Initial Comments:
A focused fundamental survey was conducted July 22 - 23, 2024, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was four and the core sample consisted of two individuals.
Plan of Correction:
483.430(e)(2) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
For employees who work with clients, training must focus on skills and competencies directed toward clients' health needs.
Observations:
Based on observation, record review, a review of staff training, and interviews, it was determined that the facility failed to ensure that staff demonstrated the necessary skills and competencies directed toward the health needs of the individuals. This applied to one (#1) of two individuals in the core sample. Findings included:
Observations were completed at the residence on July 22, 2024, from 3:00 PM to 6:30PM. At 3:50 PM, Individual #1 was observed to be seated in a recliner in the living room. At 3:51 PM, staff prompted Individual #1 to stand to use the restroom. Individual #1 then stood and walked to the restroom with staff assistance. Individual #1 returned to their living room recliner at 3:55 PM. During this observation, Individual #1 was wearing only socks. At 3:56 PM, when questioned by the surveyor, staff stated that Individual #1 should have their supramalleolar orthoses (SMOs), which are worn within their shoes, "on at all times, except when showering or when [Individual #1] is in bed." Staff then retrieved Individual #1's SMOs and put them on Individual #1's feet.
A record review for Individual #1 was completed on July 23, 2024. This review revealed that Individual #1's individual program plan (IPP), dated January 2, 2024, stated Individual #1 "utilizes orthotics which include bilateral SMOs during the day." Further review of staff training records, indicated that the staff observed was trained on Individual #1's IPP on June 20, 2024.
An interview was conducted with the director of community homes (DCH) and qualified intellectual disabilities professional (QIDP) on July 23, 2024, at 12:08 PM. The DCH confirmed that Individual #1 should have their SMOs on when ambulating in the residence. Further interview with the QIDP at 12:35 PM confirmed that staff were trained on Individual #1's IPP and that staff training failed to demonstrate the skills and competencies for Individual #1's health needs.
Plan of Correction:The QIDP of the facility will ensure that the wording of Individual #1's records regarding the usage of the supramalleolar orthoses (SMOs) should indicate that Individual #1 "is to be wearing her SMO's any time she is ambulating." This will be included in Individual #1's individual program plan no later than August 30, 2024. Additionally, all staff who are regular employees of the facility shall be trained on the usage of Individual #1's SMOs by the QIDP of the facility no later than August 30, 2024. The Director and/ or Assistant Director of Community Homes will review the staff training records to ensure all staff have been trained regarding Individual #1 SMO usage no later than September 30, 2024, and will then continue to review these records once every six months.
Currently, no other residents of the facility require the use of orthotics. However, should any other resident of the facility require the use of any orthotics, the QIDP of the facility will be responsible for writing and implementing a training for all staff of the facility on the usage of said orthotics. This training will be included in the individual's program plan at the time of implementation and all staff will all be trained on the usage of the orthotic upon the staff's next scheduled shift once the orthotic has been implemented. The Director and/ or Assistant Director of Community Homes will review the staff training records to ensure all staff have been trained regarding any orthotic equipment used by any resident of the facility quarterly for one year, beginning August 30, 2024.
483.440(c)(6)(iii) STANDARD
INDIVIDUAL PROGRAM PLAN
Name - Component - 00
The individual program plan must include, for those clients who lack them, training in personal skills essential for privacy and independence (including, but not limited to, toilet training, personal hygiene, dental hygiene, self-feeding, bathing, dressing, grooming, and communication of basic needs), until it has been demonstrated that the client is developmentally incapable of acquiring them.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that the individuals were provided training in the area of personal skills. This applied to one (#1) of two individuals in the core sample. Findings included:
A record review for Individual #1 was completed on July 23, 2024. This review revealed five training programs for Individual #1. This review failed to reveal a training program for Individual #1 in the area of personal skills. Further review revealed a "Functional Assessment" for Individual #1, dated December 2, 2023. This assessment revealed that Individual #1 had identified needs in the area personal skills, that included: "wash hands", "brush teeth", "brush/comb hair" and "shampoo hair."
An interview was conducted with the director of community homes (DCH) on July 23, 2024, at 12:00 PM. The DCH confirmed that Individual #1 had identified needs in the area of personal skills and further confirmed that Individual #1 did not have a training program in the area of personal skills.
Plan of Correction:The QIDP of the facility will ensure that all residents will have residential program goals that will serve as training in personal skills essential for privacy and independence until it has been demonstrated that the resident is developmentally incapable of acquiring them. These program goals have been created by the QIDP, and all training will begin no later than August 30, 2024.
Individual #1 will have a residential program goal in place to assist them with training in the area of personal skills related to oral hygiene. This goal has been created by the QIDP and individual #1 will begin this training no later than August 13, 2024.
Once the QIDP has all training implemented, the Director and/ or Assistant Director of Community Homes will conduct an audit of the training of all four residents of the program, to ensure the QIDP is reviewing and addressing concerns that arise on training in personal skills essential for privacy and independence. The Director and/ or Assistant Director of Community Homes will also conduct an audit the training of all four residents of the program to ensure the residential goals created by the QIDP with training in the area of personal skills related to haircare, oral hygiene, handwashing, and dressing are being implemented by all residents of the program at least twice weekly. These audits will occur twice monthly for 6 months and then monthly thereafter for a year.
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 record review and interview, it was determined that the facility failed to ensure that all interventions to manage inappropriate client behaviors were incorporated into the individual's program plan (IPP). This applied to one (#2) of two individuals in the core sample. Findings included:
Record review for Individual #2 was completed on July 23, 2024. This review revealed that Individual #2 has a behavior management plan, effective May 4, 2024, to manage symptoms of stereotypic movement disorder. This plan utilized restrictive medications including prozac, risperdal, and naltrexone. A review of physician orders, signed July 3, 2024, revealed that Individual #2 currently receives clonidine 0.2 milligrams, take one tablet by mouth three times daily for effects of impulse control disorder. Further review failed to reveal that the medication clonidine was incorporated into Individual #2's IPP.
An interview was conducted with the behavior specialist on July 23, 2024 at 11:54 AM. The behavior specialist confirmed that the medication clonidine was being used to manage inappropriate behaviors and was not incorporated into Individual #2's IPP.
Plan of Correction:The facility will ensure that the use of systematic interventions to manage inappropriate client behavior are incorporated into the client's individual program plan. The facility will ensure that all interventions to manage inappropriate client behavior are incorporated into the ISP.
Individual #2 current behavior support plan to manage symptoms of stereotypic movement disorder has been updated to reflect the start of the medication clonidine .2 mg TID.
A written check sheet for each individual with completion dates of all required procedural steps of any systematic behavioral intervention procedures will be developed by the Clinical Supervisor of Behavioral Health Services.This check sheet will detail all the required procedural steps that should be completed by the behavior specialist each time changes occur in a portion of the systematic intervention plan including the completion of an update to the behavior support plan in the ISP. The checklist will be retained in the individual's record.
The check sheets will be randomly reviewed for completion by the QIDP on a monthly basis for three months and then on a quarterly basis thereafter. The Vice President of Regulatory compliance will provide random chart audits of 10% of individuals who have had changes to any portion of their intervention plan on a quarterly basis to ensure all steps in the process have been completed
|