Initial Comments:
An extended survey visit was completed on October 19, 20 and 23, 2023. 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 15, and the sample consisted of seven individuals.
Plan of Correction:
483.430(a) STANDARD
QIDP
Name - Component - 00
Each client's active treatment program must be integrated, coordinated and monitored by a qualified intellectual disability professional who-
Observations:
Based on record review and interview with administrative staff, the facility Qualified Intellectual Disability Professional (QIDP) failed to ensure that each client's active treatment program is integrated, coordinated and monitored for three of four sample Individuals.
This practice is specific to Individual #1, #3 and #4.
Findings included:
- The facility failed to ensure that the objectives of the individual program plans are expressed in behavioral terms that provide measurable indices of performance for three of four sample individuals. This practice is specific to Individuals #1, #3 and #4. Refer to W-231.
- The facility failed to specify within training programs the type and frequency of data collection that provides clear direction about the type of data to record in order to assess progress toward the desired outcomes for four of four sample Individuals. This practice is specific to Individual #1, #2, #3 and #4. Refer to W 237.
- The facility failed to ensure that data relative to the accomplishment of the criteria specified within the Individual program plan objectives is documented in measurable terms relative to the frequency as outlined in the training plan for four of four sample Individuals. This practice is specific to Individual #1, #2, #3 and #4. Refer to W-252.
- The Qualified Intellectual Disabilities Professional (QIDP) failed to review and revise as necessary but not limited to situations in which the Individual has successfully completed an objective or objectives in the Training plans for three of four sample Individuals whose records were reviewed. This practice is specific to Individuals #1, #3 and #4. Refer to W 255.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
Please refer to W231, W237, and W252.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
Please refer to W231, W237, and W252.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The QIDP of the facility will create training plans based on Individual Program Plan (IPP) assessments and individual priority needs agreed on at the IPP meeting.
The Assistant Director will review the training plans within 1 week of their completion and prior to staff training and goal implementation. Any non- compliance will be corrected within 24 hours of discovery and prior to implementation.
Upon new goal implementation, the QIDP and House Manager will complete weekly goal audits for a minimum of one month. The goal audits will include a review to ensure the QIDP has monitored the active treatment program. Any non-compliance noted will be corrected within 24 hours of discovery. Staff retraining will occur within 24 hours of corrections.
Following one month of weekly goal audits, the QIDP will then maintain goal audits for every individual to be completed at least every two weeks. Any non-compliance noted will be corrected upon within 24 hours of discovery.
The QIDP will complete monthly goal reviews for the current review period by the 10th of the following month.
The QIDP will print individual program plans and data associated with the monthly goal review and file them in the individual's program book on a monthly basis.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
The Assistant Director will review all the monthly goal reviews completed by the QIDP for compliance no later than the 15th of the following month. This process will begin in December 2023 and will be documented on a progress summary review form. If there are any concerns noted from the review by the Assistant Director, the concern will be corrected no later than the 20th of the specific month.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective actions being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Assistant Director to review on going status of corrective action completion, beginning 12/01/2023. The Assistant Director will bring all documentation related to any audits and progress summary reviews to the meeting with the Director. The progress of the plan of correction will be documented on a plan of correction tracking grid upon review of the documentation. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
483.440(c)(4)(iii) STANDARD
INDIVIDUAL PROGRAM PLAN
Name - Component - 00
The objectives of the individual program plan must be expressed in behavioral terms that provide measurable indices of performance.
Observations:
Based on record review and interview with the Qualified Intellectual Disabilities Professional (QIDP), the facility failed to ensure that the objectives of the individual program plans are expressed in behavioral terms that provide measurable indices of performance for three of four sample individuals. This practice is specific to Individuals #1, #3 and #4.
Findings include:
A review of the records of three of four sample Individuals revealed that objectives associated with the current training plans for Individuals #1, #3, and #4 were not written to include quantifiable criteria to determine successful achievement of the objective.
Individual #1 is exemplary of this practice:
Individual #1:
A review of Individual #1's record was completed on 10/20/23 and 10/23/2023 from approximately 9:00 AM to 11:00 AM and 8:30 AM to 10:00 AM respectively This review revealed the following training plans:
Communication skills.
-The long term objective for this training plan states the following: "The individual will improve communication skills independently for 80% of trials throughout the ISP year."
- The short term objective/Set Description is as follows: "Individual will choose between watching Sponge Bob or a Katy Perry video using her AAC communication device with a model prompt in 24 out of 30 trials."
Beyond the measurement of success rate and designated type of prompt, there was no further specified criteria outlined in the training plan to allow all staff who implemnt this plan to consistenly define the same outcome by which performance is measured.
Showering Skills:
-The long term objective for this training plan states the following: "Individual will shower all areas of the body with partial physical prompting for 80% of trials throughout ISP year."
-The current short term objective/ Set Description in this training plan is as follows:
The individual will wash upper body with partial physical prompts for 24 our of 30 trials.
Beyond the measurement of success rate and designated type of prompt, there was no further specified criteria outlined in the training plan to allow all staff who implement this plan to consistently define the same outcome by which performance is measured.
