Initial Comments:
A focused fundamental survey visit was completed on April 3 and 4, 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 five, and the sample consisted of five individuals.
Plan of Correction:
483.460(l)(2) STANDARD
DRUG STORAGE AND RECORDKEEPING
Name - Component - 00
The facility must keep all drugs and biologicals locked except when being prepared for administration.
Observations:
Based on observation and interview with facility staff, the facility failed to ensure that all drugs and biologicals are locked except when being prepared for administration for five of five sample Individuals observed receiving medications. This practice is specific to Individuals #1, #2, #3, #4 and #5.
Findings include:
1. Observation of the medication administration process was completed on 04/03/2023 from 7:00AM to 8:00AM revealed the following:
Individual #1
Individual #1 was administered his medications between 7:05AM and 7:15AM. After administering Individual #1's medications, the staff person placed the blister packs back into Individual #1's medication basket, and placed the basket in the medication cabinet. The staff person then transported Individual #1 in his wheelchair out of the medication room, for a period of approximately 60 seconds, leaving the medication cabinet doors open, and the door to the medication room open.
Individual #2
Individual #2 was administered his medications between approximately 7:15AM and
7:25 AM. The staff person removed Individual #2's medication basket from the medication cabinet and placed it on the counter. After administering Individual #2's medications, returning the blister packets to the basket, the staff person returned the basket to the medication cabinet. The staff person then removed Individual #5's medication basket from the medication cabinet and placed the basket on the counter. At this point, the staff person accompanied Individual #2 out of the medication room for approximately 30 seconds, leaving the medication cabinet doors open as well as the medication room door. The staff person returned to the medication room with Individual #5.
Individual #5
Individual #5 was administered his medications between approximately 7:30AM and 7:40AM. After administering Individual #5's medications, returning the blister packets to the basket, the staff person returned the basket to the medication cabinet. The staff person then removed Individual #4's medication basket from the medication cabinet and placed the basket on the counter. The staff person accompanied Individual #5 out of the medication room for approximately 30 seconds, leaving the medication cabinet doors open as well as the medication room door. The staff person returned to the medication room with Individual #4.
Individual #4
Individual #4 was administered his medications between approximately 7:40AM and 7:50AM. After administering Individual #4's medications, returning the blister packets to the basket, the staff person returned the basket to the medication cabinet. The staff person then removed Individual #3's medication basket and a lock box from the medication cabinet and placed both items on the counter. The staff person opened the lock box to reveal a blister pack of Phenobarbital, a controlled substance. The staff person accompanied Individual #4 out of the medication room for approximately 30 seconds, leaving the medication cabinet doors open as well as the medication room door. The staff person returned to the medication room with Individual #3.
Individual #3
Individual #3 was administered his medications between approximately 7:50AM and 8:00AM. After administering Individual #3's medications, returning the blister packets to the basket and closing and locking the lock box, the staff person returned both to the medication cabinet. The staff person accompanied Individual #3 out of the medication room. At no time did this staff person lock the medication cabinet or the medication room door when leaving the area.
Interview with the House Manager on 04/03/2023 at approximately 8:10AM acknowledged that the key to the medication cabinet was hanging to the right of the cabinet doors and
acknowledged that the medication cabinet should have been locked prior to the staff person leaving the area.
Plan of Correction:1.The QIDP will re-train all staff on medication administration. Particular emphasis will be paid to ensuring the medication closet and all medications are locked each and every time, except during preparation and administration. This retraining will include the medication storage procedures from the Medication Administration policy. Documentation will be the Medication Administration Training form.
2.Performance Management steps have been completed for the worker on shift who was responsible for medication administration and ensuring proper procedures were followed. Documentation is the file for this worker.
3.Twice weekly the Home Manager will observe randomly selected medication trained staff administer medications. The Home Manager will document if active treatment is occurring and ensure medication trained staff are following the BARC policy and procedures for locking and storing medications. Any procedures not being followed will be documented and performance management steps will be taken. Documentation will be the MEDICATION OBSERVATION sheet.
