Initial Comments:
A monitoring survey was conducted on February 27-28, 2024, to determine compliance with the requirements of 42 CFR Part 483, Subpart I Requirements for Intermediate Care Facilities. The census during the survey was six. One deficiency was identified.
Plan of Correction:
483.470(g)(2) STANDARD
SPACE AND EQUIPMENT
Name - Component - 00
The facility must furnish, maintain in good repair, and teach clients to use and to make informed choices about the use of dentures, eyeglasses, hearing and other communications aids, braces, and other devices identified by the interdisciplinary team as needed by the client.
Observations:
Based on observation and staff interview, it was determined that the facility failed to maintain adaptive equipment as needed by the individuals. This was noted for the only two individuals in the home who required the use of a bed alarm for safety (Individuals #1 and #2).
The findings included:
A) A focused physical plant inspection was conducted on February 27, 2024, at 12:30 PM to assess bed alarms for Individuals #1 and #2. The program director (PD) and program coordinator (PC) accompanied the surveyors at this time. Upon testing the bed alarm for Individual #1, it was determined that it was not functioning. The bed alarm for Individual #2 was then tested and was also determined that it was not functioning.
The surveyors inquired if there was documentation that the bed alarms were tested periodically to ensure they were in working order. The PD confirmed there was no documentation of periodic testing.
B) The PD was interviewed at the time of the inspection. The PD confirmed that the bed alarms for Individuals #1 and #2 were not in working order at the time they were tested. In addition, the PD confirmed that there was no documentation indicating the alarms were periodically tested for proper functioning.
Plan of Correction:The Program Coordinator will train the Supervisor, who in turn will train the Direct Support Professional staff on the importance of furnishing, maintaining in good repair, and teaching clients to use and to make informed choices about the use of dentures, eyeglasses, hearing and other communications aids, braces, and other devices identified by the interdisciplinary team as needed by the client. The training will focus on, but not be limited to, the identified equipment and devices needed for Individual #1, #2, and all individuals. Training will include the importance of daily staff checks on each shift, and weekly supervisor checks, of bed alarms to assure they are present and properly working, and immediately notifying the Supervisor and Program Coordinator if equipment and devices become damaged, inoperable, or are missing so a plan can be put in place to assure safety until the equipment or device can be repaired or replaced. Training will be completed by April 1, 2024. The Program Director will sign and date the training record of the Supervisor, and the Coordinator will do the same for the Direct Support Professional Staff, to assure completion. The 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 Program Coordinator contacted maintenance and the alarm was immediately repaired for Individual #1, on February 27, 2024. Individual #2 is no longer able to get up and out of bed independently. He needs the assistance of two staff and uses a whistle he wears to notify staff of his needs. This is his preference and works well. The Interdisciplinary agreed to discontinue his bed alarm, and removed the bed alarm for Individual #2, on February 27, 2024.
A check list was developed by the Program Director and implemented by the QIDP on February 27, 2024 assigning staff on each shift the responsibility to check and assure the bed alarm is present and working. Documentation of the check and the staff signature will be recorded on the form. There is a requirement for the Supervisor to check to assure the bed alarm is present and working one time per week, and document her check on the form. Instructions on the form indicate that if the alarm is not working, immediately report to a supervisory team member. Individual #1 would then have line of sight supervision when in his bedroom, until a replacement bed alarm is in place.
A supervisory team member will conduct unannounced observations, at varied times, to ensure identified equipment and devices for each individual are present and in good repair. Observations will be recorded on tracking grid developed by the Program Director. The tracking grid will specify assigned equipment and devices for each individual, and whether they are present and in good repair, including Individual #1's bed alarm. Observations will begin as soon as training is complete, and all facility DSP staff will be observed at least two times by April 15, 2024. If equipment and devices are not present, or not in good repair, the staff member responsible for supervising the individual will continue to be observed at least two times every two weeks until there are three successful observations, defined by assuring their assigned individual(s) have all equipment and devices, and equipment and devices are in good repair. Documentation of these observations will be on or attached to the tracking grid. The Program Coordinator will review the tracking grid to assure completion by April 20, 2024 and document by signaling and dating.
After two successful observations the monitoring will fade to one additional time before April 30, 2024, and defined and tracked as stated above. All employees are expected to assure the facility furnishes, maintains in good repair, and teach clients to use and to make informed choices about the use of dentures, eyeglasses, hearing and other communications aids, braces, and other devices identified by the interdisciplinary team as needed by the client at all times. This will be monitored by supervisory team members at all times via management by walking around. If infractions are noted, meaning equipment or devices is damaged or missing and not reported, the employee responsible will receive retraining and progressive disciplinary action, as per agency policy, and immediate safety measures will be put in place. To assist, the Program Director blocked off a time in the Supervisor's Outlook calendar each week, on Friday, to complete adaptive and medical equipment check for each individual.
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.
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