Interview with the QIDP on 10/23/2023 at approximately 10:00 AM confirmed that the objectives of the training plans did not further specified criteria outlined in the training plan to allow all staff who implemnt this plan to consistenly define the same outcome
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The Qualified Intellectual Disabilities Professional (QIDP) and the Assistant Director of the Facility will be trained by the Director of the Facility and the Director of Clinical Services in ensuring that plan objectives of individuals #1, #2 and #3 are written in a format that allows for outcome progress to be measured by including the behavior (what), the condition (when), and criteria (how and how often) for each plan objective. This training will be documented on a Training log and will be completed by 12/08/2023.
The QIDP will then review all objectives in the individual program plans for individuals #1, #2 and #3 and revise all outcomes that fail to meet compliance. This update will be completed by 12/15/2023 and will be documented on an Audit checklist.
The Assistant Director of the Facility will review all of the audit checklists completed by the QIDP no later than 12/18/2023 as well as the training objectives revised by the QIDP, to assess compliance. The Assistant Director's review will be documented on an audit checklist in the "Assistant Director Review" section.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
The QIDP will review all individual program plans for individuals in the Facility to determine if the objectives in the individual plan are written in a format that allows for outcome progress to be measured by including the behavior (what), the condition (when), and criteria (how and how often) for each plan objective . This review will be documented by the QIDP on an audit checklist by 12/15/2023. Any training objectives that are determined to be non-compliance will be updated. This update will be completed by 12/20/2023.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The Assistant Director will review the training plans within one week after being written and prior to staff training and goal implementation. Any non- compliance will be corrected within 24 hours of discovery.
The QIDP or House Manager will complete weekly goal audits for one month after the goal is written for a minimum of one month.. The audit will include a review of each training plan to ensure the objectives are measurable. The weekly goal audits will be documented on a goal audit form. Any non-compliance noted will be corrected within 24 hours of discovery and staff retraining completed.
Following the one month of weekly goal audits after the goal is put in place, the QIDP will then maintain goal audits for every individual to be completed at least every two weeks. Any non-compliance noted will be corrected within 24 hours of discovery.
The QIDP will complete monthly goal progress summaries for the current review period by the 10th of the following month.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
The Assistant Director will review all monthly progress summaries completed by the QIDP by the 15th of the following month each month. This process will begin in December 2023. The Assistant Director will document their review on a progress summary review form. The Assistant Director will address corrective actions for any non- compliance noted in their review by the 20th of the month.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective actions being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Assistant Director to review on going status of corrective action completion, beginning 12/01/2023. The Assistant Director will bring all documentation related to any audits and progress summary reviews to the meeting with the Director. The progress of the plan of correction will be documented on a plan of correction tracking grid upon review of the documentation. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
483.440(c)(5)(iv) STANDARD
INDIVIDUAL PROGRAM PLAN
Name - Component - 00
Each written training program designed to implement the objectives in the individual program plan must specify the type of data and frequency of data collection necessary to be able to assess progress toward the desired objectives.
Observations:
Based on record review and interview with administrative staff, the facility failed to specify within training programs the type and frequency of data collection that provides clear direction about the type of data to record in order to assess progress toward the desired outcomes for four of four sample Individuals. This practice is specific to Individual #1, #2,
#3 and #4.
Findings include:
A review of records of Individual #1, #2, #3 and #4 was completed on 10/20/2023 from 8:30 AM to 11:30 AM and on 10/23/2023 from 8:30 AM to 10:00 AM. This review revealed that training programs did not provide clear directions to staff about the type of data collection to record regarding skill performance relative to the current training objective.
Individual #1 and #3 are exemplary of this practice.
Individual #1:
A review of Individual #1's training plan titled, Self-Medication 1.2 with a revision date of 06/19/2023 revealed that this individual is working on Step #1, to select the Multivitamin blister pack with a partial prompt in 24 out of 30 trails.
A review of the methodology for this training plan revealed the following statement:
"The staff member will document the prompt required to complete the step."
However subsequent review of the section titled, Lesson Procedure, outlined conflicting documentation instructions to include documenting a [plus] on the data sheet if the individual responds to the initial verbal cue within 10 seconds and successfully completes the current training objective. If the individual closes mouth prior to targeted duration, the staff member will re-attempt after 15 seconds; if the individual closes their mouth again prior to the targeted duration, staff should document a [minus] on the data sheet."
A review of data collection information for the period from 06/21/2023 through 10/13/2023 revealed there were no prompt levels recorded on these data sheets that was related to the doucmentation criteria listed within the training plan outline. Rather, the documentation consisted of notation of either 100 or zero for each data entry. There was no
explanation or key relevant to these entries in order to decipher what the entry represented in terms of skill development relative to the current training objective.
Individual #3:
A review of Individual #3's training plan titled, Toothbrushing, which was initiated on 05/03/2023, revealed this individual is currently working on Set 4 training objective which is to brush left back upper quadrant with partial physical prompt for 30 seconds for 24 out of 30 sessions.
A review of this training program revealed under the section titled, Lesson Procedure, staff are instructed to document a [plus] on the data sheet if the individual completes brushing at the current targeted step. If the individual closes mouth prior to targeted duration, the staff member will re-attempt after 15 seconds, if the individual closes their mouth again prior to the targeted duration, staff are to document a [minus] on the data sheet.
