Initial Comments:
A focused fundamental survey visit was completed on September 17 and 18, 2025. 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 five, and the sample consisted of three individuals.
Plan of Correction:
483.460(l)(2) STANDARD
DRUG STORAGE AND RECORDKEEPING
Name - Component - 00
The facility must keep all drugs and biologicals locked except when being prepared for administration.
Observations:
Based on observation and interview with facility staff, the facility failed to ensure that all drugs and biologicals are locked except when being prepared for administration for one of one sample Individual observed receiving medications. This practice is specific to Individual #1.
Findings included:
Observation completed on 09/17/2025, from approximately 7:16 AM to 7:30 AM noted that Individual #1 was brought into the medication room to receive his morning medications at 7:16 AM. The staff person who was administering medications removed two bins of medications from the medication cabinet, which had this Individuals picture on each bin, also removing bottle of Ensure (a nutritional drink) as well. Both the medications and Ensure were placed on the desktop directly in front of Individual #1. The staff person then left the medication room at approximately 7:18 AM, and returned within approximately 20 seconds with a jar of Thicket which is a substance used to thicken liquids.
The staff person then proceeded to punch out all of Individual #1's medications from the blister packs, and crush the medications. The staff person then opened the bottle of Ensure, poured it into a nosey cup ( a special cup with a cut out for the nose designed to promote drinking with less spillage), poured the crushed meds into the Ensure and then used the Thicket to thicken the liquid Ensure.
Individual #1 then drank this mixture. Upon finishing, there was medication residual left on the inside of the cup. At 7:26 AM the staff person left the medication room. The two bins containing medications remained directly in front of Individual #1.
Approximately 45 seconds later, the staff person returned with milk which she poured into the nosey cup, stirred the residual of medications into the milk, again added Thicket and gave the cup to Individual #1 which he consumed without difficulty.
A review of the medications contained in the 2 bins designated for Individual #1 contained the following medications:
BIN #1
-Claritin 10 mg. (1 Blister pack)
-Multivitamin child chew (1 Blister pack)
-Folic Acid 1 mg. (1 Blister pack)
-Vit B-12 500 mcg. (1 Blister pack)
-Tums chewable 500 mg. (1 Blister pack)
-Depakote DR 125 sprinkles (4 Blister packs: 3 packs containing 2 capsules each and 1 pack containing 1 capsule)
-Depakote DR 125 sprinkles (4 Blister packs: 3 packs containing 2 capsules each and 1 pack containing 1 capsule)
-Tums chewable 500 mg.
BIN#2:
Desitin 13% cream
Polycol 3350 powder
Debrox 6.5% ear drops
Sensodyne Toothpaste
D3 Baby drops 400 IU
Crest Mouthwash
Ofloxacin 0.3% ear drops
Interview with the staff person who left the medications out on the desktop on 09/17/2025 at approximately 7:31 AM indicated that this interviewee was unable to explain why she left the medications out on the desktop when she left the room with Individual #1 sitting directly in front of the medications.
Interview with the Program Director of ICF on 09/17/2025 at approximately 9:15 AM, confirmed that medications should not be left out when an individual is present and a staff person is not present.
Plan of Correction:1.The QIDP will re-train all staff on medication administration. Particular emphasis will be paid to ensuring the medication closet and all medications are locked each and every time, except during preparation and administration. This retraining will include the medication storage procedures from the Medication Administration policy. Documentation will be the Medication Administration Training form.
2.Performance Management steps have been completed for the worker on shift who was responsible for medication administration and ensuring proper procedures were followed. Documentation is the file for this worker.
3. Twice weekly a Home Manager will observe randomly selected medication trained staff administer medications. The Home Manager will document if active treatment is occurring and ensure medication trained staff are following the BARC policy and procedures for locking and storing medications. Any procedures not being followed will be documented and performance management steps will be taken. Documentation will be the MEDICATION OBSERVATION sheet.
4.Twice monthly the QIDP will observe randomly selected medication trained staff administer medications. The QIDP will document if active treatment is occurring and ensure medication trained staff are following the BARC policy and procedures for locking and storing medications. Any procedures not being followed will be documented and performance management steps will be taken. Documentation will be the MEDICATION OBSERVATION sheet.
5.Once monthly the Program Director will review all documentation associated with this plan of correction to ensure that all training and reviews are occurring as required. Any missing documentation or incorrect documentation will be immediately addressed with the associate responsible and documented. Documentation will be via the MEDICATION OBSERVATION sheet.
6.All Documentation will be kept in a Plan of Correction binder in the ICF Program Director's office.
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