Initial Comments:
A focused fundamental survey was conducted on October 16, 17, 18, 19, and 20, 2023 to determine compliance with the requirements of the 42 CFR, Part 483, Subpart I Requirements for Intermediate Care Facilities. The census during the survey was 216, and the sample consisted of 16 individuals. Seven deficiencies were identified as a result of the survey.
Plan of Correction:
483.420(d)(3) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must have evidence that all alleged violations are thoroughly investigated.
Observations:
Based on documentation review, record review, and staff interview, it was determined that the facility failed to thoroughly investigate unusual incidents for two individuals. (Individual #1 and #2)
The findings included the following:
A. Facility incidents and investigations from June 2, 2023 through October 15, 2023 were reviewed on October 16-19, 2023. This review revealed the following:
B. Individual #1
1. A review of facility investigation documentation was conducted October 16-19, 2023. This review revealed that on September 13, 2023 at approximately 8:30 PM. Individual #1 eloped from the facility and was discovered at 8:40 PM by the local police at a nearby convenient store. Facility staff were unaware, until being contacted by the police, that Individual #1 had eloped from the facility. Individual #1 threatened self-harm at the time to the police officers. The police then transported Individual #1 to the hospital emergency room for evaluation. Individual #1 was assessed at the hospital and was eventually treated and released back to the facility later that evening. A formal investigation regarding the elopement incident was not completed by the facility.
C. Individual #2
1. A review of facility investigation documentation was conducted October 16-19, 2023. This review revealed that on August 21, 2023 at approximately 4:00 PM, a medication error was discovered. A new order for Synthroid (administer at 9:00 AM daily) was written for Individual #2 by the Physician on August 10, 2023. The Synthroid was delivered by the pharmacy and signed for by a Nurse later that day at 6:17 PM and placed on a shelf in the medication stock room. Upon discovery of the medication error on August 21, 2023, the Medication Administration Record (MAR) and the discovery of the Synthroid blister pack in the medication stock room showed no doses were given to Individual #2 since it was ordered 11 days earlier. Nurses responsible for administering Individual #2's medication and committing the errors were not identified on the investigation documentation.
2. A formal investigation was completed as a result of the incident; however, review of the finalized investigation report document revealed that the report was not comprehensive and detailed in nature. The investigation report lacked specific details, conclusions, training required, disciplinary actions, and any corrective actions required to prevent future events. D. Interview with the quality assurance/risk management director (QARMD) on October 19, 2023 at 2:20 PM confirmed that the facility failed to thoroughly investigate two unusual incidents for two individuals.
Plan of Correction:01 Train identified staff Residential Services Supervisor (RSS), Residential Services Worker (RSW), Risk Management (RM) staff, Residential Services Aide Supervisor/Residential Services Aide Night Supervisor (RSAS/RSANS) staff, Residential Services Unit Manager (RSUM) staff, and nursing staff on the responsibilities within the incident management process.
Quality Assurance Risk Management Coordinator (QARMC) 11/30/23
02 Monitor status of completion of the training and report to the Facility Director (FD) and Division Directors (DD) at the monthly Plan of Correction (POC) meeting.
Quality Assurance Risk Management Director (QARMD) 11/17/23 and ongoing
03 Train all certified investigators on the requirement to conduct thorough investigations on all incidents that require an investigation and the definitions outlined in the Incident Management Policy.
QARMC 11/24/23
04 Monitor status of completion of the training and report to the FD/DD at the monthly POC Meeting.
QARMD 11/17/23 and ongoing
05 Conduct five random audits of incidents for individual #1 to identify any incident that requires an investigation but failed to initiate an investigation. Provide report to FD/DD at the monthly POC meeting.
QARMC 11/17/23 and ongoing
06 Conduct random audits of ten investigations for all other individuals to identify any lack of thoroughness in investigations. Provide report to FD/DD at the monthly POC meeting.
QARMD 11/17/23 and ongoing
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 observations and interview, it was determined that the facility failed to ensure the individuals received opportunities for learning to promote independence. This applied to two (Keystone and Laurel) of four buildings observed.