A review of actual data sheets from 05/04/2023 through 10/13/2023 revealed there were no plus or minus entries. The documentation on data sheets were 100's or 0's for each session.
There was no explanation or key relevant to these entries in order to decipher what the entry represented in terms of skill development relative to the current training objective.
Interview with the Associate Director on 10/20/2023 at approximately 10:15 AM
confirmed that training programs did not incorporate clear direction about the type of data to record in order to assess progress toward the desired outcomes
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The Assistant Director of the facility will update Individuals #1, #2, # 3 and # 4 goals to ensure the type and frequency of data collection is clearly stated in the training plan.
All Direct Support Staff will then be trained in the type of data collection and the frequency the data should be collected. Staff training will be documented on a Training Log and will be completed by 12/15/23.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
All residents in the facility will have their program plan reviewed to ensure the type and frequency of data collection is clearly stated in the training plan. This review will be completed by the Assistant Director of the facility by 12/15/2023. Any non-compliance will be corrected by 12/18/2023.
All Direct Support Staff will then be trained on data collection specified in the individual program plan objectives. Training of Direct Support Staff will be documented on a Training Log by 12/22/2023
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The Assistant Director will review the training plans prior to staff training and goal implementation to verify the type and frequency of data collection is clearly stated. Any non- compliance will be corrected within 24 hours of discovery. The Assistant Director reviews will be documented on the Assistant Director Review section of the goal audit checklist.
The QIDP and House Manager will complete weekly goal audits for a minimum of one month upon goal implementation to ensure staff are collecting the type of data at the frequency noted in the training plans. Any non-compliance noted will be corrected within 24 hours of discovery and staff retraining completed. The QIDP and House Manager weekly goal audits will be documented on a goal audit checklist.
Following one month of weekly goal audits, the QIDP will then maintain goal audits for every individual to be completed at least every two weeks. Any non-compliance noted will be corrected within 24 hours of discovery. The QIDP will document the outcome of these goal audits on a goal audit checklist. This practice will begin in 12/2023.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
The Assistant Director of the facility will review the goal audit checklists monthly, beginning 12/2023, and develop a plan of correction for any missing items that are identified in the audit within one week of the audit review. The Assistant Director reviews and plans of correction will be documented on the Assistant Director Review section of the goal audit checklist.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective actions being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Assistant Director to review on going status of corrective action completion, beginning 12/01/2023. The Assistant Director will bring all documentation related to any audits and progress summary reviews to the meeting with the Director. The progress of the plan of correction will be documented on a plan of correction tracking grid upon review of the documentation. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
483.440(e)(1) STANDARD
PROGRAM DOCUMENTATION
Name - Component - 00
Data relative to accomplishment of the criteria specified in client individual program plan objectives must be documented in measurable terms.
Observations:
Based on record review and interview with administrative staff, the facility failed to ensure that data relative to the accomplishment of the criteria specified within the Individual program plan objectives is documented in measurable terms relative to the frequency as outlined in the training plan for four of four sample Individuals. This practice is specific to
Individual #1, #2, #3 and #4.
Findings include:
A review of records of Individual #1, #2, #3 and #4 was completed on 10/20/2023 from 8:30 AM to 11:30 AM and on 10/23/2023 from 8:30 AM to 10:00 AM. This review revealed that data was not collected in the frequency outlined within the training plans for all sample Individuals. Individual #1 and #3 are exemplary of this practice.
Individual #1
A review of Individual #1's record revealed an Individual Program Plan (IPP) dated 03/16/2023, that included the following training plans:
1. Lesson Title: Communication
Long Term Objective: The Individual will improve communcation skills independently for 80% of trials throughout the ISP (Individual Support Plan) year (03/16/2023 to 03/15/2024). No start clear start date could be identified. A review of the methodology section indicates that this training program should be documented 7 times weekly during
2nd shift.
Set 1 : Individual will choose between watching Sponge Bob or a Katy Perry video using AAC communication device (not defined) with a model prompt in 24 out of 30 sessions.
A review of the data collection revealed the following:
-02/01/2023 through 02/28/2023 - staff failed to record 8 out of 28 sessions
-03/01/2023 through 03/31/2023 - staff failed to record 13 out of 27 sessions
-04/01/2023 through 04/30/2023 - staff failed to record 14 out of 29 sessions
-05/01/2023 through 05/31/2023 - staff failed to record 11 out of 31 sessions
-06/01/2023 through 06/30/2023 - staff failed to record 14 out of 30 sessions
-07/01/2023 through 07/31/2023 - staff failed to record 11 out of 31 sessions
-08/01/2023 through 08/31/2023 - staff failed to record 23 out of 31 sessions
-09/01/2023 through 09/30/2023 - staff failed to record 29 out of 30 sessions
-10/01/2023 through 10/20/2023 - staff failed to record 16 out of 20 sessions
2. Lesson Title: Showering
Long Term Objective: The Individual will shower areas of the body with partial physical prompting for 80% of trials throughout the ISP year (03/16/2023 to 03/15/2024).
