Initial Comments:
A focused fundamental survey visit was completed on February 22-23, 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 eight, and the sample consisted of three individuals.
Plan of Correction:
483.440(c)(3) STANDARD
INDIVIDUAL PROGRAM PLAN
Name - Component - 00
Within 30 days after admission, the interdisciplinary team must perform accurate assessments or reassessments as needed to supplement the preliminary evaluation conducted prior to admission.
Observations:
Based on record review and interview with administrative staff, the facility failed to perform within 30 days after admission, an accurate assessment as needed to supplement the preliminary evaluation conducted prior to admission. This practice is specific to
Individual #1.
Findings included:
A review of the record of Individual #1 was completed on 02/23/2024 from approximately 9:00 AM to 10:30 AM. This review revealed that this Individual was admitted to the facility on 01/25/2024. In further reivew, there was no indication that an updated comprehensive functional assesment was completed for this Individual since his admission on 01/25/2024.
Interview with the Assistant Director on 02/23/2024 at 10:55 AM confirmed that a comprehensive functional assesment had not been completed for Individual #1 since his admission to this residence.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The Qualified Intellectual Disability Professional (QIDP) and other Interdisciplinary Team (IDT) members will complete a comprehensive Functional Assessment for individual # 1.
Based on the outcome of the assessment, the QIDP will update individual # 1's training plan by 03/15/2024.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
The Assistant Director of the facility will complete an audit of all individual admissions that occurred in the past year (02/01/2023 to 02/27/2024) to ensure that Comprehensive Functional Assessments were completed within 30 days after admission. This audit will be completed by 03/15/2024 and documented on an Admission Check List that has pre and post admission requirements.
If any individual admissions are discovered to have occurred without a Comprehensive Functional Assessment being completed within 30 days after admission, the QIDP and the Interdisciplinary Team members will initiate the assessment within 24 hours of discovery. The QIDP will then update training plans based on the outcome of the assessment.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The Qualified Intellectual Disability Professional (QIDP) and other Interdisciplinary Team (IDT) members will be trained on the expectation of a Comprehensive Functional Assessment completion within 30 days after an admission. This training will be conducted by the Assistant Director of the facility or designee and will be documented on a Training log by 03/15/2024.
The ICF/ID Admission Checklist that has pre and post admission requirements will be updated to clarify completion of a Comprehensive Functional Assessment within 30 days after admission. This update will be completed by 03/08/2024.
For all future admissions, the Qualified Intellectual Disability Professional (QIDP) will use the ICF/ID Admission Checklist to ensure a Comprehensive Functional Assessment is completed within 30 days after admission. The QIDP will sign off on completion of the assessment on the Admission checklist.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
The Assistant Director will review the pre and post admission requirements completed by the QIDP during the admission process. This review will be documented on an Admission Checklist under Assistant Director Review section. Any missing Functional Assessment from within 30 days after admission will be initiated within 24 hours of identification.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the facility will ensure continued compliance and oversight of all pre and post admission processes. The Director will review the admission requirements completed by the QIDP and reviewed by the Assistant Director during the admission process. This review will be documented on an Admission Checklist under Director Review section. Any missing admission requirements will be initiated within 24 hours of identification and retraining on the admission requirements completed.
Director of the Facility is responsible for the oversight of all corrective action being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Senior Director of the Facility to review on going status of correction action completion.
This process will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
and under varied conditions to-
Observations:
Based on record review and interview with administrative staff, the facility failed to hold evacuation drills under varied conditions of time for the first and second shift of personnel during the time period of 01/2023 thorough 12/2023.
