Initial Comments:
A focused fundamental survey was conducted January 23-26, 2024, to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was six and the sample consisted of three individuals. Three deficiencies were cited.
Plan of Correction:
483.440(d)(1) STANDARD
PROGRAM IMPLEMENTATION
Name - Component - 00
As soon as the interdisciplinary team has formulated a client's individual program plan, each client must receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan.
Observations:
Based on observation, record review and staff interview, it was determined that the facility failed to ensure a continuous active treatment program was implemented according to the individuals ' program plans (IPP). This was noted for all six individuals in the home (Individuals #1, #2, #3, #4, #5, #6). The findings included:
A) A physical plant inspection was conducted on January 23, 2024, between 1:15 PM and 1:45 PM. The facility program director (PD) and program supervisor (PS) accompanied the surveyor. This inspection revealed the following:
1. The surveyor was informed that individual #4 requires the use of a bed alarm for safety due to a seizure disorder. The PS located the bed alarm pad through the bed sheets, pressed down on the pad and discovered it was not working. Upon retrieval of the alarm pad, it was found to be cut open in several areas, with numerous staples throughout.
A focused review of Individual #4 ' s IPP, dated October 16, 2023, revealed that " the use of a bed alarm was initiated in January, 2019, to better monitor [Individual #4] when sleeping. Alarm alerts staff to his movements so that prompt assistance can occur. " The surveyor inquired whether staff are required to document daily checks of the bed alarm to ensure proper functioning and was informed that they are. There was no documentation to indicate that daily checks were performed on this individual ' s bed alarm. The PD confirmed that Individual #4 was without a functioning bed alarm as stated in his IPP for an unknown period of time.
2. A bottle of Windex window cleaner was discovered under the sink the upstairs bathroom. This bathroom is shared by four individuals in the home (Individuals #1, #2, #5, and #6). According to these individuals ' IPPs, all cleaning supplies are kept locked to ensure safety. The PD confirmed at the time of discovery that the Windex should have been locked per the individuals ' IPPs.
B) Breakfast observation was conducted on January 25, 2024, from 6:45 AM until 7:15 AM. This observation revealed Individual #3 was served a pureed egg sandwich, yogurt and applesauce. In addition, this individual was served orange juice, water and coffee to drink. Individual #3 was observed to eat all of his pureed sandwich, and then drink all of his orange juice, without redirection from staff.
Review of Individual #3 ' s record revealed an IPP, dated March 9, 2023, that specified the following as part of his diet precautions: " Encourage him to eat slowly, to take small bites of foods and sips of liquid at a slow rate of intake; Encourage cyclic ingestion rate of 1:1 (one bite of a food followed by one sip of liquid, 1-2 ounces at a time). "
The PD was interviewed on January 25, 2024, at 1:00 PM. The PD acknowledged that Individual #3 consumed his breakfast meal without the benefit of redirection as outlined in his IPP.
Plan of Correction:The Program Coordinator will train the Supervisor who, in turn, will train all Direct Support Professional staff on the importance of providing a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan. This will include, but not be limited to, the importance of assuring adaptive equipment is present and working, which includes Individual #4's bed alarm, cleaning supplies are kept locked when not in use, unless otherwise permitted as per each individual's Individualized Program Plan, and diet orders are followed, which includes prompting Individual #3 for cyclical ingestion. Training will include a list of all adaptive equipment and all prescribed diets.
The training will be completed by March 1. 2024. The Program Director will sign and date the Supervisor's training to document completion, and the Program Coordinator will do the same for Direct Support Professional staff. The Supervisor will ensure all DSP staff are trained by comparing completed training records with the staff schedule. Training records will be maintained in the personnel files.
To ensure compliance, a supervisory staff, which includes Supervisors and Coordinators, will make unannounced observations to ensure each client receives a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan. Observations will focus on assuring adaptive equipment, including bed alarms, is present and in working condition as evidenced by the staff signature sheet, assuring cleaning supplies are locked, and diet orders, including cyclical ingestion, are followed. These observations will begin March 1, 2024 and all DSP staff who work in the home will have at least two checks completed during their shift by March 15, 2024. If staff on a particular shift is not in compliance, all staff member working on the shift during which the error was found will continue to be observed at least two times every two weeks until there are two successful observations during shifts each staff member works, defined by assuring adaptive equipment is present and working, cleaning supplies are locked, and diet orders are followed.
