Initial Comments:
A focused fundamental survey was conducted July 18-20, 2023, 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 record review, observations, and interviews, it was determined that the facility failed to ensure that staff demonstrated the necessary skills and competencies directed towards the health needs of the individuals. This applied to two (#2 and #3) of four individuals living at the residence. Findings included:
Observations at the residence were completed on July 18, 2023, from 5:50 AM to 7:50 AM. During these observations, this surveyor saw multiple marks on Individuals #2 and #3. Individual #2 was observed to have a quarter sized healing abrasion on the left knee. Individual #3 was observed to have a dime sized healing abrasion on the left knee, an approximately half inch long abrasion on the left elbow, and a quarter sized raw sore on the bridge of the nose. Interview was completed with residential staff on July 18, 2023, at 7:33 AM. The staff stated that she believed the injury on Individual #3's nose occurred approximately four weeks ago, and was self-inflicted. She further stated that she believed an incident report was filed when the injury originated.
On July 18, 2023, at 8:39 AM, the surveyors requested to review all incident reports at the facility for the past three months. On July 18, 2023, at 10:33 AM, the administrator confirmed via email that there were no incident reports for that period. Record review for Individual #2 and a focused review for Individual #3 was completed on July 20, 2023. These reviews failed to reveal any documentation of these observed injuries.
Interview with the qualified intellectual disabilities professional (QIDP) was completed on July 19, 2023, at 1:05 PM. The QIDP stated that staff are trained to document any marks observed on the individuals' bodies and to file an incident report. She confirmed that staff should have documented Individual #2 and #3's observed injuries and that the staff failed to document according to their training.
Plan of Correction:The facility will ensure that all staff demonstrate the skills and competencies directed to the health needs of the individuals. The QIDP will train all direct support staff on the proper procedure for reporting injuries or evidence of injuries. This training will be completed with all full-time staff of the Summers Drive house by September 30, 2023.
Incident reports have been completed for the abrasions observed on both individual #2 and individual #3 on July 18th, 2023. They have been reviewed by the QIDP and Community Home Nurse, and as of August 8th, 2023 the reports have been submitted for review by the Director of Risk Management and the Incident Review Committee.
All direct support personnel will be trained by the QIDP on how to handle any non-life threatening injuries or evidence of non-life-threatening injuries they may find on the residents of the home. This evidence includes (but is not limited to) bumps, bruises, scratches, skin discoloration or abrasions. The staff will be trained that if they discover this evidence or witness an injury occur, they will immediately call the Community Home On-Call Professional. Staff will inform the on-call professional of the following details: Who was involved, What injuries occurred, where did the incident happen, why did the incident happen, and how did the incident happen. Staff will be instructed by the on-call professional on what first aid, if any, is to be administered. Staff will be instructed to complete necessary documentation if needed. The on-call professional will fill out an internal incident report document, which will be reviewed by the Community Home Nurse, the QIDP, and then reviewed by the Director of Risk Management and the Incident Review Committee. Once this has been reviewed, the document will be given to the Director of Community Homes, who will keep the document on file for no less than three years.
Additionally, the direct support staff will be trained to begin completing a weekly body assessment for the residents of the house. These will be completed during the residents' bathing time, and will be documented via a digital form that will be shared with the QIDP and nurse of the house. Staff will indicate and describe any marks they find on the residents, regardless if the marks have been previously reported. The nurse and QIDP will read these forms and will assess the residents if staff report any mark that has not previously been reported. These weekly body assessments will begin the week of August 14, 2023 and will continue for no less than three months.
483.440(c)(5)(iv) STANDARD
INDIVIDUAL PROGRAM PLAN
Name - Component - 00
Each written training program designed to implement the objectives in the individual program plan must specify the type of data and frequency of data collection necessary to be able to assess progress toward the desired objectives.