The findings included the following:
A. Observations were conducted in the Keystone building east living areas on October 17, 2023 from 11:00 AM until 12:15 PM and 3:45 PM until 6:35 PM. During these observations, the individuals were seated in chairs or lying on couches in the living areas with two to three staff sitting at a table in the center of the room. Occasionally, one staff would get up and walk about the room to say hello to the individuals. One staff was observed sitting in a chair with arms folded, not interacting with the individuals. During these observations, individuals were observed to be sitting most of the time without activities, and staff interactions with the individuals were minimal. The staff were not observed to initiate or encourage participation in activities to provide formal or informal teaching.
B. Observations were conducted in the Laurel building east one and east two living areas on October 17, 2023 from 4:00 PM to 5:30 PM and October 18, 2023 from 9:05 AM until 9:20 AM.
1. The surveyor walked into the Laurel east one living area at 4:50 PM on October 17, 2023. At this time, two staff were seated a table with no individuals. Upon noticing the surveyor, the two staff got up from their chairs and began engaging the individuals in activities such as tossing a ball, playing Connect Four, and drawing on a chalk table.
2. On October 18, 2023, the surveyor entered the Laurel east one living area at 9:05 AM. At this time, four staff were observed sitting at a table with no individuals. Nine of the individuals were observed to be sitting in front of the television on couches, recliners or in wheelchairs, one individual was coloring, and two individuals were receiving feedings. Staff interaction remained minimal during the observation. Upon entering the east two living area at 9:15 AM, one individual was observed to be sleeping on a couch with the assigned one-to-one staff sitting next to her. Several other individuals were observed watching television or sitting with activities in front of them; however, staff interaction was minimal during this observation.
C. An interview was conducted with the quality assurance/risk management director (QARMD) on October 19, 2023 at 2:45 PM. The QARMD confirmed the facility failed to ensure that all Keystone and Laurel individuals consistently received opportunities for learning to promote independence.
Plan of Correction:01 Provide training for all Residential Service Aide (RSA), Residential Service Aide Supervisor (RSAS), Residential Service Worker (RSW), and Qualified Intellectual Disability Professional (QIDP) staff in Keystone and Laurel House that individuals 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, to include opportunities for learning to promote independence. Documentation of this training is the staff signature on the related Training Roster.
Residential Services Unit Manager (RSUM)/RSAS 12/08/2023
02 Provide training for all RSA/RSAS, RSW, QIDP, Therapeutic Activity Aide (TAA) and Therapeutic Activity Worker (TAW) staff in all other buildings that individuals 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, to include opportunities for learning to promote independence. Documentation of this training is the staff signature on the related Training Roster.
RSAS/RSUM/Therapeutic Activities Supervisor (TAS) 12/08/2023
03 RSUM will monitor the completion of the RSA/RSAS, RSW, and QIDP staff training regarding continuous active treatment and opportunities for learning to promote independence.
RSUM 12/08/2023
04 RSUM presents a report of the completed training to the Director of Residential Unit Managers (DRUM), Facility Director (FD) and Division Directors (DD) at the monthly Plan of Correction (POC) meetings.
RSUM 12/15/2023
05 TAS will monitor the completion of the TAA and TAW staff training regarding continuous active treatment and opportunities for learning to promote independence.
TAS 12/08/2023
06 TAS presents a report of the completed training to the Director of Program Services (DPS), FD and DD at the monthly POC meetings.
TAS 12/15/2023
07 RSAS, RSW, and QIDP staff conducts random observations in Keystone and Laurel House to ensure active treatment is being conducted. Audits will be assigned by the RSUM and the TAS. Audits are conducted 4 times per building for 4 weeks. Any issues identified are addressed and corrected immediately. If no issues are identified, fade audits to 3 times per building for 3 weeks. If no issues are identified, fade the audits to 2 times per building for 2 weeks. If no issues are identified, fade the audits to zero.
RSAS, RSW, and QIDP 11/20/2023 and ongoing
08 RSAS, RSW, TAW, and QIDP staff conducts random observations in all other buildings to ensure active treatment is being conducted. Audits will be assigned by the RSUM and the TAS. Audits are conducted 4 times per building for 4 weeks. Any issues identified are addressed and corrected immediately. If no issues are identified, fade audits to 3 times per building for 3 weeks. If no issues are identified, fade the audits to 2 times per building for 2 weeks. If no issues are identified, fade the audits to zero.
RSAS, RSW, TAW, and QIDP 11/20/2023 and ongoing
09 Completed audits by RSAS, RSW, QIDP are sent to the RSUM for additional review.
RSUM 11/20/2023 and ongoing
10 Completed audits are reviewed by the RSUM to ensure accurate and timely completion. Any issues identified are immediately addressed. The RSUM signature and date on each observation signifies the review of content.