This plan identifies a start date of 01/25/2022. A review of the methodology section indicates that documentation for completion of this training plan should be once daily
between 3 -9 PM.
Set 1 "The individual wet entire body with partial physical prompt for 24 of 30 sessions.
A review of the data collection revealed the following:
-02/01/2023 through 02/28/2023 - staff failed to record 4 out of 28 sessions
-03/01/2023 through 03/31/2023 - staff failed to record 8 out of 27 sessions
-04/01/2023 through 04/30/2023 - staff failed to record 8 out of 29 sessions
-05/01/2023 through 05/31/2023 - staff failed to record 8 out of 31 sessions
-06/01/2023 through 06/30/2023 - staff failed to record 11 out of 30 sessions
-07/01/2023 through 07/31/2023 - staff failed to record 10 out of 31 sessions
-08/01/2023 through 08/31/2023 - staff failed to record 10 out of 31 sessions
-09/01/2023 through 09/30/2023 - staff failed to record 10 out of 30 sessions
-10/01/2023 through 10/20/2023 - staff failed to record 8 out of 18 sessions
3. Lesson Title: Self Medication
Long Term Objective: The Individual will self administer medications with gestural prompting for 80% of trials throughout the ISP year (03/16/2023 to 03/15/2024). This plan identifies a start date of 11/28/2022. A review of the methodology section indicates that documentation for completion of this training plan should be once daily on the 3 -11pm shift as the medication administration takes place.
Set 2 ; After the stated verbal cue, the individual will select the multivitamin blister pack with a partial physical prompt in 24 out of 30 trials.
A review of the data collection revealed the following:
-02/01/2023 through 02/28/2023 - staff failed to record 8 out of 28 sessions
-03/01/2023 through 03/31/2023 - staff failed to record 10 out of 27 sessions
-04/01/2023 through 04/30/2023 - staff failed to record 10 out of 27 sessions
-05/01/2023 through 05/31/2023 - staff failed to record 10 out of 31 sessions
-06/01/2023 through 06/30/2023 - staff failed to record 14 out of 30 sessions
-07/01/2023 through 07/31/2023 - staff failed to record 14 out of 31 sessions
-08/01/2023 through 08/31/2023 - staff failed to record 10 out of 31 sessions
-09/01/2023 through 09/30/2023 - staff failed to record 15 out of 30 sessions
-10/01/2023 through 10/20/2023 - staff failed to record 8 out of 19 sessions
4. Lesson Title: Household Task
Long Term Objective: The Individual will independently take her dishes at mealtime to the kitchen 80% of trials throughout the ISP year (03/16/2023 to 03/15/2024). This plan identifies a start date of 01/25/2022. A review of the methodology section indicates that documentation for completion of this training plan should be documented daily after dinner on the 3-11 shift.
Set 5 : After the stated verbal cue, [Individual #1] will pick up the plate independently in 24 out of 30 trials.
A review of the data collection revealed the following:
-02/01/2023 through 02/28/2023 - staff failed to record 7 out of 28 sessions
-03/01/2023 through 03/31/2023 - staff failed to record 10 out of 27 sessions
-04/01/2023 through 04/30/2023 - staff failed to record 8 out of 29 sessions
-05/01/2023 through 05/31/2023 - staff failed to record 10 out of 31 sessions
-06/01/2023 through 06/30/2023 - staff failed to record 11 out of 30 sessions
-07/01/2023 through 07/31/2023 - staff failed to record 11 out of 31 sessions
-08/01/2023 through 08/31/2023 - staff failed to record 9 out of 31 sessions
-09/01/2023 through 09/30/2023 - staff failed to record 11 out of 30 sessions
-10/01/2023 through 10/20/2023 - staff failed to record 9 out of 18 sessions
5. Lesson Title: Toothbrushing
Long Term Objective: The Individual will brush their teeth for 2 minutes with partial physical assistance for 80% of trials throughout the ISP year 03/16/2023 to 03/15/2024). This plan identifies a start date of 01/25/2022. A review of the methodology section indicates that documentation for completion of this training plan should be once on second shift.
Set 4 : [Individual #1] will brush the front of the lower left quadrant of teeth for 15 seconds with partial physical assistance.
A review of the data collection revealed the following:
-02/01/2023 through 02/28/2023 - staff failed to record 5 out of 28 sessions
-03/01/2023 through 03/31/2023 - staff failed to record 6 out of 27 sessions
-04/01/2023 through 04/30/2023 - staff failed to record 8 out of 29 sessions
-05/01/2023 through 05/31/2023 - staff failed to record 9 out of 31 sessions
-06/01/2023 through 06/30/2023 - staff failed to record 11 out of 30 sessions
-07/01/2023 through 07/31/2023 - staff failed to record 8 out of 31 sessions
-08/01/2023 through 08/31/2023 - staff failed to record 17 out of 31 sessions
-09/01/2023 through 09/30/2023 - staff failed to record 14 out of 30 sessions
-10/01/2023 through 10/20/2023 - staff failed to record 6 out of 18 sessions
Individual #3
A review of Individual #3's record revealed an Individual Program Plan dated 04/18/2023, that included the following training plans:
1. Lesson Title: Tooth Brushing Duration
Long Term Objective: The Individual will complete all steps of brushing their teeth with gestural prompts for 120 seconds in 80% of trials throughout the ISP year. This goal will be implemented 3 times a day as recommended by the dental hygienist; goal will be documented one time per day between the 3pm-9 pm, for a total of 30 trials per month. Per the ISP, this training plan was initiated on 03/25/2022.