All observations will be recorded on a tracking sheet developed by the Program Director. The tracking sheet will specify whether or not assuring adaptive equipment is present and working, cleaning supplies are locked, and diet orders are followed for all individuals residing in the home. The Program Supervisor will ensure all DSP staff of the home is observed by comparing completed observation dates and times with the staff schedule. Tracking sheets will be signed and dated by the Program Coordinator to assure completion.
Once the initial observations are successfully completed, each DSP staff member will be observed one additional time by March 31, 2041 and the process outlined above will be followed.
Demonstrating "management by walking around," on an ongoing basis, supervisory staff including Supervisors and Coordinators will tour the home and assure compliance with IPP's at all times. Specifically, in regards to Individual #2's bed alarm, staff will continue to check it, and document their check, on a daily basis. The Supervisor must test the alarm personally at least one time per week, and the test results will also be recorded on the tracking sheet. All concerns must be immediately brought to the attention of the supervisory team to assure the needs of all individuals are met at all times.
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.
483.460(a)(3) STANDARD
PHYSICIAN SERVICES
Name - Component - 00
The facility must provide or obtain preventive and general medical care.
Observations:
Based on record review and staff interview, it was determined that the facility failed to follow recommendations by a specialist. This was noted for the only individual in the sample who was seen by a dermatologist (Individual #2). The findings included:
A) Individual #2's record was reviewed on January 24-26, 2024. This review revealed a dermatologist report dated February 21, 2023. The report indicated that this individual had family history of non-melanoma skin cancer and had several biopsies taken of various areas. Recommendations included "monthly self-skin checks should be performed to monitor for any moles that have changed in size, color, itch, burn or bleed." In addition, the report indicated "patient advised to have full skin exams every three to six months." There was no monthly documentation to monitor Individual #2's skin for changes to moles by a nurse.
B) The program director (PD) was interviewed on January 25, 2024. The PD confirmed that there was no monthly documentation that Individual #2 was assessed by a nurse to monitor for changes to moles in the past year.
Plan of Correction:The Director of Nursing will implement training with the nursing department to review the expectations of the Health Care Coordinator to collaborate with the supervisor and the Administrative Support to schedule follow-up with specialists as per physician recommendation and monthly nursing assessments if needed. Training will be completed by 02/23/24. Training will be documented, and the signature sheet will be forwarded to the Program Director to assure completion.
Moving forward an order was obtained from the PCP on 01/24/24 requesting that the nurse check Individual #2 monthly for moles and notify the specialist of any changes. A review was done for all of the individuals at Spruce by 01/26/2024 to ensure that recommendations by a specialist were in compliance. Compliance was noted.
Skin checks will be documented on a Body Check form and a nursing progress note placed into the Electronic Health Record documenting these findings.
The Health Services Coordinator will provide a list of individuals to the Director of Nursing that must have specialty follow up or those that have medical conditions that require monthly nursing assessments with the frequency of those visits. The Director of Nursing will do a monthly review for the next six months ensuring that the follow up recommendation has occurred. Findings will be documented in a communication by email to the IDT for Spruce using the Spruce Team group email address which includes the Program Director. If it has not occurred, the Health Care Coordinator has to immediately do the assessment or contact the specialist for an appointment. Documentation of the finding and the corrective action will be noted in the Electronic Health Record. This plan will end after six months unless we are out of compliance in which the plan will continue and be reevaluated for another month until there are no lapses in follow up recommendations. A copy of the profiler note if applicable will be sent to Program Director for the Plan of Correction files.
Failure to follow the information outlined in this plan of correction will lead to re-training and the policy for progressive discipline will take effect.
483.460(k)(2) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.
Observations:
Based on observation, documentation review, and staff interview, it was determined that the facility failed to administer medications without error. This was noted for three of the six individuals who received medications (Individuals #1, 2, and 3). The findings included:
A) Observation of the morning medication administration was conducted on January 25, 2024, between 7:20 AM and 9:20 AM. These observations revealed the following errors which were confirmed with the staff administering medications (SAM) at the time of the observation.