Findings include:
A review of the facility's evacuation drills for the period from 01/2023 through 12/2023 was completed on 02/22/2024 from approximately 9:45 AM to 10:00 AM. This review revealed evacuation drills were not varied throughout the extent of the first and second shift of personnel as follows :
First Shift of Personnel Evacuation Drills defined as 7:00 AM to 3:00 PM:
03/04/2023 12:25 PM
06/22/2023 7:50 AM
09/09/2023 10:03 AM
12/09/2023 12:44 PM
Second Shift of Personnel Evacuation Drills defined as 3:00 PM to 11:00 PM:
02/04/2023 4:26 PM
05/10/2023 9:00 PM
08/09/2023 9:19 PM
11/08/2023 6:55 PM
Interview with the Director of Adult Community Residential programs on 02/22/2024 at approximately 10:00 AM confirmed the times of the evacuation drills were not varied as noted above for both the first and second shift of personnel.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The Qualified Intellectual Disability Professional (QIDP), House Supervisor, and Assistant Director of the facility will be trained that fire drills need to be held during varied times.
This training will be conducted by the Director of the facility and documented on a Training log by 03/08/24.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
This deficient practice affected all residents of Miller A.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
All Qualified Intellectual Disability Professionals (QIDP), House Supervisors and Assistant Directors will be trained that fire drills need to be held during varied times within the year. This training will be conducted by the Director of the facility and will be documented on a Training log by 03/08/2024.
A fire drill schedule for the entire year will be created for all facilities. The schedule will indicate the time that each facility should conduct the monthly fire drill. Each fire drill will be scheduled to occur at varied times across the entire shift and varied from any drill that has occurred within the year. All QIDP, House Supervisors and Assistant Directors will be trained on the fire drill schedule by the Director of the facility. The training will be completed by 03/08/2024 and will be documented on a Training log.
The Assistant Director or a designee will review monthly fire drills by the 15th of each month to verify that the fire drill was completed at the scheduled time as per the fire drill schedule. If the fire drill was not conducted during the correct time or within one hour of another drill within the year, the facility will conduct another fire drill during the correct shift and time within the same month, but no later than the end of the month. This practice will begin in March 2024.
A Fire Drill Tracking Grid will be created for all facilities. The Assistant Director will be trained on how to use the Fire drill tacking grid to review fire drills. This training will be conducted by the Director of the facility and documented on a Training log by 03/08/2024.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
The Assistant Director or a designee will use the created Fire Drill Tracking Grid to track monthly fire drills completed by the QIDP or the House Manager. This review will be completed by the 15th of each month to verify that the fire drill was completed during the scheduled shift, at the correct time as per the fire drill schedule and is varied from any fire drill completed within the year. If the Assistant Director identifies that a fire drill was not conducted during the correct time as per the fire drill schedule, the facility will conduct another fire drill within the same month, but no later than the end of the month. This practice will begin in March 2024.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective action being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Senior Director of the facility to review the status of corrective action completion, beginning 03/01/2024
This process will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
483.480(d)(3) STANDARD
DINING AREAS AND SERVICE
Name - Component - 00
The facility must equip areas with tables, chairs, eating utensils, and dishes designed to meet the developmental needs of each client.
Observations:
Based on observation, record review and interview with administrative staff, the facility failed to equip areas with eating utensils designed to meet the developmental needs of each client. This practice is specific to Individual #1.
Findings included:
1. Observations completed on 02/22/2024 from 5:25 PM to 6:10 PM noted that.
Individual #1 was sitting at the dining room table with her peers listening to music when it was time for dinner. A staff person placed a placemat, scoop dish, tablespoon, napkin and plastic cup in front of Individual #1 at the table. Next, a staff person placed a divided platter next to Individual #1 with minced chicken divan, egg noodles and mixed vegetables and spooned the items onto the scoop dish. This staff person picked up the tablespoon and placed it in Individual #1's right hand and she began to eat.
Individual #1 scooped a heaping amount of food onto her tablespoon and placed it in her mouth. As the food overflowed from the spoon onto her face, this Individual then wipes her face with a napkin she held in her left hand. Individual #1 repeated this pattern throughout the meal until the meal was finished. During this time, Individual #1 was not offered a smaller spoon nor was Individual #1 prompted to scoop smaller amounts of food onto her tablespoon.