RSUM 11/20/2023 and ongoing
11 RSUM presents a report of the completed audits to the DRUM, FD and DD at the monthly POC meetings, noting any issues identified and corrective actions taken.
RSUM 12/15/2023 and ongoing
12 Completed audits by TAW are sent to the TAS for additional review.
TAS 11/20/2023 and ongoing
13 Completed audits are reviewed by the TAS to ensure accurate and timely completion. Any issues identified are immediately addressed. The TAS signature and date on each observation signifies the review of content.
TAS 11/20/2023 and ongoing
14 TAS presents a report of the completed audits to the DPS, FD, and DD at the monthly POC meetings, noting any issues and corrective actions taken.
TAS 12/15/2023 and ongoing
483.450(b)(2) STANDARD
MGMT OF INAPPROPRIATE CLIENT BEHAVIOR
Name - Component - 00
Interventions to manage inappropriate client behavior must be employed with sufficient safeguards and supervision to ensure that the safety, welfare and civil and human rights of clients are adequately protected.
Observations:
Based on observation, record review, and interviews, it was determined that the facility failed to ensure interventions to manage inappropriate client behavior were employed with sufficient safeguards and supervision. This applied to one of 15 individuals residing in the Keystone East II unit.
The findings included the following:
A. Observations were completed in Keystone East II building on October 18, 2023 from 7:15 AM until 9:50 AM. At 8:13 AM, this surveyor arrived in the Keystone East II living area and was approached by Individual #3, who was crying. Individual #3 took this surveyor by the arm and led them through the bathroom to a hallway and stopped at a door and pointed at it. At this time, a staff entered the hallway and said, "[Individual #3] you know you aren't allowed in there." The staff then opened a door on the opposite side of the hallway and handed Individual #3 a pair of shoes. Individual #3 then took the shoes and went to the living area. The staff then stated, "We have to keep them locked up, or she will leave, especially with just two staff here." Individual #3 was then observed sitting in the living area wearing the shoes.
B. An interview was conducted with the Qualified Intellectual Disability Professional (QIDP) on October 18, 2023 at 8:23 AM. At this time, the QIDP stated that Individual #3 does not have an approved restrictive measure for having their shoes locked up as part of the Mental Health Support Action (MHSA) plan and that this was a rights violation.
C. A focused record review was completed for Individual #3 on October 19, 2023. This review of Individual #3's MHSA plan and safety support plan failed to reveal any documentation of a restrictive measure involving limiting Individual #3 from accessing their shoes.
D. An interview was conducted with the quality assurance risk management director (QARMD) on October 19, 2023 at 2:58 PM. At this time, the QARMD confirmed that on October 18, 2023, staff implemented a restrictive measure that was not addressed in the Individual #3's MHSA plan. The QARMD further confirmed that this restrictive measure was a rights violation and had been implemented without sufficient safeguards.
Plan of Correction:01 Provide training for staff assigned to individual #3 that individual must have approval to lock personal possessions- as documented in their Mental Health Support Plan and Annual Consent for Essential Supports (ACES). Restrictions without approval are considered a rights violation. Documentation of this training is the Residential Services Aide (RSA), Residential Services Aide Supervisor (RSAS/RSANS), Residential Service Worker (RSW) and Residential Service Supervisor/Qualified Intellectual Disability Professional (RSS/QIDP) signature on the related Staff Instruction Records (SIR).
Residential Services Unit Manager (RSUM) 11/17/23
02 Interdisciplinary (ID) Team for individual #3 convenes to ensure supports are identified, plans are accurate and plans adequately reflect appropriate needed interventions for locked personal possessions. Train staff who work with individual #3 if revisions are made to plans to ensure knowledge of proper supports, needed interventions for locked personal possessions.
RSS/QIDP 11/9/23
03 Copies of the ID Team meeting and revised plan for individual #3 are reviewed by the RSUM to ensure proper supports, needed interventions for locked personal possessions, and training for staff is completed in a timely manner, as applicable. The RSUM signature and DATE on copies of the plans and SIR signifies the review of content. Issues identified are addressed immediately.
RSUM 11/17/23
04 RSUM provides a report of the review of documentation to the Facility Director (FD) and Division Directors (DD) at the monthly Plan of Correction (POC) meeting.