4.Twice monthly the QIDP will observe randomly selected medication trained staff administer medications. The QIDP will document if active treatment is occurring and ensure medication trained staff are following the BARC policy and procedures for locking and storing medications. Any procedures not being followed will be documented and performance management steps will be taken. Documentation will be the MEDICATION OBSERVATION sheet.
5.Once monthly the Program Director will review all documentation associated with this plan of correction to ensure that all training and reviews are occurring as required. Any missing documentation or incorrect documentation will be immediately addressed with the associate responsible and documented. Documentation will be via the MEDICATION OBSERVATION sheet.
6. All Documentation will be kept in a Plan of Correction binder in the ICF Program Director's office.
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 interview with administrative staff, the facility failed to ensure that there is an active program for the prevention, control and investigation of infection and communicable disease. This practice is specific to the implementation of the facility's COVID-19 Policy and Procedures.
Findings include:
Observation completed on 04/03/2023 from 7:00 AM to 8:25 AM, revealed
Survey staff #1 arrived to the facility at approximately 7:00 AM. Upon arrival, the facility staff person instructed this surveyor to take their temperature, sign the book and answer the COVID-19 questions, which was located right inside the front door.
At approximately 7:10 AM, Surveyor #2 arrived at the facility and rang the door bell.
The staff person answering the door looked at the surveyor's credentials and allowed this surveyor into the home with no further instructions or directions regarding COVID-19 screening actions for visitors.
A review of the facility's Residential COVID-19 Policy and Procedure, dated 08/12/2020 with a revision dated of 11/14/2022 revealed the following;
-Immediately upon arrival at each [agency name] location, workers/visitors will complete a self-screening process. If the person has a temperature of 100.0 degree or above, cough, sore throat, respiratory illness or difficulty breathing, they must leave immediately.
Interview with the Program Manager/Qualified Intellectual Disabilities Professional (QIDP) on 04/03/2023 at approximately 9:30AM confirmed that staff should have instructed surveyor #2 to complete the self screening process before entering the home, beyond the designated screening area. This interviewee was unable to explain why the staff person had not instructed Survey staff #2 to complete the screening.
Plan of Correction:1.The QIDP will re-train all staff on the active program for the prevention and control of a communicable disease in place within BARC Developmental Services in response to COVID-19. Particular emphasis will be paid to the sections containing information on the requirement that all staff working with all Individuals in any capacity are required to wear a mask, unless COVID testing is pending or a positive result exists, in which case an N95 or KN95 mask is provided, and that the masks are to be worn at all times (unless the staff is actively eating or drinking.) Additionally, the retraining will include specific information on the requirement to screen any and all visitors to the home by following the process in place at each home. This includes taking the visitor's temperature and assessing the visitor for symptoms of COVID-19. The retraining will include the information that staff are required to ensure that visitors use hand sanitizer before entering the home. Documentation will be the Prevention and Control of Communicable Disease retraining form for the COVID 19 BARC Developmental Services Residential COVID Policy and Procedures.
2.Performance Management steps have been completed for the workers on shift when the surveyor arrived at which time the screening process was not completed. Documentation is the file for each worker.
3.Twice weekly the Home Manager will complete unannounced observations at the home to observe staff. The Home Manager will document the use of the arrival procedure monitoring process to ensure staff are taking temperatures and screening for COVID symptoms. The Home Manager will ensure staff are wearing masks for the entire length of the visit, including immediately upon arrival. Any procedures not being followed will be documented and performance management steps will be taken. Documentation will be the COVID Arrival and Mask Use Observation Form.
4.Once weekly the QIDP will complete unannounced observations at the home to observe staff. The QIDP will document the use of the arrival procedure monitoring process to ensure staff are taking temperatures and screening for COVID symptoms. The QIDP will ensure staff are wearing masks for the entire length of the visit, including immediately upon arrival. Any procedures not being followed will be documented and performance management steps will be taken. Documentation will be the COVID Arrival and Mask Use Observation Form.
5.Once monthly the Program Director will review all documentation associated with this plan of correction to ensure that all training and reviews are occurring as required. Any missing documentation or incorrect documentation will be immediately addressed with the associate responsible and documented. Documentation will be the COVID Arrival and Mask Use Observation Form.
6.All Documentation will be kept in a Plan of Correction binder in the ICF Program Director's office.
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