Initial Comments:
A focused fundamental survey visit was completed on October 16 and 17, 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 five, and the sample consisted of three individuals.
Plan of Correction:
483.420(a)(2) STANDARD
PROTECTION OF CLIENTS RIGHTS
Name - Component - 00
The facility must ensure the rights of all clients. Therefore the facility must inform each client, parent (if the client is a minor), or legal guardian, of the client's medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment.
Observations:
Based on observations, a review of the record, and interview with administrative staff, the facility failed to ensure that an Individual was informed of the use, attendant risks of treatment, and of the right to refuse treatment for one of one sample individual seated in a dining room chair with an attached seat belt. This practice is specific to Individual #2.
Findings include:
Observations of the morning routine from approximately 7:15 AM until 8:30 AM revealed that when this surveyor arrived at the home, Individual #2 was seated at the dining room table for breakfast. Individual #2 was seated in a solid wooden chair with back and there was a black nylon strap with a buckle attached around his waist. This strap was attached to the wooden chair. Individual #2 remained in this chair,with belt attached around his waist, during the entirety of the observation period.
A review of Individual #2's record completed on 10/17/2023 between 9:00 AM and
11:30 AM revealed that there was no documented evidence for the need of a seat belt on Individual #2's dining room chair and that the facility had obtained consents for the use of the restrictive procedure of a seatbelt while seated in a dining room chair.
Interview with the Director of Intermediate Care Facilities on 10/17/2023 at approximately 9:50 AM confirmed that the facility did not obtain consents for the restrictive procedure of a seat belt on Individual #2's chair. This interviewee stated that staff reported that they fastened the seat belt to Individual #2's chair on 10/13/2023 due to him sliding forward in his chair.
There was no indication that staff had reported to the interdiciplinary team the need for the use of a seatblet on th dining chair to provide proper positioning.
Plan of Correction:CE #1: On 10-17-23 at approximately 10am the seatbelt was removed from the chair by the Program Director. A BARC investigation was started on 10/17/23 for Abuse, Unauthorized use of restraint. On 10/26/23 it was confirmed Abuse, Unauthorized use of restraint occurred for Individual #1. The Program Coordinator re-trained all staff on prohibited use of mechanical restraints on10/17/23. Documentation will be THE PROHIBITED USAGE OF ALL MECHANICAL RESTRAINTS FORM.
CE #2: The team will meet to discuss and review all individuals' restrictive procedures to ensure no restriction is being used without proper consents by 11/03/23. This will be documented on INDIVIDUAL SPECIFIC IDT MEETING NOTES.
CE #3: By 11-3-23, a Performance Management step will be completed for the Home Supervisor for not following the agency's HRC peer review approval process for restrictive procedures. The Home Supervisor will retake BARC's Individual Rights training, be retrained on how to determine what is considered a restrictive procedure, and how to get proper approval for the restrictive procedure. The Documentation is the file for this worker.
CE #4: Once weekly the Program Coordinator will go to the house unannounced and at random times to ensure no restrictive procedures are being used. Documentation will be the UNANNOUNCED HOUSE OBSERVATION SHEET.
CE #5: Once monthly the Program Director will review all documentation associated with this plan of correction to ensure that all training and reviews are occurring as required. Any missing documentation or incorrect documentation will be immediately addressed with the person responsible and documented. Documentation will be via UNANNOUNCED HOUSE OBSERVATION SHEET.
483.460(c) STANDARD
NURSING SERVICES
Name - Component - 00
The facility must provide clients with nursing services in accordance with their needs.
Observations:
Based on record review and interview with facility staff and administration, the facility failed to provide nursing services in accordance with their needs for one of one Indvidual who required a gait belt for ambulation. This practice is specific to Individual #2.
