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The Program Coordinator will train the Qualified Intellectually Disabled Professional (QIDP) Supervisor, and the QIDP will train all Direct Support Professional (DSP) staff on the importance of assuring the rights of all clients by ensuring privacy during treatments and care of personal needs. Training will include, but not be limited to, administering all treatments, including lotion, cream, eye drops, and ear drops in the privacy of a room with a closed door, such as the bedroom or the bathroom, but not during toileting. Training will be completed by May 12, 2025. The Program Director will sign and date the training record of the QIDP Supervisor, and the Program Coordinator will do the same for the Direct Support Professional Staff, to confirm completion. The QIDP Supervisor will ensure all staff are trained by comparing the completed training sheets to the staff schedules. Training records will be maintained in the personnel files.

The QIDP Supervisor will conduct unannounced observations, at varied medication administration times, to ensure staff are maintaining privacy during treatments. Observations will be recorded on tracking grid developed by the Program Director. The tracking grid will specify whether privacy was maintained while administering treatments. Observations will begin as soon as training is complete, and all facility DSP staff will be observed at least two times by June 1, 2025. If staff does not ensure privacy during treatments the staff member making the error will continue to be observed at least two times every two weeks until there are three successful observations, defined by administering all treatments in an in a private area. Documentation of these observations will be on or attached to the tracking grid.

After two successful observations the monitoring will fade to one additional time before June 10, 2025, then two times per year and conducted during the time of each staff member's semi-annual medication administration training. The Program Coordinator will review the tracking grid to assure completion by June 15, 2025 and document by signaling and dating.

The bi-annual observations will be documented on a form designated by the Medication Administration Training. Medication Administration Training includes the importance of ensuring privacy during treatments. If an error is noted the staff member making the error will receive retraining and progressive disciplinary action as per agency policy, and will continue to be observed until two additional, successful, treatment sessions are observed, defined above. Documentation of these observations will be on forms designated by the Medication Administration Training and the Learning Program Assistant tracks compliance.

The Learning Program Assistant tracks annual training dates to assure all requirements are met for all staff who administer medication and treatments, and communicates this information on a regular and on-going basis to the supervisory team and DSP staff via e-mail. As well, the Learning Program Assistant maintains this information on a spreadsheet located on the internet which all facility staff has access to.

Failure to follow the steps outlined in this plan of correction will lead to re-training and the policy for progressive discipline will take effect.

The Director of Nursing (DON) will train the Health Services Coordinator (HSC) on the importance of providing or obtaining preventative and general medical care. This training will focus on the importance of following recommendations to seek follow up care and preventative health care in a timely manner, including follow up medical appointments and lab work. Training will be completed by May 2, 2025. The Program Director will sign to confirm completion. The training record will be kept in the employee's People Operations file.

In regards to Individual #1:
1. Stage IV Chronic Kidney Disease: Individual #1 went to his Nephrology appointment on February 4, 2025. The consult indicates a follow up anointment is needed in four months. The next appointment has been scheduled for May 28, 2025. Results will be communicated to the IDT and medical providers by the Health Services Coordinator during the June Interdisciplinary team meeting, on June 10, 2025, and added to his electronic health record.
2. Prostatic Hyperplasia with Urinary Hesitancy: Lab work, including a PSA, was completed April 21, 2025. Results will be communicated to the IDT and medical providers by the Health Services Coordinator during the May Interdisciplinary team meeting, on May 14, 2025, and added to his electronic health record.
3. Macular Degeneration: An eye appointment was scheduled for May 6, 2025. Results will be communicated to the IDT and medical providers by the Health Services Coordinator during the May Interdisciplinary team meeting, on May 14, 2025, and added to his electronic health record.

The Health Services Coordinator will audit physician's orders, appointments, and lab work during the survey year, that was completed for Individual #3, in effort to assure the facility provided or obtained preventative and general medical care. If preventative or general care was not provided, per recommendations, documentation will be reviewed to identify the reason for the cause, and a note added to his electronic health record. The Heal Services Coordinator will also communicate this to the Nurse Manager. An appointment will be scheduled by ICF Administrative Support person in collaboration with the QIDP Supervisor. Documentation of the appointment scheduled will be on the placed on the medical calendar. This is all to be completed by May 2, 2025, documented in a format designated by the Director of Nursing, and the Nurse Manger will be responsible for confirming completion and documenting her review by responding to the email.

There will be ongoing monthly audits of medical appointments by the ICF Administrative Support person, on a form designated by the Director of Nursing. On a monthly basis for the next six months the Health Services Coordinator (HSC) and the Administrative Support person will review the tracking tool for appointment attendance compliance and lab testing compliance and submit their findings to the Director of Nursing, Nurse Manager, and Program Director by the first Friday of every month. Missed lab work and other missed tests and/or appointments will be rescheduled immediately. The Nurse Manager will document their review by signing and dating the tracking tool by the beginning of the following week and sending the information to the Director of Nursing. This plan will be implemented beginning May 2, 2025.

For the next six months, the Nurse Manager, or designee, will meet with the Health Services Coordinator every month to review medical appointments and corresponding documentation including physician orders to ensure that there is appropriate documentation following each appointment, results of all specialized studies have been obtained, and all recommendations for follow-up treatment have been followed, and return appointments have been made appropriately. Any deficiency identified will require immediate notification to the Director of Nursing and the Program Director. Immediate notification will need to be made to the physician if warranted and documentation in the electronic health record on the corrective action will be made. On a monthly basis, the Director of Nursing or designee will conduct a random audit of selected charts to ensure compliance. Documentation of this review will be submitted to the Program Director and Assistant Executive Director.

The ICF Supervisory Team and Direct Care staff will be trained by the Director of Nursing to access and review the medical calendar and the importance of assuring all medical appointments occur as scheduled, in effort to provide preventative and general medical care. Training will incorporate an understanding of the physician orders and the importance of compliance with the annual and routine orders. Training for the Supervisory team will be completed by May 2, 2025, and Direct Care Staff by June 1, 2025. Documentation of training will be on the agency approved form, and signed by the next level supervisor. The training record will be kept in the employee's People Operations file.

The Program Director will again train the supervisory team on the importance of providing preventative and general medical care on May 6, 2025 at the Cluster meeting, and document on the agenda and signature sheet. Supervisors and Coordinators will be required to review the calendar in the electronic health record at least one week prior to the start of the month to identify potential conflicts, and provide feedback via email to the Administrative Support person if there is a need to reschedule an appointment. The QIDP is required to copy the Program Coordinator on the email so they can assure the review was completed. The QIDP will communicate if there are no concerns to the Coordinator also so the Coordinator can confirm the review was completed. This process will go into effect starting June 1, 2025, and will not fade. The Coordinator will confirm completion by responding to the email.

When appointments are missed, the QIDP Supervisor will document the reason for the missed appointment in the electronic health record, and communicate to the Interdisciplinary Team, which includes the Program Director, Program Coordinator, Nurse Manger, Health Services Coordinator, and Administrative Support person, so the appointment is rescheduled. The Program Director developed a format to track missed appointments in effort to identify trends. Staff members responsible for the missed appointment will receive retraining and progressive disciplinary action, per agency policy.

Failure to follow the steps outlined in this plan of correction will lead to re-training and the policy for progressive discipline will be take effect.