A focused fundamental survey visit was completed on May 20 and 21, 2021. 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 three individuals.
Plan of Correction:
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Nursing services must include, for those clients certified as not needing a medical care plan, a review of their health status which must be on a quarterly or more frequent basis depending on client need.
Based on record review and interview with the administrative staff, the facility failed to ensure that nursing services perform a review of individual health status by direct physical examinations on a quarterly basis for three out of three sample Individuals. This is specific to Individual #1, #2, and #3.
A review of the records for Individuals, #1, #2 and #3, was completed on 05/21/2021 from 7:00 AM until 11:30 AM. These reviews revealed that the facility nurse failed to conduct a review of each of the individual 's health status' by direct physical examination on a quarterly basis. Individual #1 is exemplary of this practice:
Individual #1 :
A review of the record of Individual #1 revealed that the health status quarterlies completed for this Individual, dated, 09/14/2020, 12/07/2020, and 03/01/2021 evidenced the documentation of vital signs to include Temperature, Pulse, Respirations, Blood Pressure and Weight.
Beyond that information, there was no further evidence that a direct physical examination of Individual #1 was conducted
Interview with the ICF director and the qualified intellectual disabilities professional on 05/20/2021 at approximately 3:00 PM, confirmed that
this individual did not receive a direct physical examination for the three quarters noted above.
Plan of Correction:
1. The ICF Program Director (PD) will update the 90-day and IPP nursing section to indicate language to capture that an in-person physical assessment was done for quarterly nursing checks at the home. The report will include findings of the in-person assessment; along with indicating details of what was done during the assessment (ie. Disrobing to complete a full body check, checking vitals, weighing the individuals etc). A review of each individuals' health status will take place quarterly ľor on a more frequent basis depending on the individuals' need. Documentation will be via the revised 90-day/IPP nursing section.
2. The ICF Program Director will train the Nursing Supports Manager and Facility nurse for this home and for all ICF homes on the 90-day and IPP form. Documentation will be on the ICF Revised 90-day/IPP Nursing Section Training Form.
3. The ICF Program Director will retrain the Nursing Supports Manager, the Milford facility nurse, on the requirement that the facility nurse must conduct a review of each of the individual 's health status by direct physical examination on a quarterly basis. The physical examination must be thorough and include an assessment completed on site by the nurse that includes vital signs and a physical assessment of the individual. The results of the vital signs and the assessment will be documented and shared with the team. Documentation will be on the ICF Nurse Direct Assessment Requirement Training Form.
4. The ICF Program Director will retrain all facility nurses on the requirement that each facility nurse must conduct a review of each of the individual 's health status by direct physical examination on a quarterly basis. The physical examination must be thorough and include an assessment completed on site by the nurse that includes vital signs and a physical assessment of the individual. The results of the vital signs and the assessment will be documented and shared with the team. Documentation will be on the ICF Nurse Direct Assessment Requirement Training Form.
5. Once per month, the facility nurse, or another assigned nurse, will personally complete vital signs and a direct physical examination for each individual residing in the home. The completion of the vital signs and direct physical examination will be documented. Documentation will be the ID note completed by the nurse to document the assessment and vital signs.
6. Once per quarter, the facility nurse, or another assigned nurse, will complete the nursing section of the newly revised 90 Day Review form, and at the year mark, the Individual Program Plan, and include the results of a direct physical assessment that includes vital signs taken by that nurse. The completion of this document will occur no more than 90 days from the completion of the last document. The facility nurse will submit the completed newly revised 90 Day Review / Individual Program Plan to the Nursing Supports Manager within two business days of the meeting. Documentation will be the Newly Revised 90 Day Review and the Individual Program Plan.
7. The Nursing Supports Manager will review the 90 Day Review / Individual Program Plans that are received from the facility nurse immediately upon receipt. The Nursing Supports Manager will ensure that a direct physical assessment is documented as occurring in the 90 Day Review / Individual Program Plan and that vital signs were taken. If a direct physical assessment did not occur or vital signs were not taken, the Nursing Supports Manager will immediately ensure that these are completed and that performance management steps are taken. Documentation will be the 90 Day Review / Individual Program Plan.
8. Once per month, the ICF Program Director will review all ID notes completed by the nurse to document direct physical assessments and any 90 Day Reviews / Individual Program Plans that occurred that month to ensure that all required direct physical assessments and vital signs were completed as required by the facility nurse. Any missing direct physical assessments will immediately be brought to the attention of the supervisor of the facility nurse so that the direct physical assessment can immediately occur and so that performance management steps can be taken. Documentation will be the Direct Physical Assessment Tracking Form.