Findings include:
A review of Individual #2 ' s record was completed on on 10/17/2023 from approximately 9:00 AM to 11:00 AM, and revealed the following information:
Home Health Care Notes:
-A review of documents titled [name of agency] Home Health Care: Visit Notes
[specialty, physical therapy] dated; 10/28/2022, 11/02/2022, 11/04/2022, 11/07/2022 and 11/09/2022 revealed that under each dated entry, under the subsection titled, Equipment Recommendations, it was noted "Gait belt for mobility or for ambulation".
Under the section titled: Recommendations, it states, "Continue to promote walking with close supervision."
-A review of a document titled, [name of agency] Home Health Care: Home Instruction Program dated 12/04/2022 revealed that staff should continue to promote functional mobility
for Individual #2 by walking with Individual #2.
-A review a document titled, [name of agency] Home Health Care: Home Instruction Program,dated 12/14/2022 revealed a discharge date from physical therapy as 12/14/2022 with the following recommendations: (1) Staff are to continue to promote functional mobility with supervision and (2) to continue to promote offloading (minimizing or removing weight on a specific area) every 2 hours for maintaining skin integrity.
-Further review of all the above noted documents revealed there was no indication (i.e. signature of physician) that the above recommendations for a gait belt or a 2 hour offloading schedule was reviewed by or presented to Individual #2's primary care physician (PCP).
Interview with the facility nurse and the Director of Nursing on 10/17/2023 at approximately at 10:55 AM and 11:15 AM respectively, confirmed that the recommendations were not presented to Individual #2's PCP and that Individual #2 does not have a gait belt nor a 2-hour offloading schedule.
Plan of Correction: CE #1: On 10/27/23 the house nurse implemented a 2-hour repositioning chart for individual #2 and trained staff on its use. This was documented on a BARC REPOSITIONING TRAINING CHART.
On 10-24-23 a new physical therapy appointment was scheduled by the house nurse for Individual #2 that will occur on 11-2-23. Individual #2 will be re-evaluated for gait concerns and adaptive equipment recommendations, including the need for a gait belt. The house nurse will attend the initial session and the discharge session. An ID note will be sent out the same business day to the team with any new orders. Within one business day, the nurse will send any recommendations to the doctor for review and approval. The staff will be trained on any new orders that are put in place for Individual #2. Documentation will be the ID Notes and Staff Training.
CE #2: The team will meet to discuss the needs of the individuals residing in the homes regarding OT, PT, and speech and determine if there are any unmet needs by 11/03/23. If there are any determined, appropriate steps will be taken immediately. The team will also ensure that each induvial who requires an individual specific protocol has one in place regarding OT, PT, and speech. This will be documented on INDIVIDUAL SPECIFIC IDT MEETING NOTES.
CE #3: Each week the Director of Nursing will review the Medical Appointment Schedule to determine which individuals have PT, OT, or Speech appointments. After any PT, OT, or Speech session, the Director of Nursing will review each visit note to ensure recommendations are being sent to the appropriate doctors. The Director of Nursing will follow up on any concerns or changes with the house nurse and the house nurse will share the information and train the team. Documentation will be the Director of Nursing's signature and date on a copy of the doctor signed PT, OT, or Speech Order.
CE #4: Twice monthly the Program Director will review the Weekly Medical Appointment Schedules, ID notes from all PT, OT, and Speech visits, & the PT, OT, and Speech Orders to ensure that all appointments occurred as scheduled. Additionally, the Program Director will ensure that the appropriate doctor was sent the recommendations and signed orders were received as appropriate. The Program Director will ensure that the Director of Nursing has reviewed and signed the PT, OT and Speech orders. Documentation will be the Program Director's signature on the copy of the doctor signed PT, OT, or Speech Order.
CE #5: Once monthly the Department Director will review all documentation associated with Tag 0331 of this plan of correction to ensure that all training and reviews are occurring as required. Any missing documentation or incorrect documentation will be immediately addressed with the person responsible and documented. Documentation will be the Department Director's signature on each form.