Set 1: Individual will brush all teeth for 10 seconds with a gestural prompt in 24 out of 30 sessions.
A review of the data collection revealed the following:
-02/01/2023 through 02/28/2023 - staff failed to record 3 out of 28 sessions
-03/01/2023 through 03/31/2023 - staff failed to record 8 out of 31 sessions
-04/01/2023 through 04/30/2023 - staff failed to record 3 out of 30 sessions
-05/01/2023 through 05/31/2023 - staff failed to record 10 out of 31 sessions
-06/01/2023 through 06/30/2023 - staff failed to record 7 out of 30 sessions
-07/01/2023 through 07/31/2023 - staff failed to record 5 out of 31 sessions
-08/01/2023 through 08/31/2023 - staff failed to record 16 out of 31 sessions
-09/01/2023 through 09/30/2023 - staff failed to record 27 out of 30 sessions
-10/01/2023 through 10/20/2023 - staff failed to record 16 out of 20 sessions
2. Lesson Title: Showering
Long Term Objective: The Individual will shower areas of the body with partial physical prompting for 80% of trials throughout the ISP (Individual Support Program) year. This goal will be implemented daily and documented 1 time 3pm-9 pm in the residence for a total of 30 trials a month. Per the ISP, this training plan was initiated on 02/15/2023.
Set 2: The Individual will wash upper body with partial physical prompt for 24 out of 30 sessions.
A review of the data collection revealed the following:
-02/15/2023 through 02/28/2023 - staff failed to record 3 out of 19 sessions
-03/01/2023 through 03/31/2023 - staff failed to record 3 out of 31 sessions
-04/01/2023 through 04/30/2023 - staff failed to record 0 out of 30 sessions
-05/01/2023 through 05/31/2023 - staff failed to record 1 out of 31 sessions
-06/01/2023 through 06/30/2023 - staff failed to record 2 out of 30 sessions
-07/01/2023 through 07/31/2023 - staff failed to record 1 out of 31 sessions
-08/01/2023 through 08/31/2023 - staff failed to record 18 out of 31 sessions
-09/01/2023 through 09/30/2023 - staff failed to record 27 out of 30 sessions
-10/01/2023 through 10/20/2023 - staff failed to record 19 out of 20 sessions
3. Lesson Title: Self Medication
Long Term Objective: The Individual will self administer medication with partial physical prompting in 80% of trials during medication pass throughout the ISP (Individual Support Program) year. This goal will be implemented daily and documented on the 3-11p shift. The individual will self-administer the 8 pm dose daily in 24 out of 30 trials. Per the ISP, this training plan was implemented on 10/29/2022.
Set 2: After the stated cue, the Individual will select the oyster shell calcium blister pack with a partial physical prompt in 24 out of 30 sessions.
A review of the data collection revealed the following:
-02/01/2023 through 02/28/2023 - staff failed to record 0 out of 28 sessions
-03/01/2023 through 03/31/2023 - staff failed to record 6 out of 31 sessions
-04/01/2023 through 04/30/2023 - staff failed to record 1 out of 30 sessions
-05/01/2023 through 05/31/2023 - staff failed to record 7 out of 31 sessions
-06/01/2023 through 06/30/2023 - staff failed to record 2 out of 30 sessions
-07/01/2023 through 07/31/2023 - staff failed to record 2 out of 31 sessions
-08/01/2023 through 08/31/2023 - staff failed to record 21 out of 31 sessions
-09/01/2023 through 09/30/2023 - staff failed to record 27 out of 30 sessions
-10/01/2023 through 10/20/2023 - staff failed to record 17 out of 20 sessions
4. Lesson Title: Communication (Choice)
Long Term Objective: Individual will make a selection when presented with an array of items with a gestural prompt in 80% of trials during medication pass throughout the ISP (Individual Support Program) year. This goal should be completed daily on the second shift during the week and anytime throughout the day on the weekend in 24 out of 30 trials. Per the ISP, this training plan was initiated on 02/15/2023.
Set 3: After the stated cue, [Individual] will make a choice between spinning again sensory toy or bottle top with a gestural prompt in 24 out of 30 sessions.
A review of the data collection revealed the following:
-02/15/2023 through 02/28/2023 - staff failed to record 2 out of 28 sessions
-03/01/2023 through 03/31/2023 - staff failed to record 7 out of 31 sessions
-04/01/2023 through 04/30/2023 - staff failed to record 3 out of 30 sessions
-05/01/2023 through 05/31/2023 - staff failed to record 8 out of 31 sessions
-06/01/2023 through 06/30/2023 - staff failed to record 6 out of 30 sessions
-07/01/2023 through 07/2/2023 - staff failed to record 0 out of 2 sessions
Data collection was not available to review for the period 07/03 through 10/20/2023. Interview with the Associate Director was unable to explain why data was no longer being documented after 07/02/2023.
