Initial Comments:
A focused fundamental survey was conducted on January 14, 15, 16, and 17, 2025 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 32, and the sample consisted of four individuals. Two deficiencies were identified as a result of the survey.
Plan of Correction:
483.420(d)(2) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.
Observations:
Based on staff interview and investigation report review, it was determined facility staff failed to report two allegations of potential abuse in a timely manner to facility administration for two individuals residing at the facility. (Individuals #1 and #2)Findings included:A. Individual #1
1. Review of a facility investigation and staff interview revealed an incident of a potential inappropriate staff interaction with an individual had occurred "sometime" on December 25, 2023. No specific time was given. The allegation was not reported to facility administration until January 7, 2024 at 11:30 a.m., fourteen days after the alleged incident had occurred. Review of the investigation findings revealed the alleged inappropriate interaction abuse was not confirmed.
B. Individual #21. Review of a facility investigation and staff interview revealed an incident of a potential rights violation had occurred on January 17, 2024 at approximately 5:10 p.m. The allegation was not reported to facility administration until January 18, 2024 at 11:30 a.m., one day after the alleged incident had occurred. Review of the investigation findings revealed the alleged rights violation was not confirmed.
C. The Assistant Vice President (AVP) was interviewed on January 17, 2025 at 11:00 a.m. During the interview the AVP confirmed the above-mentioned findings.
Plan of Correction:W0153
The deficient area of concern is based on two incidents of alleged abuse where facility staff failed to report the incidents to administration in a timely manner, resulting in a delay in the investigation and separation of the alleged perpetrator and the alleged victims.
The first incident involved Individual #1, an allegation of sexual abuse/inappropriate staff interaction that occurred sometime on 12/25/23, but not reported until 1/7/24. The conclusion of this investigation was determined to be "not confirmed".
The second incident involved Individual #2, an allegation of rights violation allegedly occurring on 1/17/24, but not reported until 1/18/24. This allegation involved the alleged staff taking away the dinner plate of Individual #2, and disposing the contents because Individual #2 was taking too long to eat her meal. The results of this investigation was also determined to be "not confirmed".
Based on the fact that there were two incidents of late reporting of alleged abuse, neglect and mistreatment of residents the facility will implement the following corrective action and systematic change to eliminate the continuance of the deficient practice:
Under the guidance of the Assistant Vice President, and in conjunction with the Program Manager, Clinical Staff (QIDP & Program Specialists), all staff will be in-serviced on the Incident Management Bulletin and established facility protocols related to reporting alleged abuse, neglect and mistreatment of residents.
In addition, nuances of the investigations for Individual #1 and #2 will be included.
The in-service model will be a written test that will be provided to all existing staff as a means of determining competence, awareness, and accountability to report allegations of abuse, neglect, and mistreatment of residents.
"New staff" will also receive this in-service as part of their orientation to ensure that the new employee has the awareness and competencies of Incident Management and "Abuse/Neglect" protocols as they are going onto the floor to engage with the staff and resident population.
To monitor the progress of the facility's corrective action, the Monthly Incident Management meetings will document progress on the Plan of Correction in terms of completion rates.
The Assistant Vice President will ultimately be responsible for the completion of the Plan of Correction and to ensure the deficient practice identified in W153 does not reoccur.
483.420(d)(3) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must have evidence that all alleged violations are thoroughly investigated.
Observations:
Based on documentation review, record review, and staff interview, it was determined that the facility failed to comprehensively investigate an incident of potential inappropriate interaction for one individual. (Individual #1)
The findings included:
A. Individual #1
1. Staff interview with the Assistant Vice President (AVP) on January 14, 2024, revealed that on December 25, 2023 staff observed and later reported an interaction between staff and Individual #1 that was a potential inappropriate physical interaction. However, the staff did not immediately report the incident. The incident was not reported until January 7, 2024. A formal investigation regarding the incident initiated at that time.
2. A formal investigation was completed on February 2, 2024. However, review of the finalized investigation report document revealed that the report was not comprehensive and detailed in nature. The investigation report lacked specific details regarding disciplinary actions, training, or any corrective actions required to prevent future events.
B. The AVP was interviewed on January 14, 2025 at 11:00 a.m. During the interview the AVP confirmed the above-mentioned findings.
Plan of Correction:W0154 STAFF TREATMENT OF CLIENTS
The deficient area of concern stems from a late report of alleged sexual abuse that occurred on 12/25/23. The findings and conclusion for alleged sexual abuse was unfounded. However, the Facility Action did not address details regarding disciplinary action, training or any corrective actions to prevent future events.
Though the facility contends that no sexual abuse by the alleged perpetrator, the facility failed to provide training for "potential inappropriate physical interaction" that could eliminate future incidents from occurring.
To address the deficient area identified in W154, the facility will implement the following corrective action and systemic changes to prevent future incidents from occurring:
Under the direction of the Assistant Vice President, in conjunction with Clinical and Management Staff, the facility will develop an in-service that differentiates between "appropriate physical interactions versus inappropriate physical interactions".
All existing staff will be in-serviced on "appropriate interactions" and new staff, during orientation, will receive the in-service in preparation to working on the floor.
For example, many of our residents might want a "hug" of a favored staff, and staff will reciprocate with a short "hug", as a "hello or good-bye". Appropriate.
In contrast, Individual #1 is very affectionate, and may seek more extended contact such as "holding hands", "kissing", or extended contact. Inappropriate. Individual #1 is currently on a Personal Space-5: Maintaining appropriate distance when interacting with others.
The objective will be to provide staff with parameters of appropriate physical interactions and touch versus other forms of contact that are inappropriate and should be avoided.
The "Appropriate Physical Interactions-Inappropriate Physical Interactions" will include a written test that will be provided to all staff that can be used as a reference to ensure that the deficient practice identified in W154 does not reoccur.
The facility will monitor the progress of the Plan of Correction within the Monthly Incident Management meetings identifying completion rates as we get to the identified Completion Date.
The Assistant Vice President, in conjunction with the Program Director, Program Manager and Clinical Staff (QIDP/Program Specialists) will be ultimately responsible for ensuring that the plan of correction for W154 Staff Treatment of Clients is completed within the due date and the elimination of the deficient practice.
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