483.460(l)(2) STANDARD
DRUG STORAGE AND RECORDKEEPING
Name - Component - 00
The facility must keep all drugs and biologicals locked except when being prepared for administration.
Observations:
Based on observation and interview with facility staff, the facility failed to ensure that all drugs
and biologicals are locked except when being prepared for administration for one of two sample Individuals observed the medication administration process. This practice is specific to Individual #1.
Findings included:
Observations completed on 10/16/2023 from 7:35 AM until 8:10 AM revealed during the medication administration process with Individual #1, the staff person who was administering medications walked out of the office at 7:52 AM, for approximately 30 seconds, leaving Individual #1 sitting in the office with his medication bin containing all prescribed medication on the desktop and the medication closet door open where all other Individual's oral and topical medications are located.
Examples of oral medications in Individual #1's medication bin included Phenobarbital, Lacosamide (vimpat), neurologic and psychoactive medications, and Hydrochlorothiazide for cardiac issues of edema.
Interview with the Director of ICF on 10/17/23 at approximately 10:00 AM confirmed that the staff person should have locked up the medication prior to leaving the office.
Plan of Correction:CE #1: For Individual #1, the contracted agency staff who was responsible for leaving the medication room during medication administration without following proper procedures received a performance management step on 10/19/23. Documentation is the file for this worker. A retraining on locked medications was completed by the PC on 10/17/23. Documentation is the RETRAINING ON MEDICATION ADMINISTRATION: LOCKED MEDS.
CE #2: The Program Coordinator re-trained all staff on medication administration on 10/17/23. Particular emphasis will be paid to ensuring the medication closet and all medications are locked each and every time, except during preparation and administration. This retraining will include the medication storage procedures from the Medication Administration policy. Documentation will be the Medication Administration Training form.
CE #3: Twice weekly the Home Manager will observe randomly selected medication trained staff administer medications. The Home Manager will ensure medication trained staff are following the BARC policy and procedures for locking and storing medications. Any procedures not being followed will be documented and performance management steps will be taken. Documentation will be the MEDICATION OBSERVATION sheet.
CE #4: Twice monthly the Program Coordinator will observe randomly selected medication trained staff administer medications. The Program Coordinator will ensure medication trained staff are following the BARC policy and procedures for locking and storing medications. Any procedures not being followed will be documented and performance management steps will be taken. Documentation will be the MEDICATION OBSERVATION sheet.
CE #5: Once monthly the Program Director will review all documentation associated with this plan of correction to ensure that all training and reviews are occurring as required. Any missing documentation or incorrect documentation will be immediately addressed with the person responsible and documented. Documentation will be via the MEDICATION OBSERVATION sheet.
483.480(a)(1) STANDARD
FOOD AND NUTRITION SERVICES
Name - Component - 00
Each client must receive a nourishing, well-balanced diet including modified and specially-prescribed diets.
Observations:
Based on observation, record review and interviews with the qualified intellectual disabilities professional (QIDP) and administrative staff, the facility failed to provide each individual with a nourishing, well-balanced diet including modified and specially-prescribed diets for one of one sample individuals who has an outlined dysphagia eating protocol. This practice is specific to Individuals #1.
Findings included:
1. Observation of the morning meal on 10/16/2023 between approximately 7:15 AM and
7:35 AM revealed that when this surveyor arrived at the facility, the Individuals were seated at the dining room table with their breakfast meal in front of them. Individual #1 independently ate his oatmeal, then proceeded to eat his yogurt and pureed fruit in its entirety before spoon eating his honey thick liquids, which was in a bowl. While Individual #1 was eating, the two staff members were at the other end of the dining room table feeding two other Individuals. There was no prompting from staff to Individual #1 during this meal period .
2. A review of the record for Individual #1 was completed on 10/17/2023 between
9:00 AM and 11:30 AM. This review revealed that Individual #1 has a diagnosis of Oropharyngeal Dysphagia with aspiration of all consistency liquids without controlled cup.
