Initial Comments:
A focused fundamental survey was conducted March 20 and 21, 2024 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 sample consisted of two individuals. Five deficiencies were identified as 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 facility incident report review, it was determined facility staff failed to report two allegations of potential abuse in a timely manner to facility administration for one of four of the individuals residing in the facility. (Individual #3) Findings included:
1. Individual #3
a. Review of a facility investigation report and staff interview revealed an incident of potential verbal abuse involving this individual had occurred on April 2, 2023 at 9:00 am. The allegation was not reported to facility administration until April 2, 2023 at 2:30 pm. via a text message; five and a half hours after the alleged incident of verbal abuse occurred. Interview with the Qualified Intellectual Disabilities Professional (QIDP) on March 20, 2024 revealed the alleged incident of verbal abuse was determined to be inconclusive.
b. Review of a facility investigation report and staff interview revealed an incident of potential use of an authorized restraint July 22, 2023 at 2:30 pm. The allegation was not reported to facility administration until July 23, 2023 at 12:30 am.; one day after the alleged incident occurred. Interview with the QIDP on March 20, 2024 revealed the alleged incident of the use of an unauthorized restraint was determined to be confirmed.
2. The QIPD was interviewed at 4:00 pm on March 20, 2024. During the interview the QIDP confirmed the above-mentioned findings
Plan of Correction:With regard to item 1-a, the facility staff failed to report allegations of potential abuse in a timely manner to facility administration for individual #3. An incident of potential abuse involving this individual occurred on 04/02/2023 at 9:00AM and was not reported until 04/02/2023 at 2:30PM. A certified investigation was completed in regard to this incident and determined inconclusive. All staff were retrained on recognizing abuse, including timely reporting of abuse, on 04/05/2023. There will be an additional training at the April 18, 2024, team meeting. Effectiveness of these interventions will be evidenced by no further incidents of staff failing to report allegations of abuse and neglect in a timely manner to facility administration. The QIDP will have overall responsibility for these interventions.
With regard to item 1-b, the facility staff failed to report allegations of potential abuse in a timely manner to facility administration for individual #3. An incident of potential abuse on 07/22/2023 at 2:30PM was not reported to facility staff until 07/23/2023 at 12:30AM. A certified investigation was completed in regard to this incident and was determined to confirm the use of an unauthorized restraint. All staff were retrained on abuse to include the prompt reporting of abuse, types of abuse (including unauthorized restraints) on 07/20/2023. Effectiveness of these interventions will be evidenced by no further incidents of staff failing to report allegations of abuse and neglect in a timely manner to facility administration. The QIDP will have overall responsibility for these interventions.
483.430(e)(3) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
Staff must be able to demonstrate the skills and techniques necessary to administer interventions to manage the inappropriate behavior of clients.
Observations:
Based on staff interview and one facility investigation report review, it was determined that facility staff utilized a physical intervention that is not an approved behavioral intervention specified in one individual's behavioral support plan. (BSP) (Individual #3)
Findings included:
1. Individual #3
a. The record of Individual #3 was reviewed on March 20, 2024. Individual #3's record revealed Individual #3 presently has a BSP for physical aggression, self-injurious behavior, elopement, and spitting. Individual #3's BSP included proactive strategies, interruption, redirection, and general visual supervision Restrictive physical interventions were not an integral part of the current plan.
b. Staff interview and review of a facility investigation report revealed that on September 27, 2024 at 2:30 pm., one facility staff implemented a physical behavioral intervention that is not authorized in the current BSP. The staff person physically restrained Individual #3's arms by his side and escorted him through the facility into the bathroom. The behavioral intervention used was also not an approved physical intervention technique that the facility trains staff to implement in an emergency. The facility immediately initiated a certified investigation into the incident.
c. Review of the investigation report revealed that the facility had determined that direct care staff had utilized a restrictive behavioral intervention that was not included in the current BSP. The staff member responsible for Individual #3 at that time received retraining and counseling as a result of this incident.
2. The QIDP was interviewed on March 20, 2024 at 4:00 pm. During the interview the QIDP confirmed the staff utilized a physical intervention that is not an approved behavioral intervention specified in the current BSP.
Plan of Correction:With regard to item 1, a certified investigation confirmed an unauthorized restraint had been utilized with individual #3, that was not outlined in the Behavior Support Plan. The staff member responsible was disciplined according to agency policy and retrained on Individual #3's behavior plan on 07/27/2023. All staff were initially trained on Individual #3's behavior support plan on 04/28/2023 and again on 08/17/2023. All staff were trained on the importance of following individual support and behavior plans, this training included approved interventions and redirection techniques for Individual #3. Effectiveness of these interventions will be evidenced by no further incidents of staff failing to follow the approved behavior support plan. The QIDP will have overall responsibility for these interventions.
483.440(d)(1) STANDARD
PROGRAM IMPLEMENTATION
Name - Component - 00
As soon as the interdisciplinary team has formulated a client's individual program plan, each client must receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan.