Observations:
Based on record reviews and interview, it was determined that the facility failed to collect data with enough frequency to adequately measure progress toward residential program goals. This applied to two (#1 and #2) of four individuals in the core sample. Findings included:
1. A record review was completed for Individual #1 on July 20, 2023. At that time, a review of the residential program goals and data collection for the months of April, May, and June of 2023, was completed. This review revealed that data collected for Individual #1's residential program goals were as follows:
- Will turn off the water once showering is complete with two hand over hand prompts. This goal was to be implemented on Monday, Wednesday, and Friday of each week. Documentation revealed that this goal was implemented two out of 12 days in April, six out of 14 days in May, and nine out of 13 days in June of 2023.
- Will pack lunch in preparation for LEAP with three hand over hand prompts. This goal was to be implemented on Sunday, Monday, Tuesday, Wednesday, and Thursday of each week. Documentation revealed that this goal was implemented four out of 21 days in April, four out of 23 days in May, and three out of 21 days in June of 2023.
- Will count money that is located in the petty cash pouch with three verbal prompts. This goal was to be implemented on Saturday and Sunday of each week. Documentation revealed that this goal was implemented zero out of 10 days in April, zero out of eight days in May, and zero out of eight days in June of 2023.
- Will unload two plates and two cups from dishwasher once cycle is complete with three hand over hand prompts. This goal was to be implemented on Wednesday and Saturday of each week. Documentation revealed that this goal was implemented two out of nine days in April, one out of nine days in May, and two out of eight days in June of 2023.
2. A record review was completed for Individual #2 on July 20, 2023. At that time, a review of the residential program goals and data collection for the months of April, May, and June of 2023, was completed. This review revealed that data collected for Individual #2's residential program goals were as follows:
- Will purchase a desired item while shopping in the community with one verbal prompt. This goal was to be implemented one time per month. Documentation revealed that this goal was implemented zero out of one day in April, one out of one day in May, and zero out of one day in June of 2023.
- Will set the dining room table prior to dinner with one verbal prompt. This goal was to be implemented on Monday, Wednesday, and Friday of each week. Documentation revealed that this goal was implemented six out of 12 days in April, nine out of 14 days in May, and eight out of 13 days in June of 2023.
- Will start the dishwasher after dinner with one gestural prompt. This goal was to be implemented on Tuesday and Thursday of each week. Documentation revealed that his goal was implemented three out of eight days in April, five out of nine days in May, and four out of nine days in June of 2023.
- Will unload two plates and two cups from the dishwasher once the cycle is complete with three gestural prompts. This goal was to be implemented on Tuesday and Thursday of each week. Documentation revealed that this goal was implemented three out of eight days in April, five out of nine days in May, and four out of nine days in June of 2023.
- Will wipe the dining room table clean after dinner with two gestural prompts. This goal was to be implemented on Monday, Wednesday, and Friday of each week. Documentation revealed that this goal was implemented six out of 12 days in April, eight out of 14 days in May, and eight out of 13 times in June of 2023.
An interview was conducted with the qualified intellectual disabilities professional (QIDP) on July 20, 2023 at 10:20 AM. The QIDP confirmed that data collection was lacking for Individuals #1 and #2, and further confirmed that data was not collected with enough frequency to measure the individuals progress in their residential goals.
Plan of Correction:The facility will ensure to collect data with enough frequency to adequately measure the individuals' progress towards residential program goals for individuals #1 and #2, and all other individuals supported by the agency.
The Qualified Intellectual Disability Professional (QIDP) will train all support staff for individuals (#'s 1 and 2) and all individuals supported by the agency on the importance of documenting data frequency to adequately measure the individuals' progress towards residential program goals. QIDP will review 20 % of the training plans for appropriate frequency of documentation bi-weekly for 6 months and then monthly thereafter for a year. The Director and/or Assistant Director of Community Homes will conduct an audit of 20% of training to ensure the QIDP is reviewing and addressing concerns that arise on frequency of documentation monthly for 6 months and then quarterly thereafter for a year.
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 individuals were provided training in the area of personal skills. This applied to one (#2) of two individuals in the core sample. Findings included:
A record review for Individual #2 was completed on July 20, 2023. This review included a functional assessment completed on April 23, 2023, in which Individual #2 was identified to have needs in the area of personal skills related to haircare, oral hygiene, handwashing, and dressing. This review failed to reveal a training program for Individual #2 in the area of personal skills.
