Initial Comments:
A focused fundamental survey visit was completed on July 8 and 9, 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 six, and the sample consisted of three individuals.
Plan of Correction:
483.460(c)(3)(iii) STANDARD
NURSING SERVICES
Name - Component - 00
Nursing services must include, for those clients certified as not needing a medical care plan, a review of their health status which must be on a quarterly or more frequent basis depending on client need.
Observations:
Based on record review and interview with administrative staff, the facility failed to ensure
for those clients certified as not needing a medical care plan, a review of their health status which must be on a quarterly basis for one of three sample Individuals. This practice is specific to Individual #1.
Findings include:
A review of the record for Individual #1 was completed on 07/08/2025 from 9:00 AM until 11:00 AM. In a review of quarterly nursing reviews of health status for this Individual,
this review revealed for the time period of August 2024 to July 9, 2025, Individual #1 had a physical examination completed by the nurse on 09/11/2024 and 12/10/2024. There was no documented evidence that Individual #1's health status had been reviewed for the first and second quarter of 2025.
Interview with the Nurse Manager on 07/09/2025 at approximately 9:15 AM, confirmed there was no documented physical examination by the nurse conducted for Individual #1 during the first and second quarter of 2025.
Plan of Correction:CE1 Individual #1's Nursing Quarterly Health Status Reviews for March and June were completed by 7/15/2025 by the Nurse Manager. The Director of Nursing retrained the Nurse Manager on timeliness of Quarterly Health Status Reviews and expectations for the completion of the Quarterly Review by 7/15/2025. This is documented on a Record of Discussion.
CE2 he Director of Nursing directed the Nurse Manager to complete an audit of quarterly Health Status Reviews for all individuals supported by 7/23/2025. The results of the audit will be documented on a spreadsheet in Teams. If the Quarterly Health Status Reviews are not completed in time, the Director of Nursing will follow up with the Nurse Manager for completion by 7/30/2025 and address through appropriate personnel action, as necessary.
CE3 The Director of Nursing developed a spreadsheet for each Qualified Intellectual Disability Professional and Nurse Manager with the due dates of the Quarterly Health Status Review. The spreadsheet was developed by 7/15/2025. The Nurse Manager will complete an audit of the Quarterly Health Status Review each month. By the 15th of the following month, the Nurse Manager will submit the audit of their caseload's Quarterly Health Status Reviews to the Director of Nursing. The Director of Nursing will review the Nurse Managers' reports and verify them against the spreadsheet of Quarterly Health Status Reviews. If the Quarterly Health Status Reviews are not completed in a timely manner, the Director of Nursing will follow up with the responsible Nurse Manager for completion and address through appropriate personnel action, as necessary. The Director of Nursing will forward the audits of the Health Status Reviews to the Director of Quality Improvement within a week and/or by the 22nd of the following month. The Director of Quality Improvement will alert via email the Executive Director of Nursing and the Executive Director of Programs if the Audits are not received from the Director of Nursing.
In addition, the Director of Quality Improvement will add the Quarterly Health Status Review to the Medical Book Audit tool. The tool will be used at audits which occur at least once every 2 months, to document that the Review is completed and filed. The Quality Improvement Team will present quarterly training at Nursing Meetings to explain and discuss regulations which affect nursing and the corresponding policies and procedures. Minutes of this training will be maintained by the Director of Quality Improvement.
CE4 The Director of Nursing will oversee the Quarterly Health Status Review compliance each month. The Quality Improvement personnel will complete audits using the revised Medical Book Audit Tool of the Quarterly Health Status Review according to the established schedule. The results of the audit will be shared within 24 hours with the Qualified Intellectual Disability Professional, the Director of Quality Improvement, the Director of Nursing, and Operations Leaders. If there are missing, or late, Quarterly Health Status Review(s) found, the Director of Quality Improvement will alert the Executive Director of Nursing by email to address the finding with the Director of Nursing. The Director of Nursing will follow up with the responsible Nurse Manager for completion and address through appropriate personnel action, as necessary.
CE5 The Executive Director of Nursing is responsible for overseeing the process and assessing corrective action implementation, including taking necessary personnel action as needed.
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