RSUM 11/17/23
05 Initiate observations for individual #3 to ensure access to her personal possessions. Complete 3 observations per week for individual #3 for 4 weeks. Any issues identified are corrected immediately.
RSAS/RSANS 11/9/23
06 Completed observations are provided to the RSUM for review of content. RSUM signature and DATE on each observation verifies the review of content.
RSUM 11/17/23
07 RSUM provides a report of the review of observations to the FD and DD at the monthly POC meeting.
RSUM 11/17/23
08 Provide training for all RSA staff that individuals must have approval to lock personal possessions- as documented in their Mental Health Support Plan and ACES. Restrictions without approval are considered a rights violation. Documentation of this training is the RSA, RSAS/RSANS, RSW and RSS/QIDP signature on the related SIR.
RSUM 11/17/23 and ongoing
09 RSAS/RSANS, RSW, RSS/QIDP and RSUM staff conducts random observations to ensure individuals have access to their personal possessions. Audits are conducted 4 times per building for one month. Any issues identified are addressed and corrected immediately. If no issues are identified, fade audits to 3 times per building for one month. If no issues are identified, fade the audits to 2 times per building for one month.
RSAS/RSANS, RSW, QIDP and RSUM 11/17/23 and ongoing
10 Completed observations are reviewed by the RSUM to ensure accurate and timely completion. Any issues identified are immediately addressed. The RSUM signature and DATE on each observation verifies the review of content.
RSUM 11/17/23 and ongoing
11 RSUM presents a report of the completed audits to the FD and DD at the monthly POC meetings, noting any issues identified and corrective actions taken.
RSUM 11/17/23 and ongoing
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, record review, and staff interview, it was determined that the facility failed to administer medication without error. This was noted for one individual in Laurel building, West 2. (Individual #6)
The findings included the following:
A. Observations were conducted in the Laurel building on October 18, 2023. The observations revealed that breakfast started to be served at 7:20 AM. Individual #6 finished his breakfast around 8:00 AM and returned to his living area for personal hygiene and leisure activities.
B. Medication administration was observed on the west side of building from 8:20 AM to 9:10 AM. This observation revealed that Individual #6 received his medications at 8:58 AM, which included the medication Midodrine.
C. Physician's orders were reviewed immediately after the observations. The review revealed that Individual #6 was to receive the medication Midodrine: 10 milligrams, one tablet, twice a day, 30 minutes before breakfast and 30 minutes before dinner.
D. The nurse who administered the medication in error was in the process of administration at 9:30 AM. The medical director (MD) was interviewed on October 18, 2023,at 9:30 AM. The MD confirmed that Individual #6 did not receive the medication Midodrine as ordered.
Plan of Correction:01 Audit individual #6's Medication Administration Record (MAR) for Physician's orders that contain special instructions such as "30 minutes before meal" or similar.
Registered Nurse Supervisor (RNS) 10/18/23
02 Physician to review order for Individual #6's Midodrine to evaluate the need for special instructions.
Nurse Manager (NM) 10/18/23
03 Audit MARs for all other individuals for Physician's orders that contain special instructions.
RNS 10/25/23
04 Physician to review these orders to evaluate the need for special instructions.
NM 10/25/23
05 Train all RNS, Registered Nurse (RN), and Licensed Practical Nurse (LPN) staff regarding Nursing Procedure "Transcribing Physician's Orders"
NM/RNS 11/25/23
06 Train all RNS, RN, and LPN staff regarding EBC procedure #366 "Medication Preparation and Administration"
NM/RNS 12/6/23
07 RNS completes random audits comparing the Physician's 90-day orders with the MARs to ensure all medication times in the hour column are consistent with the Physician's orders. Complete 3 audits for each building (9) weekly for 4 weeks. If no issues are identified, complete 2 audits for each building (6) for 4 weeks. If no issues are identified, fade to 1 audit for each building (3) for 4 weeks. If no issues are identified, then fade to zero. Any issues identified are addressed and corrected immediately. RNS sends email to NM after each audit is completed.
RNS/NM 12/6/23 and ongoing
08 NM presents a report of the completed audits to the Director of Clinical Services (DCS), Facility Director (FD) and Division Directors (DD) at monthly Plan of Correction (POC) meetings, noting any issues identified and corrective actions taken.