A Physician's Order dated 10/16/2023, states that Individual #1's diet is a
" 2000 calories level 1 pureed, honey thickened liquids with use of teaspoon only. Cue to eat and drink slowly and to alternate between food and drink."
Subsequent a review of a document titled "Individual Specific Dysphagia Protocol for [Individual #1]" states the following;
-Requires 1:1 supervision when eating.
-Staff is to assist Individual #1 in maintaining safety by ensuring that Individual #1 eats two spoonful of food or drink at a time and then pause to swallow.
-Staff give Individual #1 verbal prompts to drink after four spoonful of food.
-Staff will give individual #1 verbal cues to slow down, stop after two spoonful and swallow.
-Individual #1 was noted for silent aspiration, so staff should monitor for excessive swallowing during meals. Please report to nursing if Individual #1 is observed swallowing multiple times for the same mouthful of food of Individual #1 is noted with excessive throat clearing.
Interview with the QIDP and Director of ICF on 10/17/2023 at approximately 10:15 AM, confirmed that staff did not implement the dysphagia protocol as outline for Individual #1.
Plan of Correction:CE #1: An official investigation was started on 10/18/23 to determine if neglect, failure to provide the needed supervision for Individual #1 occurred. On 10/26/23 it was confirmed that neglect, failure to provide the needed supervision for Individual #1 occurred. On 10/19/23 a HRC peer review was competed for Individual #1 to eat before or after other individuals, this is to ensure 1:1 supervision for Individual #1 is occurring until he can be re-evaluated. On 10/23/23 Individual #1 was re-evaluated by Bayada Speech Therapist to determine what level of assistance is required during mealtimes to ensure that Individual #1 is eating and drinking as safely as possible. HRC peer review was completed by the Program Coordinator for the restrictive procedures prior to implementation. Documentation is the Investigation Report, HRC Approval, & the Report from Bayada Speech Therapist.
CE #2: By 11-3-23 the team will meet to discuss the meal profiles and ensure that the diets and level of supervision during eating and drinking are up-to date. After any necessary revisions are made by the nurse, the Program Coordinator will retrain the people that work at the house on the specific meal profile for each individual. The Program Coordinator will retrain all people working in the home on the requirement to follow eating protocols for all individuals who have one. This includes proper use of scoop plates and dishes, non-slip mats and all other adaptive equipment prescribed for use by an individual. This also includes any eating protocols for staff to prompt individuals to slow down when eating or drinking and to alternate food and sips of a beverage. Documentation will be the Eating Protocol training sign-in sheet.
CE #3: Twice weekly the HM will do random and unannounced observations to ensure that staff are following all Eating Protocols for all individuals. Observations should occur during different mealtimes. The HM will document observances on the Mealtime Observation Notes and any feedback given to staff will be documented. Twice weekly the HM will submit the Mealtime Observation Notes to the PC for review. Any feedback given by the PC to the HM will be documented on the Mealtime Observation form. Twice a week the Program Coordinator will submit the Mealtime Observation Notes to the Program Director for review. Any feedback given by the Program Director to the Program Coordinator will be documented on the Mealtime Observation form.
CE #4: Twice a month the 2003 Program Coordinator will do random and unannounced observations to ensure that staff are following all Eating Protocols. Observations should occur during different mealtimes. The Program Coordinator will document observances on the Mealtime Observation Notes and any feedback given to staff will be documented. Twice a monthly the Program Coordinator will submit the Mealtime Observation Notes to the Program Director for review. Any feedback given by the Program Director to the PC will be documented on the Mealtime Observation form.
CE #5: Once monthly the Program Director will review all documentation associated with this plan of correction to ensure that all training and reviews are occurring as required. Any missing documentation or incorrect documentation will be immediately addressed with the associate responsible and documented. Documentation will be the Program Director's signature on all forms.
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