Observations:
Based on direct observation, staff interview, and record review it was determined that the facility failed to ensure one individual received continuous active treatment opportunities to promote learning and maximize independence. (Individual #3)
The findings included:
1. Individual #3
a. Observations were conducted in the facility on March 20, 2024 from 1:00 pm until 4:30 pm. During these observations Individual #3 would on occasion would get up and walk with staff about the home. During this observation Individual #3 was observed to be sitting most of the time without activities. The individual was also observed laying in his bed with the covers over his head. Staff interactions during this time with Individual #3 was minimal. The staff were not observed to initiate or encourage participation in activities to provide formal or informal teaching.
b. Observations were conducted in the facility on March 21, 2024 from 7:45 am until 10:30 am. During this observation Individual #3 was observed laying in his bed with the covers over his head. Staff interactions during this time with Individual #3 was minimal. The staff were not observed to initiate or encourage participation in activities to provide formal or informal teaching.
c. Although Individual #3 has a designated alternate activity schedule to be followed while he is in the facility, observations revealed that it was not consistently implemented as required in Individual #3's individual support plan.
d. Interview with the QIDP and IDT documentation review revealed that from Individual #3's admission to the ICF there have been three attempts to participate in the day program. Based on lack of progress in engaging in activities and continuous physical aggression directed at others, the day program will no longer accept Individual #3 as a client. The day program utilized is owned and operated by the ICF's agency provider. No alternate day program provider has been provided as of the survey date.
2. An interview was conducted with the QIDP on March 22, 2024 at 10:30 am. The QIDP confirmed the facility failed to ensure one individual received continuous active treatment opportunities to promote learning and maximize independence.
Plan of Correction:With regard to Item 1, it was determined that the facility failed to ensure one individual received continuous active treatment. Three attempts were made for Individual #3 to attend Day Program; however, they were unsuccessful at that time. Individual #3 has been provided a 1:1 staff who is responsible for working with him on active treatment goals during the day. A new goal for Individual #3 will be to enter the community with their staff once a week to learn new social skills and increase independence. This goal has been implemented effective 04/01/2024. A meeting will be set up for April 2024 to develop a transition plan for Individual #3 in order to attempt integration into Martha Lloyd's Day Program. Effectiveness of these interventions will be evidenced by increased opportunities for engagement, learning and independence for Individual #3. The QIDP will have overall responsibility for these interventions.
483.450(e)(2) STANDARD
DRUG USAGE
Name - Component - 00
be used only as an integral part of the client's individual program plan that is directed specifically towards the reduction of and eventual elimination of the behaviors for which the drugs are employed.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure all prescribed behavior modifying medications were included in an individual's program plan. This was noted for one of two individuals in the sample. (Individual #2)
The findings included:
1. Individual #2
a. The record of Individual #2 was reviewed on March 21, 2024. This review revealed physician's orders, dated January 19, 2024. These orders included the following behavior modifying medications: Zyprexa, Buspar, Melatonin, Lexapro and Diazepam.
b. Psychotropic medication reviews were conducted with a psychiatrist on a routine basis within the past year. Documentation of these reviews revealed that on August 8, 2023, Individual #2 was prescribed Lexapro five milligrams (mgs) daily for an increase in anxiety. According to documentation, on September 20, 2023, the Lexapro was increased to 10 mgs daily.
c. Further review of the record revealed a behavior support plan, dated April 20, 2022. Upon inquiry by the surveyor, the facility presented a current behavior support plan, dated October 4, 2023. This plan addressed the following target behaviors: unnecessary physical contact, self-injurious behaviors, and elopement. The behavior modifying medications listed in the plan were Zyprexa, Buspar, and Diazepam. This plan did not include the medication Lexapro.
2. The QIDP was interviewed on March 20, 2024, at 4:00 pm. During the interview, the QIDP confirmed the above-mentioned findings.
Plan of Correction:With regard to item 1, Individual #2 had the following orders for Zyprexa, Buspar, Melatonin, Lexapro, and Diazepam. Lexapro was prescribed for Individual #2 on August 8th, 2023, and increased to 10mgs on Sept. 20th, 2023. Upon review of the behavior support plan dated October 4th, 2023, Lexapro was not listed on the plan. The QIDP is responsible for updating the Behavior Support Plan. Individual #2's Behavior Support Plan was updated on 04/01/2024 to include Lexapro. Human Rights Approval was obtained for the introduction of Lexapro on 08/16/2023. The QIDP was retrained on updating behavior support plans when a new medication is prescribed. Effectiveness of these interventions will be evidenced by updated and accurate Behavior Support Plans. The QIDP will have overall responsibility for these interventions.
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 staff interview and incident report review, it was determined the facility failed to ensure three individuals' medications were administered without error. (Individual's #1, #2 and #3)
Findings included:
1. Individual #1
a. On March 30, 2023, Buspar was omitted.
b. On March 30, 2023, Synthroid was omitted.
c. On April 9, 2023, Dilantin was omitted.
d. On April 9, 2023, Cogentin was omitted.
e. On May 11, 2023, Ofloxacin was omitted.
f. On August 18, 2023, Dilantin was omitted.
2. Individual #2
a. On April 9, 2023, Buspar was omitted.
b. On July 14, 2023, Dilantin was omitted.
c. On August 3, 2023, Buspar was omitted.
d. On April 9, 2023, Claritin was omitted.
