Initial Comments:
A monitoring survey was conducted January 10-11, 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 five individuals. Two deficiencies were identified.
Plan of Correction:
483.450(e)(4)(i) STANDARD
DRUG USAGE
Name - Component - 00
Drugs used for control of inappropriate behavior must be monitored closely for desired responses and adverse consequences by facility staff.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure a medication used to control inappropriate behavior was monitored closely for desired responses. This was noted for one of the two individuals in the facility who received psychotropic medications for behavioral control (Individual #1). The findings included:
A) The record of Individual #1 was reviewed on January 10-11, 2024. The review revealed that this individual was scheduled for an appointment with a new psychiatrist on November 29, 2023. This appointment was postponed until December 4, 2023.
B) Review of the documentation for the December 4, 2023 appointment revealed that Individual #1 is prescribed the medication Abilify for a diagnosis of anxiety, with one of the target symptoms listed as auditory hallucinations. During this appointment, the psychiatrist inquired to Individual #1 if he experiences auditory hallucinations, and this individual responded affirmatively. In addition, there was no evidence that current behavioral data was provided for review by the psychiatrist. This resulted in an increase in Abilify from five milligrams (mgs) to 10 mgs daily, without the benefit of the interdisciplinary team (IDT) process for agreement.
C) The program director (PD) was interviewed on January 10, 2024, at 2:30 PM. The PD confirmed that there was no evidence of behavioral data provided for review by the psychiatrist. In addition, the PD confirmed that the increase of the behavior modifying medication was implemented without the benefit of the IDT process.
Plan of Correction:The Clinical Coordinator will train the Behavior Analyst, on consulting the monthly ICF appointment calendar before the beginning of each month. This appointment schedule is located on the G Drive. The Behavior Analyst will also be trained on contacting administrative support to ensure knowledge of any upcoming psychiatric appointments so that behavioral data may be shared with the psychiatrist so the psychiatrist's review of behavior modifying medications is well supported with data and documentation. This is in effort to assure drugs used for control of inappropriate behavior are monitored closely for desired response and adverse consequences. The training was completed on January 24, 2024 and the training record will be signed by the Clinical Director to ensure completion.
At least 3 days before the quarterly psychotropic review, the Behavior Analyst will send the behavior data to the Health Services Coordinator via email, to be included in the consult paperwork that is sent to the psychiatrist or directly to the psychiatrist. The Behavior Analyst will also document in the electronic health record that the behavior data was sent to the Health Services Coordinator or psychiatrist for the quarterly psychotropic review. The Behavior Analyst will follow up within 7 days of the appointment to confirm that the behavior data was sent, received, reviewed by the psychiatrist, and included as part of the consult by reviewing the completed information packet scanned by the DSP staff to the Interdisciplinary Team after each appointment.
Behavioral data will be reviewed and analyzed by the Behavior Analyst at least monthly, and documented in Interdisciplinary Team Meeting (IDT) monthly progress notes in Individual #1's electronic health record. The Behavior Analyst will collect data and report on drug effectiveness at monthly IDT meetings for all drugs used for control of inappropriate behaviors.
To assure completion the Behavior Analyst will email the Clinical Coordinator the collected behavioral data for the next month. The Behavior Analyst will also relay to the Clinical Coordinator the date of the upcoming psychiatric appointments for the next three months for all individuals who are prescribed drugs to control inappropriate behavior. To assure compliance, the Behavior Analyst will include the Clinical Coordinator on all emails when sending clinical data to the Interdisciplinary team, which includes the Health Services Coordinator, to be included in the psychiatric consult. The emails will be printed and maintained by the Clinical Coordinator in a POC binder in her office. The Clinical Coordinator will document her oversight of the process by noting review of the emails in the Behavior Analyst's supervision notes. If the Clinical Coordinator does not receive the emailed data prior to the day before the appointment she will contact the Behavior Analyst to request this. If this process is successful, it will continue for an additional three months, following the steps outlined, and then fade to a discussion topic during monthly supervision meetings. If the process is not successful, it will be repeated until there are two consecutive successful appointments for all individuals in the facility.
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.
483.460(k)(1) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure all medications were administered in accordance to physician's orders. This was noted for the only individual in the sample who was prescribed a pre-sedation medication (Individual #2). The findings included:
A) A review of Individual #2's record was conducted on January 10-11, 2024. This review revealed a verbal order from the physician, signed August 3, 2023, that prescribed the medication Diazepam 10 milligrams (mgs), two tablets (20 mgs) by mouth as needed one hour prior to dental/urology/ENT [ears, nose, and throat] exams.
Further review of the record revealed a current 90-day recapitulation of physician's orders, signed by the physician on October 27, 2023. These orders prescribed "Diazepam 10 mgs, take two tablets (20mgs) by mouth once as needed for anxiety prior to procedures only".
B) Individual #2's medication administration record (MAR) from August 2023, through January 2024, were reviewed. The review revealed that this individual received the pre-sedation medication Diazepam on December 6, 2023. The MAR did not specify the reason that this medication was administered. Upon further investigation, it was discovered that the Diazepam was administered prior to an ENT appointment.
C) The program director (PD) was interviewed on January 10, 2024 at 3:15 PM. The PD confirmed that Individual #2 received the pre-sedation medication Diazepam prior to the December 2023 ENT appointment. In addition, the PD confirmed that there was no current physician's order to administer this medication prior to ENT appointments.
Plan of Correction:The Director of Nursing will train the Health Services Coordinator on the significance of assuring that all drugs are administered in compliance with the physician's orders. Training will include the importance of assuring all verbal orders received by the nurse are included on the following 90-day orders. Training will be completed by January 31, 2024 and signed by the Program Director to confirm completion. Training will be filed in the employee's personnel record by January 31, 2024.
A physician order was obtained for Individual #1 to receive diazepam 10mg for presedation one hour prior to ENT appointments. That new order for presedation was received on January 24, 2024. Verification that the pharmacy label of the presedation matched the physician order and matched the verbal order was done by the Director of Nursing. Family verbal consent was obtained on July 26, 2023 and written consent obtained on July 29, 2023. Human Rights Committee verbal approval was obtained on July 26, 2023 and written approval obtained August 1, 2023 to August 3, 2023.
The Health Services Coordinator or designee will compare current restrictive measures for each individual in the facility to their physician orders to assure there is a physician order for each medication used to control behavior, that all medications fall within the consent/approval range. The audit will take place by January 8, 2024 and results of the audit will be forwarded to the Interdisciplinary Team, including the Director of Nursing. This and all audit forms will be free of empty spaces. The Health Services Coordinator will also scan a copy of the MARS and attach the physician orders, and the restrictive measures, so the Director of Nursing can confirm her findings and make note of this on the revised audit form.
Moving forward, the Health Service Coordinator will assure there is a system for drug administration which assures that all drugs are administered in compliance with the physician's orders by comparing the physician orders of the current month to the previous physician's orders and all verbal and telephone orders received to date, for all individuals in the home, each moth, without fading. A copy of the changes will be scanned to the Director of Nursing within 24 hours of the change to ensure accuracy. This will be done for three months and scanning will fade if there are no discrepancies. If there are discrepancies, this plan of correction will continue.
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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