Interview with the Associate Director on 10/20/2023 at approximately 10:15 AM revealed that administrative staff were aware of problems with the training plans. Continued interview with this interviewee confirmed data was not collected in the frequency indicated on the training plans. This interviewee was unable to indicate why the data was not collected as outlined for all training plans.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
All Direct Support Staff will be trained by the QIDP on how to read the teaching plans for individuals # 1, #2, #3, and #4 and to educate on and reinforce data collection as often as noted in the individual training plan. Training of Direct Support Staff will be documented on a Training Log.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
All Direct Support Staff will be trained by the QIDP on how to read the training plans of all individuals in the Facility by 12/22/2023, to ensure they understand how to collect data for each individual. This will ensure staff are collecting data as often as noted in the training plan. Training of Direct Support Staff will be documented on a Training Log.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The QIDP and House Manager will complete weekly goal audits for a minimum of one month once the goal is put in place. Any non-compliance noted will be corrected upon discovery and staff retraining completed. Continued failure by staff to collect data as indicated in the training plan will result in progressive corrective action.
The QIDP will complete one month of goal audits, followed bi-weekly audits for each individual to verify that staff are collecting data as often as noted in the training plan. Any non- compliance noted will be corrected within 24 hours.
The goal audit will evaluate data collected by staff. Any non-compliance noted will be corrected within 24 hours. The QIDP will document the outcome of these goal audits on an audit checklist. This practice will begin in 12/2023.
The QIDP will complete monthly goal progress summaries for the current review period by the 10th of the following month on a monthly basis.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
The Assistant Director of the facility will review the goal audit checklists completed by the QIDP on a monthly basis to confirm that staff data collection is ongoing and staff are collecting data as often as noted in the individual training plan. This process will begin on 12/2023. Through the review, if there are any concerns with the goal audit, the Assistant Director will retrain the QIDP. Continued failure to implement goal procedures as noted above will result in progressive corrective action.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective actions being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Assistant Director to review on going status of corrective action completion, beginning 12/01/2023. The Assistant Director will bring all documentation related to any audits and progress summary reviews to the meeting with the Director. The progress of the plan of correction will be documented on a plan of correction tracking grid upon review of the documentation. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
483.440(f)(1)(i) STANDARD
PROGRAM MONITORING & CHANGE
Name - Component - 00
The individual program plan must be reviewed at least by the qualified intellectual disability professional and revised as necessary, including, but not limited to situations in which the client has successfully completed an objective or objectives identified in the individual program plan.
Observations:
Based on record review, and interview with administrative staff, the Qualified Intellectual Disabilities Professional (QIDP) failed to review and revise as necessary but not limited to situations in which the Individual has successfully completed an objective or objectives in the training plans for three of four sample Individuals. This practice is specific to Individuals #1,
#3 and #4.
Findings include:
A review of the records of Individual #1, #3, and #4 were completed on 10/23/2023 from 9:00 AM to 11:30 AM and on 10/23/2023 from 9:00 AM to 10:30 AM. This review revealed that training plans continued to be implemented with no change after an Individual had successfully completed an identified objective of a training plan.
Individual #3 and #4 are exemplary of this practice.
Individual #3:
A) Annual goal toothbrushing skills
The current Short Term Objective (STO) #3 states " will brush right back upper quadrant with partial physical prompt for 30 seconds 24 out of 30 trials." The training plan states this STO was met on 08/06/2023. However, a review of training plan data collection for the period from 08/06/2023 until the date of the survey, 10/20/2023 revealed Individual #3 remained on this STO more than two months after criteria was met for this STO #3
Individual #4:
A review of the training plans for Individual #4 for the period from 02/01/2023 to 10/19/2023, revealed the following information :
A ) Annual Goal Communication: To improve communication skills.
This goal was revised on 02/09/2023 and short term objective (STO) #1 was implemented on 02/10/2023. This STO states, " When presented with 2 different snacks, individual will choose preference with partial physical prompt 10 out of 12 trials."
A review of the training plan data collection revealed Individual #4 met criteria for this STO on 02/22/2023. This Individual remained on STO #1 until 07/20/2023 approximately
5 months after criteria was met for this objective.
B) Annual Goal Tooth Brushing: To improve Oral Hygiene.
STO #6 was revised on 02/01/2023 and implemented on 02/01/2023. step #6 states,
" Individual will brush the back of the upper left quadrant of teeth for 15 seconds with total physical assistance in 24 out of 30 trials."
A review of his training plan data collection revealed Individual #4 met criteria for this STO on 03/06/2023. This Individual remained on STO #6 until 06/04/2023 approximately
3 months after criteria was met for this STO.
C) Annual Goal Hand Sanitizing: To improve Hand Hygiene.
STO #4 was the current training set on 02/01/2023. STO #4 states, " Prior to meals, the individual will tolerate having his hands sanitized for 20 seconds in 24 out of 30 occasions."
A review of the training plan data collection revealed Individual #4 met criteria for this STO on 03/04/2023. This Individual #4 remained on STO #4 until 10/02/2023 approximately
6 months after criteria was met for this STO.