3. Individual #2
a. On October 2, 2023, Ativan was omitted.
4. The above-referenced errors resulted in a total of 11 medication administration errors, from March 30, 2023 to October 2, 2023.
5. Interview with the QIDP on March 20, 2024 at 4:00 pm and documentation review indicated the above-referenced individuals did not experience any ill effects as a result of these medication errors.
6. The QIDP was interviewed on March 20, 2024, at 4:00 pm. During the interview, the QIDP confirmed the above-mentioned findings.
Plan of Correction:With regard to Item 1-a and 1-b, Individual #1's Buspar and Synthroid were omitted on 3/30/23. Staff committing the error was retrained by the ICF Supervisor on the ICF/ID Medication Administration Plan and Procedures and the Medication Pass Check List. This check list specifically includes ensuring that medications were compared from MAR to cassette and checking the medication cassette at the end of the pass for each individual to ensure all medications were given. In addition to retraining, staff received an additional practicum to ensure all medication administration procedures are being followed correctly on 04/24/2023. Staff was also disciplined according to agency policy on 04/06/2023.
With regard to item 1-c and 1-d, Individual #1's Dilantin and Cogentin were omitted on 04/09/23. Staff committing the error was retrained by the ICF Supervisor on the ICF/ID Medication Administration Plan and Procedures and the Medication Pass Check List. This check list specifically includes ensuring that medications were compared from MAR to cassette and checking the medication cassette at the end of the pass for each individual to ensure all medications were given.
With regard to item 1-e, Individual #1's Ofloxacin was omitted on 05/11/23. Staff committing the error was retrained by the ICF Supervisor on the ICF/ID Medication Administration Plan and Procedures and the Medication Pass Check List. This medication was a traveling medication that gets sent back and forth to Day Program; however, on this date, the medication did not come home with Individual #1. MAR to ensure all medications are accounted for. On 2/16/24, a contract was signed with Tarrytown Pharmacy. As of April 1, 2024, the pharmacy now separates Day Program Medications from Residential Medications to avoid medications having to be carried back and forth. A blister pack will be sent to Day Program monthly for Individual #1 and any other individual who takes a medication during the day. This intervention will benefit Individual #1 and all other individuals as evidenced by no further medication errors due to failure to transport medications to and from the day program. The Health Services' Supervisor will have the overall responsibility for monitoring this intervention.
With regard to Item 1-f, on 08/18/23, a Dilantin 100mg capsule was found behind Individual #1's chair in the living room. Individual #1 takes Dilantin 4x daily. It is unknown how long the pill had been on the floor or how it got there. Individual #1 had been receiving medications in the living room due to an injury. Medication Passers were retrained by the ICF Supervisor on making sure to check individuals' mouths after each medication pass to ensure that they have swallowed all the medications given. All medication passers will be reminded at the team meeting on April 18, 2024, that all medications should be passed in the medication room. Any exceptions to this must be approved by nursing and additional safeguards put into place to ensure medications are not spit out or dropped. The Health Services' Supervisor will have the overall responsibility for monitoring this intervention.
With regard to Item 2-a, Individual #2's Buspar and Claritin was omitted on 04/09/23. Staff committing the error was retrained by the ICF Supervisor on the ICF/ID Medication Administration Plan and Procedures and the Medication Pass Check List.
With regard to Item 2-b, individual #2's Dilantin was omitted on 07/14/23. Staff committing the error was retrained by the ICF Supervisor on the ICF/ID Medication Administration Plan and Procedures and the Medication Pass Check List.
With regards to 2-c, individual #2's Buspar was omitted on 08/03/23. Staff committing the error was retrained by the ICF Supervisor on the ICF/ID Medication Administration Plan and Procedures and the Medication Pass Check List.
With regard to Item 3-a, individual #2's Ativan was omitted on 10/02/23. Staff committing the error was retrained by the ICF Supervisor on the ICF/ID Medication Administration Plan and Procedures and the Medication Pass Check List, which includes specifically ensuring that medications were compared from MAR to cassette to ensure all medications are administered, also checking the cassette at the end of the pass for each individual, to ensure all medications are given for the time/day. Staff was also disciplined according to agency policy on 10/3/2023.
Medication Errors were discussed with all staff at the October 19, 2023, team meeting. A new medication administrator was initiated in August 2023 and has taken over the medication administration training courses for employees. A review of the ICF Medication Administration Plan and Procedures will be reviewed with all staff at the April 18, 2024, team meeting. On 2/16/24, a contract was signed with Tarrytown Pharmacy. As of April 1, 2024, we are now receiving pharmacy services through this company. Medications will now come in blister packs that are color coded for the time of day the medication is to be administered. Each blister pack will also have a picture of the medication on the label that can be compared to the MAR. Each blister pack is also labeled with a number on the back of the pack to correlate with the day of the month. This method will better aid medication passers to ensure that all medications were passed for a specific date and time. These interventions will be evidenced by no further incidents of medication errors. The Health Services' Supervisor and Medication Trainer will have the overall responsibility for these interventions.
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