2,. A review of Individual #1's record was completed on 02/23/2024 from 9:00 AM to 10:30 AM. This review revealed a document titled "Primary Care Physical Examination Visit" dated 01/25/2024 that included the following diagnoses: Gastro-esophageal reflux disease (GERD) and mild dysphagia. In a subsequent review of a document titled "Eating Precaution Plan/Nutritional Summary" dated 01/25/2024 that included the following information:
-Food Texture: Level 5: Minced and Moist (Mechanical Soft)
-Liquid/Drink Texture: Level 0: Thin
-Special Instructions: Encourage small bites and sips; [Individual #1] may require cues to slow down.
Interview with the Director of Adult Campus Residential Programs on 02/22/2024 at approximately 5:45 PM, noted that this interviewee was unable to indicate both why Individual #1 was not provided a smaller utensil for eating, or why this Individual was not prompted to slow down the rate of ingestion of food.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The QIDP, Occupational Therapist (OT), and the Speech and Language Pathologist (SLP) will gather a list of all adaptive items used by individual #1 during meal times and meet with the Interdisciplinary Team (IDT) members to review the list and ensure all team members are in agreement with the items on the list. If changes are needed, the QIDP will ensure that these changes are made and implemented within 24 hours. The meeting documentation and any related training on adaptive items will be submitted to the Director of the facility for review prior to filing by 03/07/2024
The QIDP, OT, SLP and Interdisciplinary Team (IDT) members will meet and review individual # 1's current Eating Precaution Plan which includes food consistency and special instructions. If changes are needed, the QIDP will ensure that these changes are made and implemented within 24 hours. The meeting documentation and any related training on individual # 1's Eating Precaution Plan will be submitted to the Assistant Director of the facility for review prior to filing by 03/07/2024.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
The QIDP, OT, and SLP will gather a list of all adaptive items used by all the individuals in the facility during meal times. The QIDP will then meet with the Interdisciplinary Team (IDT) members to review the list and ensure all team members are in agreement with the adaptive items on the list. If changes are needed, the QIDP will ensure that these changes are made and implemented within 24 hours. The meeting documentation and any related training on adaptive items will be submitted to the Director of the facility for review by 03/15/2024
The QIDP, OT, SLP and Interdisciplinary Team (IDT) members will meet and review Eating Precaution Plans used by all the individuals in the facility and ensure all team members are in agreement with the plans. If changes are needed, the QIDP will ensure that these changes are made and implemented within 24 hours. The meeting documentation and any related training on the Eating Precaution Plan will be submitted to the Director of the facility for review prior to filing by 03/15/2024.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The Assistant Director of the facility will create a meal observation schedule that includes meals across the day; breakfast, lunch and dinner. Meal observations will be completed at least once per week by either the QIDP or House manager.
The QIDP or the House Manager will use the created meal observation schedule to complete unannounced mealtime observations as assigned. The QIDP or the House Manager will review Eating Precaution Plans prior to the meal observations. These observations will be documented on a Mealtime Observation Checklist form.
If during the observation, any issues are noted, they will be immediately addressed by the observer and staff will be provided with re-training. Any intervention or training needed will be noted on the observation form.
If after training there are recurrent concerns, the concerns will be addressed via progressive corrective action up to and including termination of employment.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
Completed meal time observations by the QIDP or the House Manager will be submitted to the Assistant Director for review on a weekly basis prior to filing. This practice will begin on 03/03/2024.
If after training there are recurrent concerns, the concerns will be addressed via progressive corrective action up to and including termination of employment. This practice will begin in April 2024.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Assistant Director of the facility will submit all the completed mealtime observations to the Director no later than the 5th of the following month.
The Director of the facility will review and compare the meal observation schedule and completed Mealtime Observation Checklist form and ensure all meal observations were completed for the previous month. If there are any concerns noted from the review, the responsible party will be provided with re-training.
The Director of the Facility is responsible for the oversight of all corrective action being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Senior Director of the facility to review the status of corrective action completion, beginning in March 2024.
This process will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
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