Initial Comments:
An extended survey visit was completed on April 21 and 22, 2025. The purpose of this visit was to evaluate compliance with the Requirements of 42 CFR, Part 483, Subpart 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:
483.430(e)(1) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
The facility must provide each employee with initial and continuing training that enables the employee to perform his or her duties effectively, efficiently, and competently.
Observations:
Based on observation and interview with administrative staff, the facility failed to provide continual training that enables the employee to perform their duties effectively, efficiently and competently by not ensuring that one of one Individual observed during the dinner meal who receives a regular consistency diet. This practice is specific to Individual #1.
Findings include:
1. Observation completed on 04/21/2025 from approximately 4:48 PM to 5:20 PM, revealed that Individual #1 was seated at the dining room table with his dinner plate in front of him. On the table were bowls which contained beef stew, salad, a dinner roll and sliced, canned peaches. This individual served himself various food items from each bowl and placed them on his plate.
. There was one direct care staff sitting diagonally across the table facing Individual #1 and the house manager was intermittently sitting across the table directly in front of Individual #1. Individual #1 started off eating his meal (beef stew with bite size pieces) with his fork in the right hand. He then began to increase his rate of eating with no prompting from staff to slow down. Individual #1 then attempted to eat his salad. He was having difficulty spearing the lettuce from his salad with his fork. At this point he began to push the lettuce with creamy salad dressing onto his fork with his left hand, but he was unable to get enough of the lettuce onto the fork, so he used his fork and fingers to lift the lettuce into his mouth. Immediately he then took his left hand, which now had creamy salad dressing on his fingers and began to rub his face and forehead. He repeated this pattern for approximately 3 to 4 times before the staff sitting diagonally across the table asked him to slow down. The house manager later prompted Individual #1 to slow down.
When Individual #1 asked the house manager for more food, the house manager asked Individual #1 to eat his peaches first. Individual #1 then stabbed a peach slice with his fork, brought it to his mouth and then used his left hand to push the peach slice into his mouth.
At no time did staff offer to help him cut the peach slices or prompt Individual #1 to cut his peach slices prior to eating them. Although Individual #1 had a napkin at this place setting, at no time was he prompted to use the napkin.
2. A review of Individual #1's record was completed on 04/22/2025 from approximately 8:45 AM to 10:35 AM. This review revealed Individual #1 has a maintenance goal titled, Maintain Napkin Use #18-H which was initiated on 03/26/2025 should be implemented daily at meals. Under the section titled, Present Behavior, it states,
-"[Individual #1] needs [verbal prompts] on how to use a napkin. [Individual #1] will sometimes get over stimulated and will either refuse to use his napkin or will need increased prompting."
Interview with the Program Director of ICF/MR on 04/22/2025, confirmed staff should have prompted Individual #1 throughout the meal to use his napkin, and to slow down when eating. This interviewee was unable to indicate why staff had not intervened throughout the meal to encourage Individual #1 to engage in appropriate mealtime skills
Plan of Correction:1. By 5-23-25, The team will meet to discuss the needs of the individual #1 regarding any Occupational and/or speech needs. These needs include possible adaptive spoons/forks, adaptive plates/bowls to assist with Individual #1 ability to eat without using his fingers. The team will also review that Individual #1 must be prompted to use his napkin throughout his entire meal. This will be documented on Individual Specific IDT meeting notes.
2. By 5-23-25, the Program Director (PD) will retrain all associates/contractors in all settings on the procedure to follow when implementing individuals' specific goals. This includes knowing each of the goals for all the individuals residing in the home, when they should be implemented, and understand the hierarchy of prompts. All goals must be implemented throughout the individuals' daily routines. Goals must be documented only after it is run and documented by the associates/contractors that ran the goal, so the information is accurate. Associates/contractors must continue to prompt each individual continually to reinforce the skills being taught. Documentation will be the Milford POC Goals, Prompting, and Documentation Retraining Sign Off.
3. Three times weekly, the House Manager will do unannounced observations during meals to ensure that associates/contractors are encouraging and prompting all individuals to prepare, serve and eat meals with the least amount of assistance necessary and that associates/contractors are providing general prompting as needed throughout the meal. The HM will ensure that each associate providing active treatment is doing so according to the Hierarchy of Prompts. The House Manager will document if associates/contractors prompting was offered according to each individuals specific goals. The House Manager will document her observations on the Milford Meal Observations Form and any feedback given to associates/contractors will be documented. Once weekly the HM will submit the Milford Meal Observations Form to the PD for review. Documentation will be the Milford Meal Observations Form.