An interview was conducted with the qualified intellectual disabilities professional (QIDP) on July 20, 2023 at 8:50 AM. The QIDP confirmed that Individual #2 had needs identified within the functional assessment for personal skills and further confirmed that Individual #2 does not have a goal 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 will be created by the QIDP, and all training will begin no later than September 30, 2023.
Individual #2 will have a residential program goal in place to assist them with training in the area of personal skills related to haircare, oral hygiene, handwashing, and dressing. This goal will be created by the QIDP and individual #2 will begin this training no later than August 11, 2023.
Once the QIDP has all trainings implemented, the Director and/ or Assistant Director of Community Homes will conduct an audit of 50% of training to ensure the QIDP is reviewing and addressing concerns that arise on training in personal skills essential for privacy and independence being implemented monthly for 6 months and then quarterly thereafter for a year.
483.440(f)(3)(ii) STANDARD
PROGRAM MONITORING & CHANGE
Name - Component - 00
The committee should insure that these programs are conducted only with the written informed consent of the client, parents (if the client is a minor) or legal guardian.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that restrictive interventions were implemented only after the human rights committee (HRC) verified the written informed consent of the guardian. This applied to one (#1) of two individuals in the core sample. Findings included:
Record review for Individual #1 was completed on July 20, 2023. This review revealed that Individual #1 had a restrictive procedure of "A hospital bed with side rails for the continued health and safety progress." This review further revealed that the guardian provided written consent for this procedure on August 22, 2022. The human rights committee provided approval for this plan on August 1, 2022.
An interview was completed with the qualified intellectual disabilities professional (QIDP) on July 20, 2023, at 9:00 AM. The QIDP confirmed that the restrictive procedure of bed side rails for Individual #1 was implemented without the HRC verifying the written consent of the guardian.
Plan of Correction:The facility will ensure that restrictive interventions were implemented only after the human rights committee verified the written informed consent of the guardian for individual #1 and all individuals that are on restrictive interventions.
The Director and/ or Assistant Director of Community Homes will complete a training for each Qualified Intellectual Disability Professional on the proper criteria for Human Rights approvals for individual #1 and all individuals that are on restrictive interventions to ensure restrictive interventions are implemented only after the human rights committee verifies the written informed consent of the guardian. This training will occur no later than August 31, 2023.
The Interdisciplinary Team led by the QIDP has met and determined that Individual #1 no longer requires the use of a bed with side rails for the benefit of their health and safety. The bed with side rails was removed from Individual #1's bedroom by August 1, 2023.
The QIDP is continuing to review all consents for each individual on restrictive interventions to ensure HRC verified written informed consents were obtained from the guardian. The Director of Community Homes will complete a look back review to verify that HRC written informed consents were obtained from the guardian. Any missing HRC verification will be obtained immediately upon discovery. These reviews will occur at least once every six months and will be ongoing.
The QIDP will present written informed consent of the guardian as part of the information for the Human Rights Committee to review before approval on each restrictive intervention. The Director and/or Assistant Director of Community Homes will review all the material being presented to the Human Rights Committee (HRC) before and after HRC review to ensure restrictive interventions and guardian written informed consents are being provided to HRC, and to ensure interventions are being implemented only after the human rights committee verifies the written informed consent of the guardian. These reviews will occur at least once every six months and will be ongoing.
483.460(k)(1) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.
Observations:
Based on observation, review of medication administration record (MAR), review of physician's orders, and interview, it was determined that the facility failed to ensure that medications were administered in accordance with physician's orders. This applied to one (#2) of two individuals in the core sample. Findings included:
Observations were completed at the residence on July 18, 2023, from 3:20 PM to 6:30 PM. During that time, the surveyor observed Individual #2 receive one medication from staff at 3:58 PM. Record review for Individual #2 was completed on July 19, 2023. This review revealed physician orders signed and dated July 5, 2023, which stated that Individual #2 was to receive sulfamethoxazolo tmp Ds 800-160 milligrams, one tablet daily by mouth two times a day with meals at 7:00AM and 5:00 PM. Review of the MAR from July 2023 revealed that Individual #2 stopped receiving the sulfamethoxazolo on July 8, 2023, at 7:00 AM.