- Individual #2 was administered one spray of Flonase to each nostril. The SAM handed the medication to the surveyor for review. The surveyor requested the SAM to re-read the label. The SAM administered another spray to each nostril. Physician's orders dated January 4, 2024, indicated that this individual should receive two sprays of Flonase to each nostril.
In addition, Individual #2 did not receive the benefit of an eye scrub pad to wash his eyes prior to the administration of eye drops for glaucoma. The SAM noticed this after the eye drops were administered. Physician's orders dated January 4, 2024, indicated that eye scrub pads were to be utilized twice a day.
- Individual #1's medication was prepared by the SAM at 8:43 AM. The SAM noticed that this individual did not receive Lactase prior to the breakfast meal. Physician's orders dated January 4, 2024, indicated that this individual should receive Lactase one half hour before meals.
- Individual #3's medication was prepared by the SAM at 9:10 AM. The SAM noticed that this individual did not receive Synthroid at 6:30 AM. Physician's orders dated January 4, 2024, indicated that Synthroid should be taken one half hour prior to breakfast.
B) The program director (PD) was made aware of these errors on January 25, 2024, at 9:45 AM.
Plan of Correction:The Program Coordinator will train the Supervisor who, in turn, will train all Direct Support Professional staff on the importance of ensuring that that all drugs are administered without error. The training will include, but not be limited to, comparing all medication pharmacy labels to the kardex to assure medications are administered as per specialized instructions, such as two sprays of medication into each nostril, scrubbing eyes before administering drops, and administering required medications 30 minutes before meals, as ordered. The training will be completed by March 1, 2024. The Program Director will sign and date the Supervisor's training to document completion, and the Program Coordinator will do the same for Direct Support Professional staff. The Supervisor will ensure all DSP staff are trained by comparing completed training records with the staff schedule. Training records will be maintained in the personnel files.
Following the medication errors for individual #1, #2, and #3, the nurse was consulted, and it was requested that she consult the Primary Care Physician for a verbal order as to how to proceed. Verbal orders were obtained for each individual on January 25, 2024. The order for individual #1 indicates it is okay to miss the morning dose of Lactose prior to breakfast and indicates it should not be administered late. The order indicates the medication should be continued prior to lunch and dinner, and as scheduled. The order for Individual #3 indicates it is okay to administer the Levothyroxine late after breakfast since it is a daily dose, and to continue medication as scheduled. The staff member responsible for the errors was identified and received timely, verbal, retraining by the Program Director. Additionally, this staff member will receive documented training and disciplinary actions as per agency policy.
A supervisor will conduct unannounced observations, at varied medication administration times, to ensure that all medication is administered without error which includes ensuring two sprays of medication are administered into each nostril, scrubbing eyes before administering drops, and administering required medications 30 minutes before meals, as ordered. Observations will be recorded on a tracking grid developed by the Program Director and will specify whether the medication is administered without error. These observations will begin March 1, 2024 and all DSP staff will be observed at least two times by March 15, 2024. If staff does not ensure medication is administered without error, the staff member making the error will continue to be observed at least two times every two weeks until there are two successful observations, defined by administering all medication without error.
After two successful observations the monitoring will be faded to one additional time by March 31, 2024, then two times per year and conducted during the time of each staff member's semi-annual medication administration training. Observations through March 31, 2024 will be recorded on the tracking grid developed by the Program Director and the bi-annual observations will be documented on a form designated by the Medication Administration Training. Medication Administration Training stresses the importance of administering all medications without error. The Program Coordinator will ensure compliance by reviewing the tracking grid and documenting her review via signature and date.
If there is an error in administration, the staff member will receive corrective action and will continue to be observed until three additional, successful, medication administration sessions are observed, defined by administering medications without error.
The Learning Program Assistant, or designee, will track annual training requirements to ensure all requirements are met for all staff who administer medication and communicate this information on a regular and on-going basis to the Administrative Coordinator and DSP staff via e-mail. As well, the Learning Program Assistant will maintain this information on a chart located on the internet which all Devereux PA Adult Services 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.
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