4. Twice monthly the Program Director will do unannounced observations during meals to ensure that the house manager and associates/contractors are encouraging and prompting all individuals to prepare, serve and eat meals with the least amount of assistance necessary and that associates/contractors/contractors are providing general prompting as needed throughout the meal. The Program Director will document if associates/contractors prompting was offered according to each individuals specific goals. The Program Director will document her observations on the Milford Meal Observations Form and any feedback given to the House Manager and associates/contractors will be documented. At the end of each month the Program Director will submit the Milford Meal Observations Form to the Residential Director for review. Documentation will be the Milford Meal Observations Form.
5. The Program Director will review all documentation associated with this plan of correction within a week of the completed documentation from the House Manager. Any missing documentation or incorrect documentation will be immediately addressed with the associate responsible and documented. Documentation will be the POC binder in the Program Directors office.
483.450(b)(4) STANDARD
MGMT OF INAPPROPRIATE CLIENT BEHAVIOR
Name - Component - 00
The use of systematic interventions to manage inappropriate client behavior must be incorporated into the client's individual program plan, in accordance with §483.440(c)(4) and (5) of this subpart.
Observations:
Based on observations, record review and interview with the behavior specialist, the facility failed to incorporate the use of systematic interventions to manage inappropriate behavior which are written as rigorously as other training objectives, for one of one sample Individuals
who engages in repeated property destruction. This practice is specific to Individual #1.
Findings include:
1. A review of facility incident reports was completed on 04/21/2025 from 9:30 AM to 10:15 AM. This review revealed the following incidents resulting in injuries to Individual #1 after this individual would strike a wall or an object:
8/26/2024:
-"[Individual #1] was in the bathroom the morning of 8/26/24 and due to environmental noise in his home, [Individual #1] became agitated and punched the wall next to him.
[Individual #1] has a past history of this behavior. House Manager tried to eliminate the noise as much as possible, however [Individual #1] was already over stimulated thus him punching the wall. Staff escorted [Individual #1] into his bedroom ...to de-escalate. Upon entering his bedroom [Individual #1]walked across the room and punched a hole in his bedroom wall with his right hand with his hand going entirely through the wall. Staff noted blood on his hand...and swelling to his right ring finger. This was again called into nursing on call. Nursing assessed [Individual #1] in person and... nursing made the decision to transport [Individual #1] to a [local] ER where he could be assessed further for injury. An X-ray was completed, and he was diagnosed with a fracture of the proximal phalanx of right ring finger."
11/11/2024:
-"On 11/11/24, after lunch [Individual #1's] housemates were making loud vocalizations and [Individual #1] began to become angry with the noise. Staff attempted to redirect [Individual #1] and [Individual #1] was walking away from the living room, but he started kicking the walls in the house with his left foot multiple times. [Individual #1] was redirected by the house manager and [Individual #1] went to his room where he started to calm down. This behavior of kicking walls resulted in X-rays being taken on 11/13/2024. He was diagnosed with a contusion of the left foot."
11/27/2024:
"The morning of 11/27/24, [Individual #1] was being transported to workshop and on the way to workshop [Individual #1] started to get upset and started hitting the dashboard of the van with his left hand... At lunch time, staff noticed that his left hand was swollen and a little bruised (the one he used to hit the dashboard in the van). Nursing assessed after lunch and noted that [Individual #1] needed to go to the ER for assessment....[Individual #1] had 3
X-rays of his left hand. The results showed a left index finger fracture."
2/22/2025:
"On The evening of 2/22/25, [Individual #1] became upset and went to his room. While in his room, he used his right hand to hit the wall in his bedroom. On 2/24/25, staff noted some swelling to his right palm. Nursing was notified and assessed [Individual #1]. Nursing noted that [Individual #1] should go to Urgent Care for assessment where X-rays were taken. The X-rays showed no fracture or broken bones just a bad bruise."
2/26/2025
"The morning of 2/26/25, [Individual #1's] peer was screaming and making a lot of noise and [Individual #1] became agitated. Staff attempted to assist [Individual #1] with calming however [Individual #1] walked to the bathroom and punched the wall with his right hand. Staff assisted [Individual #1] in calming and once calm they were able to assess his right hand. Staff noted swelling and slight bruising in his right pinky finger and notified nursing. Nursing noted that he should be taken to urgent care for assessment. [Individual #1] was transported Urgent Care . He received an X-ray of his right hand and the X-ray showed a 5th middle phalanx fracture to is right hand."