9. All Documentation will be kept in a Plan of Correction binder in the ICF Program Director's office.
COMPREHENSIVE DENTAL DIAGNOSTIC SERVICE
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Comprehensive dental diagnostic services include periodic examination and diagnosis performed at least annually.
Based on record review and interview with administrative staff, the facility failed to provide comprehensive dental diagnostic services at least annually for two of three sample individuals. This practice is specific to Individual #1 and #2.
A review of Individual #1's record was completed on 05/21/2021 from approximately
9:30 AM to 11:30 AM, and revealed the following information:
A review of a document titled, Dental Visit Form dated 01/14/2019, under the section titled, Description of Gums, revealed this individual's gums were inflamed. Further review of this document revealed the statement that Individual #1 has "two teeth [that] have slight mobility, we have and will continue to monitor. No signs of infection. Follow-up needed in one year." Further review of this document revealed that this Dental Visit Form, dated above was the most current dental visit available in this record. Subsequent review of Physician Orders dated 2/12/2021, revealed this individual has severe gingivitis.
A review of a document titled, General ID Notes, dated 10/29/2020 revealed that the facility attempted to schedule an dental appointment but was informed that the surgery center where this individual receives his dental care, "had not resumed annual appointments at this time due to Covid-19."
Further review of the General ID notes from 10/29/2020 through the date of the survey, 05/21/2021, failed to indicate that the facility had made any futher attempts to schedule a dental appointment for Individual #1.
Interview with the qualified intellectual disabilities professional (QIDP) on 05/21/2021
10: 30 AM revealed that there were no further efforts to secure a dental appointment for this Individual post 10/29/2021.
A review of Individual #2's record was completed on 05/21/2021 between 9:00 AM and 11:00 AM. In a document titled Individual Program Plan (IPP) dated 08/24/2020. under the the section of this IPP titled Nursing Review/Medical Status Update, it is noted that
"...dental examinations to be completed every six months. If under general anesthesia, can be done annually, but requires a dentist order." This document notes that the most recent dental examination was completed on 01/29/2020. There was no documented evidence that a dental examination has occurred since the 01/29/2020 examination.
Interview with the QIDP on 05/21/2021 at approximately 10:00 AM confirmed that Individual #2 has not had a dental examination since the 01/29/2020.
Plan of Correction:
1. All Covid appointment restrictions have been lifted and all appointments are resuming for BARC. The Program Manager/Program Coordinator and Facility Nurse will meet to develop a plan to ensure that all dental appointments are brought up to date; and will meet monthly to review the status and progress of the dental appointments. The facility nurse and Program Manager will review upcoming dental appointments that are due soon; and indicate that is in their Interdisciplinary Team notes. The facility nurse/Health Care Coordinator will schedule all necessary dental appointments; and capture the status of the scheduling via an ID note.
2. The ICF Program Director will update the Interdisciplinary Team form to reflect language that indicates that the residential team discussed and reviewed upcoming dental appointments that are scheduled and/or need to be scheduled. The ICF Program Director, Nursing Support Manager will review Interdisciplinary Team notes and IDT meeting notes that will indicate that a review of appointments took place. The ICF Program Director will follow up with the Program Manager/Program Coordinator; and the Facility Nurse Manager will follow up with the Facility nurse monthly to ensure that all medical appointments are scheduled and up to date.
3. The Nursing Support Manager will create a dental review form to utilize weekly to check the status of outstanding dental exams. The form will indicate the date of the last dental exam, the upcoming date that the new dental exam should take place on and the date that the Facility Nurse called to schedule the appointment. The facility nurse will write an ID note for all calls pertaining to scheduling that were made for dental appointments. Once a dental appointment is scheduled and an ID note has been written, the ICF Program Director will file the information in the POC book. Both the ICF Program Director and Facility Nurse Manager will review all dental appointment notes monthly and/or when they arise. The NSM will restructure her oversight to ensure that dental appointments are occurring by doing the following:
a. The NSM will check the status of any outstanding Annual Dental Exams for all individuals.
b. The NSM will track ID notes / calls made to schedule any needed appointments. All past due appointments need to immediately be rescheduled.
c. Weekly progress will be documented by the NSM and forwarded to the ICF Program Director.
d. The NSM will meet with each nurse to review the status of Annual Dental Exams for each individual.
Documentation will be via the nurse's dental tracking form.
4. Once per month, the ICF Program Director will review all ID notes completed by the nurse/healthcare coordinator to document dental appointments that are scheduled. Any missed dental appointments will immediately be brought to the attention of the supervisor of the facility nurse so that the scheduling of dental appointments take place immediately and so that performance management steps can be taken. Documentation will be the Dental Review Form.
5. All Documentation will be kept in a Plan of Correction binder in the ICF Program Director's office.