NM/DCS 12/6/23 and ongoing
483.470(l)(1) STANDARD
INFECTION CONTROL
Name - Component - 00
There must be an active program for the prevention, control, and investigation of infection and communicable diseases.
Observations:
Based on observation, review of facility documentation and staff interview, the facility failed to ensure that an active program for the prevention and control of a communicable disease was maintained. This practice is specific to the implementation of the facility re-opening plan practices specific to COVID-19.
The findings included the following:
A. Direct observations during campus walkthrough's in Sunset, Laurel, and Keystone buildings revealed that several staff were not donning PPE in accordance with the facility's Yellow Zone Protocol.
B. Observations in the Sunset building on October 17, 2023 at approximately 3:20 PM, revealed signs on the front entrance door, which indicated this building was in the "Yellow zone". According to this document, the staff needed to wear the following personal protective equipment (PPE): gown (open in back), eye protection, N 95 mask, and gloves.
1. The unit manager accompanied the surveyor to the Sunset west side of the building for observations of appropriate PPE. These observations revealed staff in the living areas were not wearing all the PPE as required by the yellow zone protocol. All the staff, including nursing and dietary staff, were observed to be wearing only a surgical mask, no face shield or goggles, no gowns, and no gloves.
2. Dinner observations, from 5:30 PM to 6:45 PM, in the Sunset building, revealed several staff in the dining area assisting individuals with getting their meal trays and feeding individuals while not wearing all of the PPE required by the yellow zone protocol.
3. On October 18, 2023 at 6:45 AM, staff were observed entering the Sunset building without donning the appropriate PPE. A nurse walked through the hallway and into the nursing office carrying a N95 mask and gown in her hands; not wearing any PPE. Dietary staff was observed prepping for breakfast service without any PPE.
C. At 9:05 AM, four staff in the Laurel east one living area were observed to be sitting at a table conversing with each other. Two of the four staff were not wearing a mask or a face shield. Upon noticing the surveyor, the staff donned the appropriate PPE.
D. Observations were conducted in the Keystone building (East and West) on October 17, 2023 from 3:00PM to 6:30PM, and on October 18, 2023 from 6:50AM to 9:30AM. Signs at the front entrance of the building revealed that this building was in the "yellow zone."
On October 17, 2023 at approximately 3:00 PM, three staff were observed to be walking through the front entrance of the Keystone building without wearing any personal protective equipment (PPE), then proceeded down the main hallway toward their respective assigned areas. On October 17, 2023 at 3:44 PM, one of four staff working in the Keystone east living area was observed wearing a mask, while zero of the four staff were observed wearing a face shield or eye protection. On October 17, 2023 at 4:00 PM, one nurse was observed to be wearing an N95 mask and was not observed donning a face shield or eye protection. One of three staff were observed in the Keystone west living area not to be wearing face shields. On October 18, 2023 at approximately 7:35 AM, one dietary staff was observed to be wearing a surgical mask while removing food items in the dining room with their mask pulled down below their nose during the entirety of the morning meal observation. This staff was not observed at any time donning a face shield, eye protection, or gloves. Five of seven direct care staff in the Keystone dining room area were observed to be wearing surgical masks, while two direct care staff were observed to be wearing N 95 masks.
E. An interview was conducted with the quality assurance/risk management director (QARMD) on October 19, 2023 at 2:55 PM. The QARMD confirmed the facility failed to ensure that all Keystone, Laurel, and Sunset staff consistently donned PPE as required by the yellow zone protocol.
Plan of Correction:01 Initiate all staff training on required Personal Protective Equipment (PPE) to reduce the opportunities for the COVID-19 virus to enter the Center and subsequently infect the people who live and work at the Center. This training defines the appropriate PPE required to enter a particular zone (Green, Yellow, Red).
Registered Nurse Supervisor (RNS)/Infection Preventionist (IP) 12/1/23
02 Ensure COVID-19 exposure status signs are posted at the entrances of all buildings. This is done to inform anyone entering the building of the color zone and exposure status. This signage lists and displays PPE required for that zone.