3/27/2025:
"On 03/27/2025,[Individual #1] was at home this morning and was in the med room at approximately 8:15AM. He heard another his housemate screaming. Without warning[Individual #1] kicked the metal medication cabinet... He was taken to urgent care where
X-rays were taken. [Individual #1] was discharged at approximately 10:5PM with a diagnosis of a foot sprain."
2. Observations of the residence was conducted on on 04/21/2025 from approximately
3:45 PM to 4:00 PM, revealed the following:
Individual #1's Bedroom:
-Several boards approximately 1-1/2 to 2 foot wide and 3 foot long boards screwed into the wall.
Bathroom #2:
-Several painted boards screwed into the walls of this bathroom with 2 painted boards screwed into each wall on both sides of the toilet.
-Two repaired holes approximately 3 inches in circumference in the fiberglass shower wall.
Powder room:
-A plastic/ vinyl board , approximately 3 foot long and 2 foot wide, screwed into the top of the door facing the hallway.
Interview with the Program Director on 04/22/2025 at approximately 8:40 AM, revealed the boards were screwed into the walls to cover the holes in the wall from Individual #1 punching the walls.
3. A review of Individual #1's record revealed the following diagnoses for this individual:
-Severe intellectual disabilities
-Fragile X Syndrome
-Autism
-Impulse Control disorder
-Attention Deficit Disorder
Subsequent review of Individual #1's behavior support plan (BSP) completed on 04/22/2025 from 10:15 to 10:30 PM revealed this plan was initiated on 03/24/2022
and revised on 05/25/2023 and 05/25/2024.
In further review, there was no information within the plan that identified property damage as a target behavior nor how staff are to intervene when Individual #1 exhibits this behavior.
Interview with the behavior specialist on 04/22/2025, at approximately 10:30 AM, confirmed that property damage should be an identified targeted behavior in the BSP and there are currently no intervention strategies identified/available for staff to implement when this behavior is exhibited.
Plan of Correction:1. By 5-23-25, the Behavior Specialist will review and update the Behavior Support Plans (BSP) for Individual #1. The BSP will be updated to include property destruction and the support interventions for staff to use when Individual #1 is exhibiting this behavior. Once revised by the Behavior Specialist all residential and vocational associates will be trained on the revised plan. Documentation will be Individual #1's BSP behavior chart, the revised BSP and the Behavior Support Plan Training sign-in sheets.
2. By 5-23-25, the Behavior Specialist and the Program Director will review the Behavior Support Plans (BSP) for the other individuals residing in the home. The review will determine if each BSP includes;
- Clearly defined target behaviors with descriptive and easily understood operational definitions for each target behavior.
- Measurable criteria for each target behavior that includes the objectives for reducing maladaptive behaviors.
- Specific and concrete support interventions for staff to utilize when each target behavior is observed.
- Clearly defined crisis interventions with specific instructions for staff that include when and how the interventions should be utilized.
Any BSP found to be missing in any of the above areas will be revised by the Behavior Specialist so that it is a full and comprehensive Behavior Support Plan, and all residential and vocational associates will be trained in the revised plan. Documentation will be the Milford Individuals BSP behavior chart, the revised BSPs and the Behavior Support Plan Training sign-in sheets.
3. During every shift (seven days a week/ three times daily) the staff in residential and vocational will document all targeted behavior, including property destruction that Individual #1 exhibits. Twice weekly, the Home Manager will do unannounced visits during the weekdays and weekends to observe staff interacting with Individual #1 to ensure that the BSP is being implemented correctly. Feedback and retraining will be immediately provided if needed. While doing the visit, the Home Manager will review the BSP data collection to ensure that all data has been collected, is up to date and is accurately documented. Any inconsistencies in data collection or errors noted will be addressed immediately. Documentation will be the BSP Observation Form.
4. Once weekly the Behavior Specialist will do unannounced visits to Individual #1's residential home/vocational setting to observe staff interacting with Individual #1 to ensure that the BSP is being implemented correctly. Feedback and retraining will be immediately provided if needed. While doing the visit, the Behavior Specialist will review the BSP data collection to ensure that all data has been collected, is up to date and is accurately documented. Any inconsistencies in data collection or errors noted will be addressed immediately. Documentation will be the BSP Observation Form.
5. The Program Director will review all documentation associated with this plan of correction within a week of the completed documentation on the individual #1 BSP observation forms. Any missing documentation or incorrect documentation will be immediately addressed with the associate responsible and documented. Documentation will be the BSP Observation Form.
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