Interview with the Associate Director on 10/20/2023 at approximately 10:30 AM confirmed that the training plans for the above individuals were not modified or changed in response to the Individuals' successful accomplishment of the objectives.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The Qualified Intellectual Disability Professional (QIDP) of the Facility will be trained to review all Short Term Objective (STO) steps based on Individual Program Plan (IPP) assessments for priority needs for individual # 1, # 3 and # 4. This training will be completed by the Assistant Director of the Facility or the Director of Clinical Services and will be documented on a Training log by 12/08/2023.
Post the QIDP training, the QIDP will then review and move individuals # 1,# 3 and # 4 to the next step of the STO having achieved current step of the STO. The QIDP will then train the staff on the teaching plan highlighting the next step in the STO by 12/15/2023.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
The Assistant Director of the facility will complete an audit on STO of all individuals in the facility. This audit will be completed by 12/15/2023. Through the audit, if any STO steps are determined to have been achieved and the individual was not moved on to the next step, the Assistant Director will document this on the review section of the Audit Checklist and communicate the same with the QIDP so that any need areas identified can be corrected. Need areas will be corrected within 72 hours of discovery.
3. What corrective measures or systematic changes will be put into place to ensure that the The QIDP of the facility will create training plans based on IPP assessments and individual priority needs agreed on at the IPP meeting.
The Assistant Director will review the training plans created by the QIDP prior to staff training and goal implementation. If there are any concerns from the Assistant Director's review, the Assistant Director will communicate the same with the QIDP and the training plan will be updated within two days.
Once the training plan is put in place, the QIDP and House Manager will complete weekly goal audits on STO progress at least twice a week on varying days and times for all the individuals in the facility. Upon meeting an STO criteria noted in the individual program plan, the QIDP will train staff and implement the next step in the individual STO. Any non-compliance noted will be corrected upon discovery and staff retraining completed. This practice will begin in 12/2023.
The QIDP will complete monthly goal progress summaries for the current review period by the 10th of the following month on a monthly basis.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
On a monthly basis, the QIDP will provide a training plan and a monthly goal report on each individual's progress for review by the Assistant Director. The Assistant director will document their review on a monthly report review form by the 15th of each month. This process will verify progress on STO steps implemented at the IPP until the individual has reached the set criterion. This process will start no later than 12/01/2023.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective actions being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Assistant Director to review on going status of corrective action completion, beginning 12/01/2023. The Assistant Director will bring all documentation related to any audits and progress summary reviews to the meeting with the Director. The progress of the plan of correction will be documented on a plan of correction tracking grid upon review of the documentation. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
and under varied conditions to-
Observations:
Based on record review and interview with administrative staff, the facility failed to hold evacuation drills under varied conditions of time for the third shift of personnel during the time period of 10/2022 thorough 09/2023. This practice is specific to building B of this residential site.
Findings include:
A review of the facility's evacuation drills for the period from 10/2022 through 09/2023 was completed on 10/19/2023 from approximately 9:15 AM to 9:45 AM. This review revealed evacuation drills were not varied throughout the extent of the third shift of personnel as follows :
Third Shift of Personnel Evacuation Drills defined as 11:00 PM to 7:00 AM:
10/15/2022 12:06 AM
01/17/2023 6:15 AM
04/07/2023 4:03 AM
07/27/2023 11:53 PM
Interview with the Assistant Director of ICF Residential on 10/19/2023 at approximately 9:45 AM confirmed the times of the evacuation drills were not varied as noted above for the third shift of personnel in Building B.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
Qualified Intellectual Disability Professional (QIDP), House Supervisor, and Assistant Director will be trained that fire drills need to be held under varied conditions of time. The training will include a fire drill schedule with varied times. Per the fire drill schedule, each fire drill will need to be completed within 15 minutes prior to or after the scheduled time each month. This training will be conducted by the Director of the Facility and will be documented on a Training log by 12/15/2023.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
This deficiency affected all individuals in the facility.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The Director of Facility will review the facility yearly fire drill schedule and ensure that fire drill times are varied for the year. Fire drills will be completed within 15 minutes prior to or after the scheduled time each month. Each fire drill will be scheduled to occur at varied times (at least 2 hours apart on the same shift) throughout the year, as per the fire drill schedule.
In the beginning of the month, the administrative assistant will send out information for that month's fire drill. This information will include time the fire drill is to be conducted and the hypothetical location of the fire.
The House supervisor or shift supervisor will be expected to run the drill by the 15th the day of each month and submit the drill form for review by the Assistant Director of the Facility.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
The Assistant Director or a designee will review the fire drill by the 20th of each month to verify that the fire drill was conducted and also verify that the time was varied from other shifts within the facility. This review will include an audit to ensure that the completed drill was pulled within 15 minutes prior to or after the scheduled time each month. If the fire drill is determined not to have been conducted at a varied time the facility will complete a correct drill within the same month at the next available shift, but no later than the end month. This review will be documented on the fire drill form under "director approval". This practice will begin in December 2023.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective actions being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Assistant Director to review on going status of corrective action completion, beginning 12/01/2023. The Assistant Director will bring all documentation related to any audits and progress summary reviews to the meeting with the Director. The progress of the plan of correction will be documented on a plan of correction tracking grid upon review of the documentation. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
483.470(i)(2)(iv) STANDARD
EVACUATION DRILLS
Name - Component - 00
The facility must investigate all problems with evacuation drills, including accidents.