Residential Services Unit Manager (RSUM), Therapeutics Activity Supervisor (TAS), Facility Director (FD), Quality Assurance Risk Management Director (QARMD), Facility Operations Manager 4 (FOM4), Director of Dietary Services (DDS), Storekeeper 2. 11/17/23 and Ongoing
03 Infection Preventionist completes random monthly PPE audits in Ebensburg Center buildings.
Infection Preventionist 11/17/23 and ongoing
04 FD assigns random PPE audits in Ebensburg Center buildings on all shifts.
FD 12/6/23 and ongoing
05 Random weekly PPE audits are completed as assigned. Remediation and retraining are completed immediately. Any trends or patterns are discussed at the monthly Plan of Correction (POC) meeting. Completed audits are sent to Infection Preventionist or designee for review.
RSUM, Residential Services Aide Supervisor/Night Supervisor (RSAS/RSANS), Nurse Manager (NM), RNS, Safety Manager, TAS, RNS/IP complete assigned PPE audits. 12/15/2023 and ongoing
06 Infection Preventionist will review completed PPE audits and report out at the monthly POC meeting.
Infection Preventionist 12/15/23 and ongoing
483.480(b)(1)(i) STANDARD
MEAL SERVICES
Name - Component - 00
Each client must receive meals with not more than 14 hours between a substantial evening meal and breakfast of the following day.
Observations:
Based on observations and interview, it was determined the facility failed to ensure there was no more than 14 hours between the evening meal and the breakfast meal on the following day. This applied to one of four buildings observed during the dinner and breakfast meals.
The findings included the following:
A. Observations of the dinner meal in Keystone building were completed on October 17, 2023 from 5:15 PM until 6:35 PM. Observations of the breakfast meal in Keystone building were completed on October 18, 2023 from 7:30 AM until 9:15 AM.
B. On October 17, 2023, Individual #4 was observed to arrive in the dining room at 6:00 PM and begin the dinner meal at 6:05 PM. On October 18, 2023, Individual #4 was then observed to arrive in the dining room for breakfast at 8:57 AM. This individual was observed to begin the breakfast meal at 9:02 AM.
C. On October 17, 2023, Individual #5 was observed to receive their dinner tray in their room, due to being on bed rest, at 6:30 PM and began eating their meal at 6:32 PM. On October 18, 2023, Individual #5 was observed to receive their breakfast tray in their room at 9:40 AM and began eating their meal at 9:41 AM.
D. Interview with the resident unit manager (RUM) was conducted on October 18, 2023 at 2:00 PM. The RUM confirmed that meals are scheduled 14 hours apart with dinner scheduled at 5:30 PM and breakfast scheduled at 7:30 PM, and further stated that while the individuals do get an evening snack, it is not a substantial meal. He confirmed that both Individual #4 and Individual #5 received their breakfast meal on October 18, 2023, more than 14 hours after the dinner meal on October 17, 2023. He further confirmed that the building's current meal schedule times are already set at 14 hours; therefore, any delay potentially causes other individuals to receive their meals greater than 14 hours apart.
Plan of Correction:01 Train all staff that there should be no more than 14 hours from the evening meal on the following day. Documentation of this training is the staff signature on the related Training Roster.
Residential Services Aide Supervisor (RSAS)/Residential Services Aide Night Supervisor (RSANS) 11/28/23
02 Residential Services Unit Manager (RSUM) will monitor the completion of all staff training regarding no more than 14 hours between the dinner meal and the breakfast meal on the following day. RSUM presents completed trainings to the Facility Director (FD) and Division Directors (DD) at the monthly Plan of Correction (POC) meeting.
RSUM 11/28/23
03 Observations for the start times of the evening meal and the start times of the breakfast meal on the following day are to be conducted for individuals #4 and #5 for 2 weeks.
RSUM 12/12/23
04 RSUM will monitor the completion of observations and ensure that there is no more than 14 hours between the evening meal and the breakfast meal on the following day.
RSUM 12/12/23
05 Train all Residential Services Aide (RSA) staff on documenting start times for the evening meal and the breakfast meal on the meal sheets for each living area. Documentation of this training is the staff signature on the related Training Roster.
RSAS/RSANS 11/28/23
06 RSUM will monitor the completion of all staff training regarding documenting start times for the evening meal and the breakfast meal on the meal sheets for each living area. RSUM presents completed trainings to the FD and DD at the monthly POC meeting.
RSUM 11/28/23
07 RSUM will monitor the completion of the documentation on the meal sheets for 4 weeks to ensure that there is no more than 14 hours between the evening meal and the breakfast meal. If any issues are identified, they are immediately addressed. If no issues are identified, RSUM will monitor the completion of the documentation on the meal sheets for 2 weeks to ensure that there is no more than 14 hours between the evening meal and the breakfast meal. If no issues are identified, RSUM will monitor the completion of the documentation on the meal sheets for 1 weeks to ensure that there is no more than 14 hours between the evening meal and the breakfast meal.
