A focused fundamental survey visit was completed on March 22 and 23, 2021. 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 six, and the sample consisted of three individuals.
Plan of Correction:
Name - Component - 00
Nursing services must include, for those clients certified as not needing a medical care plan, a review of their health status which must be on a quarterly or more frequent basis depending on client need.
Based on record review and interview with the administrative staff, the facility failed to ensure that nursing services perform a review of individual health status by direct physical examinations on a quarterly basis for three out of three sample Individuals. This is specific to Individual #1, #2 and #3.
A review of the records for Individuals, #1 , #2 and #3 was completed on 03/23/2021 from 7:30 AM until 11:00 AM. These reviews revealed that the facility nurse failed to conduct a review of each of the individual 's health status by direct physical examination on a quarterly basis. Individual #3 is exemplary of this practice:
Individual #3 :
A review of Individual #3's record revealed that the health status quarterlies completed for this Individual, dated, 05/19/2020, 08/11/2020 and 11/03/2020,and 1/26/2021 contained the following statement: "unable to assess due to COVID - 19 for pulse and respiration and blood pressure". In further review of this quarterly health status assessment, it was noted that
all other body systems were documented as being assessed.
When questioned regarding the ability of the facility nurse to complete assessments for all body systems with the exception of pulse, respiration and blood pressure, ..."due to COVID-19 "
interview with the qualified intellectual disabilities professional (QIDP) on 03/23/2021 at approximately 9:15 AM, revealed that this interviewee was unable to indicate how this review was conducted / completed.
Interview with the residential director ICF on 03/23/2021 at 9:30 AM confirmed that the individuals did not receive a direct physical examination performed by the facility nurse for the four quarters listed above. Continued interview with the residential director revealed that the nurse manager, who has oversight of the facility nurse, was unaware that the facility nurse was not conducting the direct physical examinations on a quarterly basis and that the quarterly examinations should have been completed.
Plan of Correction:
1. The facility nurse that failed to conduct a review of each of the individual 's health status by direct physical examination on a quarterly basis is no longer with the agency. The nurse is not eligible for rehire. Documentation is the associate file for the nurse in the Human Resources department.
2. The ICF Program Director will retrain the Nursing Supports Manager and once hired, the facility nurse, on the requirement that the facility nurse must conduct a review of each of the individual 's health status by direct physical examination on a quarterly basis. The physical examination must be thorough and include an assessment completed on site by the nurse that includes vital signs and a physical assessment of the individual. The results of the vital signs and the assessment will be documented and shared with the team. Documentation will be on the ICF Nurse Direct Assessment Requirement Training Form.
3. The ICF Program Director will retrain all facility nurses on the requirement that each facility nurse must conduct a review of each of the individual 's health status by direct physical examination on a quarterly basis. The physical examination must be thorough and include an assessment completed on site by the nurse that includes vital signs and a physical assessment of the individual. The results of the vital signs and the assessment will be documented and shared with the team. Documentation will be on the ICF Nurse Direct Assessment Requirement Training Form.
4. Once per month, the facility nurse, or another assigned nurse, will personally complete vital signs and a direct physical examination for each individual residing in the home. The completion of the vital signs and direct physical examination will be documented. Documentation will be the ID note completed by the nurse to document the assessment and vital signs.
5. Once per quarter, the facility nurse, or another assigned nurse, will complete the nursing section of the 90 Day Review, and at the year mark, the Individual Program Plan, and include the results of a direct physical assessment that includes vital signs taken by that nurse. The completion of this document will occur no more than 90 days from the completion of the last document. The facility nurse will submit the completed 90 Day Review / Individual Program Plan to the Nursing Supports Manager within two business days of the meeting. Documentation will be the 90 Day Review and the Individual Program Plan.
6. The Nursing Supports Manager will review the 90 Day Review / Individual Program Plans that are received from the facility nurse immediately upon receipt. The Nursing Supports Manager will ensure that a direct physical assessment is documented as occurring in the 90 Day Review / Individual Program Plan and that vital signs were taken. If a direct physical assessment did not occur or vital signs were not taken, the Nursing Supports Manager will immediately ensure that these are completed and that performance management steps are taken. Documentation will be the 90 Day Review / Individual Program Plan.
7. Once per month, the ICF Program Director will review all ID notes completed by the nurse to document direct physical assessments and any 90 Day Reviews / Individual Program Plans that occurred that month to ensure that all required direct physical assessments and vital signs were completed as required by the facility nurse. Any missing direct physical assessments will immediately be brought to the attention of the supervisor of the facility nurse so that the direct physical assessment can immediately occur and so that performance management steps can be taken. Documentation will be the Direct Physical Assessment Tracking Form.
8. All Documentation will be kept in a Plan of Correction binder in the ICF Program Director's office.