Observations:
Based on record review and interview with administrative staff, the facility failed to investigate all problems with evacuation drills. This practice is specific to Buildings A and B.
Findings include:
A review of the facility's evacuation drills for the period from 10/2022 through 09/2023 was completed on 10/19/2023 from approximately 9:15 AM to 9:45 AM. This review indicated that on three of the 12 evacuation drills reviewed for each residence building , residence building A and residence building B, evacuees exited through an area near or directly outside the designated fire area when a closer exit was available. This practice occurred on three out of 12 drills in Building A and three out of 12 drills in Building B as noted below:
Building A:
-10/09/2022
-03/11/2023
-04/07/2023
Building B:
-10/15/2023
-04/07/2023
-09/02/2023
An example of this practice of exiting through an area near or directly outside the fire area in each building is as follows:
Building A:
On 03/11/2023 at 12:30 PM, a fire drill was conducted in which the designated area of fire was listed as the kitchen area. Individual #2 was in the back living room of the residence.
When the alarm sounded, Individual #2 exited the back living room walking past an exit to an outside porch, and proceeded to walk outside the area of the kitchen where the fire was located, through the dining room, to the entranceway to the front door in order to exit the building. There was no re-direction by staff to Individual #2 to take an alternate route to exit the building.
Interview with the Assistant Director of ICF Residential on 10/19/2023 at approximately 9:45 AM confirmed that Individual #2 failed to use the closest exit away from the designated fire area.
Building B:
On 09/02/2023 at 10:15 AM, the designated area of fire was listed in the
"R. Res. bedroom" identified by the Assistant Director of ICF Residential Services on 10/19/2023, approximately 9:25 AM as the men's bedrooms located side by side next to the living room. Individuals #1, #5, #6 and #7 were in their bedrooms located down the hallway from the men's bedrooms. An exit door is located immediately to the right of Individuals #1, #5, #6 and #7 bedrooms when exiting the bedrooms.
When the alarm sounded, staff and Individuals #1, #5, #6 and #7 proceeded to exit going down the hallway, past the fire location identified as "R. Res. bedroom", walking through the living room and exited through the front door. All of the individuals needed verbal or physical assistance from staff in order to exit the building. e.g. Individuals #1, #5, and #7 required physical assistance to use their walkers, and Individual #6 required staff to push her wheelchair through the path noted above.
In both instances, there was no indication that the facility had identified or addressed the issue of exit through a designated area of fire during these evacuation drills. Interview with the Assistant Director of ICF Residential on 10/19/2023 at approximately 9:45 AM confirmed that Individuals noted in the above fire drills failed to utilize and exit that was not near the designated fire area.
When asked why staff didn't use the closest available exit, this interviewee stated that the staff and individuals "are just used to using the front door as the exit:. When asked if the facility/agency reviews the evacuation drills, this interviewee stated that the Administrative Assistant reviews the evacuation drills. This interviewee was unable to indicate why these conditions had not been identified by the Administrative Assistant.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The Assistant Director of the facility will review facility A and B's floor map and ensure all exits are clearly identified. This review will include applicable exits for individual # 1, #2, #5, #6 and # 7.
The Assistant Director will review the floor map with the QIDP and the House Manager of the facility. This review will include training on the expectation for all individual and staff to exit the building via the closest safe exit to the individual during all fire drills. This training will be conducted by 12/08/2023 and be documented on a Training Log.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
QIDP of the facility will review the entire facility floor map with the House Supervisor and Shift Supervisors of the facility and all staff. This review will include training on the expectation for all individuals and staff in the facility to exit the building via the closest safe exit to the individual during all fire drills. This training will be completed by 12/15/2023 and will be documented on a Training Log.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The House Supervisor or Shift Supervisor of the facility will conduct observations of evacuation drills each month. This will be noted in the "comments" section of the fire drill form. If observation reveals that evacuation from the building during the drill was not through the closest safe exit, staff will receive additional training on proper fire drill evacuation procedure noted above and the drill will be repeated before the last day of the specific month. This additional training will be documented on a Training log. Continued failure to implement fire drill evacuation procedures as noted above will result in progressive corrective action.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
The Assistant Director of the facility will review completed fire drill no later than the 20th of each month. The Assistant Director of the facility will sign off on the forms to verify this review. If upon review, errors are noted, the Assistant Director will provide additional training to the House Supervisor regarding proper evacuation procedures as noted above and the drill will be repeated before the last day of the specific month. This additional training will be documented on a Training log. Continued failure to implement fire drill evacuation procedures as noted above will result in progressive corrective action.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective actions being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Assistant Director to review on going status of corrective action completion, beginning 12/01/2023. The Assistant Director will bring all documentation related to any audits and progress summary reviews to the meeting with the Director. The progress of the plan of correction will be documented on a plan of correction tracking grid upon review of the documentation. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
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