Initial Comments:
A special monitoring survey visit was completed on December 1, 2023. 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 seven, and the sample consisted of seven Individuals.
Plan of Correction:
483.440(c)(7) STANDARD
INDIVIDUAL PROGRAM PLAN
Name - Component - 00
A copy of each client's individual plan must be made available to all relevant staff, including staff of other agencies who work with the client, and to the client, parents (if the client is a minor) or legal guardian.
Observations:
Based on record review and interview with administrative staff, the facility failed to ensure that a copy of each client's individual program plan is available to all relevant staff, including staff of other agencies who work with the client, and to the client and legal guardian. This practice is specific to Individual #1, #2, #3, #4, and #5.
Findings included:
1. A review of the records of Individual #1 through 7 was completed on 12/01/2023 from
8:30 AM to 11:00 AM. This review revealed the following information:
Individual #1
A review of Individual #1's record revealed that the current Individual Program Plan dated 11/03/202. When questioned if this was the current plan in place for Individual #1, interview with the Qualified Intellectual Disability Professional (QIDP) completed on 12/01/2023 at 9:40 AM, indicated that the current Individual Program plan for this Individual was completed on 10/26/2023. As of the date of this survey,12/01/2023, the current Individual Program Plan was not available within this Individual's record for staff to review.
Individual #2
A review of Individual #2's record revealed that no Individual Program Plan was in the record. When questioned what is the date of the current plan in place for Individual #2, interview with the QIDP completed on 12/01/2023 at 9:40 AM, indicated that the current Individual Program plan for this Individual was completed on 07/26/2023. As of the date of this survey, 12/01/2023, the current Individual Program Plan was not available within this Individual's record for staff to review.
Individual #3
A review of Individual #3's record revealed an Individual Program Plan dated 05/26/2022.
When questioned if this was the current plan in place for Individual #3, interview with the QIDP completed on 12/01/2023 at 9:55 AM, indicated that the current Individual Program plan for this Individual was completed on 05/18/2023. As of the date of this survey, 12/01/2023, the current Individual Program Plan was not available within this Individual's record for staff to review.
Individual #4
A review of Individual #4's record revealed an Individual Program Plan dated 04/21/2022.
When questioned if this was the current plan in place for Individual #4, interview with the QIDP completed on 12/01/2023 at 10:50 AM, indicated that the current Individual Program plan for this Individual was completed on 04/13/2023. As of the date of this survey, the current Individual Program Plan was not available within this Individual's record for staff to review.
Individual #5
A review of Individual #5's record revealed an Individual Program Plan dated 09/29/2022.
When questioned if this was the current plan in place for Individual #5, interview with the QIDP completed on 12/01/2023 at 10:10 AM, indicated that the current Individual Program plan for this Individual was completed on 09/21/2023. As of the date of this survey, the current Individual Program Plan was not available within this Individual's record for staff to review.
2. Interview with the Qualified Intellectual Disability Professional on 12/01/2023 at approximately 9:15 AM revealed that this interviewee acknowledged that the records of the seven Individuals had been in her office since April 2023, thus making them unavailable to staff.
Plan of Correction:1. All program charts for individuals #1-#5 have been reviewed and current IPP's that were not filed in the program charts were filed into the charts on 12/1/23. Current IPP, goal plans, monthlies, and current assessments are completed by the QIDP and then will be filed by the ICF Support Specialist within 30 days of the annual IPP. A program chart review checklist has been created by the QIDP to review that current documentation is filed in the charts. The checklist review includes that a current IPP, current goal plans, current monthlies, IPP invitations, and current assessment are in the program chart on the 5th of each month. The checklist will be done by the QIDP each month, beginning 1/5/24 to ensure the filing of documents has been completed.
2. For remaining individuals #6 and #7 the QIDP reviewed their program charts on 12/1/23. The QIDP filed current IPP's, goal plans, monthlies and current assessments into these charts on 12/1/23. A program chart review has been created for all individuals and will review that the current IPP, goal plans, monthlies and current assessments are in the charts. The ICF Support Specialist will file the completed documents from the QIDP within 30 days of the IPP. The QIDP will complete the checklist by the 5th of each month and if documents are not in the charts they will be filed within 24 hours
3. A monthly Program Chart review checklist has been created for each individual chart. The list includes a review of the program chart and all documents within, including current IPP's, goal plans, monthlies, and current assessments. On the 10th of the month the Executive Director's designee will complete a chart review to ensure that the QIDP's review and filing of documents was completed. The designee will forward the chart review findings to the Executive Director for review.
4. On the 10th of each month the Executive Director's designee will complete a chart review to ensure that the QIDP has in fact completed the initial review and/or filed appropriate documents. The designee will initial on the program chart review checklist and document if anything was not filed. This will be reported to the Executive Director within 24 hours.
5. The Executive Director will review the designee's findings within 3 business days of receipt. If the QIDP has not completed the checklist by the 5th of the month and/or the designee fails to complete the chart review by the 10th of the month the Executive Director will enact the progressive disciplinary system.
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