RSUM 1/12/2024
483.480(b)(2)(iii) STANDARD
MEAL SERVICES
Name - Component - 00
Food must be served in a form consistent with the developmental level of the client.
Observations:
Based on observation, review of facility provided documentation, and interview, it was determined that the facility failed to ensure that food texture was served in accordance with the individuals developmental needs. This applied to one individual residing in the Keystone building.
The findings included the following:
A. A review of a health care support action (SA) for mealtimes dated September 12, 2023, as well as a review of the meal tag for supper on October 17, 2023, was completed on October 17, 2023. The SA revealed that Individual #5's liquids were to be prepared as follows: "Liquids are thickened to the recommended consistency and poured into a regular glass..." The meal tag revealed Individual #5 was to receive "moderately thick liquids."
B. Observations of the supper meal in Keystone building were conducted on October 17, 2023 from 5:15 PM until 6:35 PM. At 6:05 PM, the staff assisting Individual #5 poured this individual a glass of juice and then opened a carton of chocolate milk and poured it in a glass. Individual #5 was observed to drink both liquids immediately. When the staff was questioned regarding the texture of the liquid, the staff replied, "she can actually have both thin and thickened liquids based on the support action."
C. An interview was conducted with the resident unit manager (RUM) on October 17, 2023 at 6:20 PM. The RUM confirmed that Individual #5 should have received "moderately thickened liquids" with the meal.
Plan of Correction:01 Train identified Residential Service Supervisor/Qualified Intellectual Disability Professional (RSS/QIDP) who fed individual #5 on referencing and reviewing meal tags prior to the meal to provide the prescribed meal consistencies and ensure safety.
Residential Services Unit Manager (RSUM) 11/13/2023
02 The RSS/QIDP assigned to individual #5 conducts mealtime observations of Individual #5 using the Meal Tag and Consistency Observation form one time per week for 4 weeks. Observer addresses identified issues immediately and provides RSUM with completed observation.
RSS/QIDP 11/15/2023 and ongoing
03 RSUM reviews and presents observation findings to the Facility Director (FD), Division Directors (DD) at monthly Plan of Correction (POC) meetings.
RSUM 11/17/2023 and ongoing
04 RSS/QIDP staff will review caseloads to identify individuals that receive meals by mouth and provide list to RSUM.
RSS/QIDP 11/15/2023
05 Train all staff, via the train down method, on referencing and reviewing meal tags prior to the meal to provide the prescribed meal consistencies and ensure safety.
FD/DD 12/08/2023
06 RSS/QIDP, Residential Service Worker (RSW), and Residential Services Aide Supervisor (RSAS) staff conduct mealtime observations for Breakfast, Lunch, and Dinner meals using Meal Tag and Consistency Observation forms for assigned individuals. Audits are assigned by the RSUM. Observations are conducted 4 times per building for 4 weeks. Observer addresses identified issues immediately. If no issues are identified, fade to 3 times per building for 3 weeks. If no issues are identified, fade to 2 times per building for 2 weeks. If no issues are identified, fade to zero.
QIDP/RSW/RSAS 11/20/2023 and ongoing
07 Observations completed by QIDP/RSW/RSAS are sent to RSUM for additional review.
RSUM 11/20/2023 and ongoing
08 RSUM Staff reviews and presents observation findings to FD and DD at monthly POC meeting.
RSUM/DPS 12/15/2023 and ongoing
09 Therapeutic Activity Worker (TAW) staff conduct mealtime observations for Breakfast, Lunch, and Dinner meals using Meal Tag and Consistency Observation forms for assigned individuals. Audits are assigned by the TAS. Observations are conducted 4 times per building for 4 weeks. Observer addresses identified issues immediately. If no issues are identified, fade to 3 times per building for 3 weeks. If no issues are identified, fade to 2 times per building for 2 weeks. If no issues are identified, fade to zero.
TAS 11/20/2023 and ongoing
10 Observations completed by TAW are sent to TAS for additional review.
TAS 11/20/2023 and ongoing
11 TAS Staff reviews and presents observation findings to FD and DD at monthly POC meeting.
TAS 12/15/2023 and ongoing
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