting will be documented on a Mini IDT and sent to the Associate Executive Director within 7 days of the meeting.
CE#3
When an individual displays a behavior or symptom that may need to be addressed with in the Individual Program Plan the interdisciplinary team meets within 5 days to review current symptoms. The team initiates a baseline to obtain information or lack of information. The team reconvenes to review symptoms and lack of symptoms within 30 days of the initial meeting. Information is than presented to the psychiatrist for review if the team feels that a consideration of a behavior modifying medication if needed. Meetings are documented on a Mini IDT with recommendations if needed and dispersed to the team.
The team meets to discuss every 90 days to review current use of behavior modifying medications to review if the prescribed medications will be reduced or eliminated based on the response symptoms and document findings on a Medication Review Form.
The team receives every 90 days a spreadsheet from the Clinical Director noting all individuals who are receiving prescribed behavior modifying mediations to ensure that the team is aware of any need to address anomalies. Those anomalies are address with in 5 days.
CE#4
On or before April 28, 2024, the QIDP, Nursing and the Clinical Director for the next 6 months will meet to discuss 90-day medication reviews and will document the findings. Any anomalies will be addressed and approved through the team consent process. These findings will be sent to the Associate Executive Director to verify completion.
On or before April 28, 2024, the Social Services Supervisor will audit facility IDT's from the past 6 months to ensure that all new prescribed behavior modifying medications are addressed with the interdisciplinary team. Any anomalies will be addressed, and the team will reconvene within 7 days of the audit. The findings will be sent to the Associate Executive Director to verify completion.
CE#5
CE#5 The Associate Executive Director will be responsible for monitoring the process and reporting any discrepancies and corrective actions taken to the Senior Executive Director at the monthly Director's meetings.
483.450(e)(2) STANDARD
DRUG USAGE
Name - Component - 00
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.
Observations:
Based on record review and interview with the administrative staff, the facility failed to integrate behavior modifying drugs into the Individual's program plan that is directed specifically towards the elimination and reduction of the inappropriate behavior for one of three Individuals who are prescribed behavior modifying medications. This practice is specific to Individual #3.
Findings include:
A review of the record for Individual #3's was completed on 03/27/2024 between 10:00 AM and 11:00 AM. This review revealed a 90 day physicians's order dated 02/05/2024 - 05/05/2024 for the following medication; Escitalopram (Lexapro) 5 MG tablet, "take 1 tablet by mouth daily for the diagnosis of Depressive Disorder. Further review of Individual #3's record revealed an Annual Clinical Assessment, dated 12/26/2023, which noted that "[Individual #3] does not require participation of a positive behavior support plan."
In review of Individual #3's Individual program plan, dated 01/03/2024,
revealed there was no evidence that the interdisciplinary team integrated the use of this behavior modifying medication into the Individual Program Plan (IPP) and specify how the specific target behavior for which the medication is prescribed will be reduced or eliminated in response to changes in these symptoms.
Interview with the Clinical Director and Behavior Specialist on 03/27/2024 at approximately 10:40 AM, confirmed that Individual #3 does not have a plan to address specific symptoms associated with depression to include strategies for reduction of medication in response to changes in these symptoms. The clinical Director stated that he was unaware that Individual #3 was receive the above mentioned behavior modifying medication.
Plan of Correction:The facility will ensure to integrate behavior modifying drugs into the individual program plan.
CE#1
On or before 4/28/24 the interdisciplinary team will meet with the psychiatrist. During the meeting an assessment will be completed to determine if the original ruling out of Season Affective Disorder continues to be appropriate. If meets criteria the team will meet on the same day as the assessment to initiate plan to reduce behavioral symptoms.
CE#2
On or before 4/28/24 the team will meet for the remaining individuals to ensure that each individuals program plan has appropriate plans in place to eliminate and reduce inappropriate behaviors. Any anomalies will be addressed at the IDT and will be rectified within 7 days of the meeting. IDT will be sent to the Associate Executive Director to verify completion within 7 days of the meeting.
CE#3
If a behavioral concern is noted, it is documented on a behavioral concern sheet and submitted to the Clinical Director/Designee for review. Once received observations and interviews of staff are initiated to obtain further data. Information is presented to the interdisciplinary team and based on the information the determination is made if additional data is needed and if a plan is needed to reduce inappropriate behavior. If a plan is needed the plan is developed by the Behavioral Specialist and implemented once staff are trained. If the plan is restrictive in nature the consent process will be initiated and the individual and designated contact will provide consent if agree. Once consent is provided by individual and designated contact the plan will go to BMRC and HRC for approval before the plan is implemented and staff are trained on positive behavioral support.
CE#4
As of 4/28/24 the behavioral specialist will complete validity checks monthly to ensure that the plan is appropriate and remains appropriate for the next 6 months. The team will convene and address any anomalies that are found at the time of checks with in 7days. The findings and any recommendations will be documented on a Mini-IDT form and sent to the team within 7 days of the meeting.
CE#5 The Associate Executive Director will be responsible for monitoring the process and reporting any discrepancies and corrective actions taken to the Senior Executive Director at the monthly Director's meetings.
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