Interview with the community home nurse was completed on July 19, 2023, at 1:25 PM, the nurse stated that Individual #2's sulfamethoxazolo medication was a 5-day order that began on July 3, 2023. The nurse acknowledged that the sulfamethoxazolo order was carried over on the 90-day physican orders with no time limited instructions or end date. She further acknowledged that the current orders were signed by the physician July 5, 2023.
A subsequent interview with the director of nursing (DON) was completed on July 20, 2023, at 9:35 AM. During this interview the DON confirmed the discrepancy was not identified by the facility and that Individual #2 was not receiving bactrim in compliance with the current physican orders signed on July 5, 2023.
Plan of Correction:The facility will ensure that the system for drug administration assures that all drugs are administered in compliance with the physician orders.
Nurses will be trained by the Director of Health Services on the proper procedure regarding physician orders. Once physician order is received, the certified nurse will review the order and send the order directly to the pharmacy. The pharmacy will transcribe and enter the order into Quickmar. Once the order is entered, the nurse responsible for individual #2 and all individuals supported by the agency will review that the order corresponds exactly with the written physician order. Nurse will ensure proper start and end dates are present on the order entered into the computer and/or the duration of the medication is specified.
Director of Health Services will conduct an audit of 10% of new medication orders and compare these orders to the MAR monthly for 90 days and then quarterly to ensure the MAR corresponds to the physician order correctly for one year. This will ensure the individual receives their medications as ordered by the physician.
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, review of physician's orders, and interview, it was determined that the facility failed to ensure that medications were administered without error. This applied to one (#1) of two individuals observed during morning medication administration. Findings included:
Observation of the morning medication administration was completed on July 18, 2023, from 6:14 AM to 6:35 AM. At 6:28 AM, staff prepared Individual #1's medications, which included: levothyroxine, chlorpromazine, metronidazole, vitamin D3, omeprazole DR, and sm stool softener. These oral medications were crushed and placed in yogurt, and administered to Individual #1 at 6:35 AM.
A review of Individual #1's current physician's orders was completed on July 18, 2023. This review revealed that Individual #1's physician's orders state, "takes medication orally whole with water or crushed in applesauce or pudding."
An interview was conducted with the director of nursing (DON) on July 20, 2023, at 9:30 AM. The DON confirmed that Individual #1's physician's orders state that crushed medications should be administered in either applesauce or pudding. The DON further confirmed that staff did not administer Individual #1's medications in accordance with the physician's order.
Plan of Correction:The facility will ensure that the system for drug administration must assure that all drugs, including
those that are self-administered, are administered without error.
Appropriate actions were taken for the medication error that occurred on July 18, 2023 and an incident
report was filed. The physician's orders for Individual #1 were discussed and updated to include yogurt
as a food item option for administration since individual #1 likes yogurt. All staff working with individual
#1 will be educated about the need to ensure they are following the physician's orders as written to
administer medications as ordered.
All Direct care professionals in the home will be educated on the medication administration process to
ensure they are following the physician orders correctly and using the appropriate technique for all
individuals supported by the agency. Medication administration will be observed randomly on staff
members administering the medications by the nurse responsible for the individuals weekly for 6 weeks,
then monthly for 90 days, and then quarterly thereafter for one year to ensure the medications are
being administered exactly per physician orders including correct technique of administration. As part of
the observations, nurse will ensure that the individuals supported by the agency are given the
medications in the correct food, as stated on the orders. Facility will ensure that the food stated in the
orders is available for medication administration. Observation forms will be submitted to the Director of
Health Services for review upon completion to ensure staff members are following physician orders
appropriately. Medication observations will start the week of August 14, 2023.
|