Initial Comments:
A focused fundamental survey visit was completed on March 18 and 19, 20024. 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 four, and the sample consisted of two Individuals.
Plan of Correction:
483.460(k)(2) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.
Observations:
Based on observation, record review and interview with facility staff and administration, the facility failed to assure that all drugs, including those that are self-administered, are administered without error for one of three individuals observed during the morning medication administration. This practice is specific to Individual #1.
Findings include:
1. Observations completed at the residence on 03/18/2024 between 7:00 AM and
8:00 AM. When questioned regarding the time of medication administration in the morning,
interview with the overnight staff person at approximately 7:15 AM revealed that she was waiting for the morning staff to arrive to complete this task. Further observation noted that the breakfast meal was served to the Individuals in this residence between 7:35 AM and
7:48 AM. No medications were administered prior to the start of the breakfast meal.
Subsequent observations completed on this same date between 8:30 AM and 8:45 AM
noted that the morning staff was then on site, and medication administration for Individual #1 was completed at that time. The staff person completing this task removed a blister pack containing single 20 mg capsules of Omeprazole (generic for Prilosec), punched out one capsule of this medication and placed it in a small cup with applesauce then spoon fed the medication to this Individual.
In a review of the instructions listed on this blister pack, the following was listed;
Take 1 capsule by mouth in the morning 1/2 hr. before breakfast.
Subsequent review of the Medication Administration record dated 03/2024, and Physician's orders for the three month period from 3/2024 until 6/2024, was completed on 03/19/2024 from approximately 8:45 AM to 11:00 PM. Both documents identified the same order for the use of this medication -20 mg. capsules of Omeprazole- "Take 1 capsule by mouth in the morning 1/2 hr before breakfast."
Interview with the Assistant Health Services Supervisor on 03/19/2024 at 9:40 AM confirmed that Individual #1 should have received this medication as ordered, 30 minutes prior to breakfast.
2. This same staff was then observed removing a bottle from the medication cabinet that was labeled polyethylene glycol 3350 (generic for MiraLAX), This item is powdered substances.
A review of the pharmacy label affixed to the bottle of polyethylene glycol 3350 listed the following instructions : "Mix 17 grams in 8 ounces of water and take by mouth twice daily. If refused, give via G-tube." Subsequent review of the instructions on the this same bottle indicated that the bottle cap is a measurement device, and filling said cap to the line near the top of that cap is equivalent to a 17 gram dosage.
The survey staff then asked the facility staff what dosage of this medication would be administered at this time. This staff replied that the doseage to administer was 17 grams.
This staff person was observed to use a small plastic dosing cup which had varied measurements listed on the side of the cup to include teaspoons, tablespoons and milliliters. There was no measurement indicator expressed in grams listed on this cup.
In further questioning, this staff person stated that she administers two plastic cups of this powdered medication, which is equal to 17 grams, with 8 ounces of water.
The House Manager ,who was nearby, approached the staff person, and instructed the staff person to use the cap on the polyethylene glycol 3350 bottle instead of the clear plastic cup
to measure out 17 mg. of the powder.
When the staff person transferred the powdered medication from the plastic cup to the measuring cap which is equivalent to 17 grams, the contents of the cup was equivalent to 2 capfuls of the medication, 34 grams of powder, representing double the doseage prescribed by the physican for administration in the morning. The facility staff then removed the powdered medication, and re-poured the correct amount into the bottle cap.
Further interview with the Home Manager on 03/18/2024 at approximately 8:50 AM, acknowledged that the amount of medication that Individual #1 would have received without the surveyor intervening would have been twice the amount of the dosage prescribed by the physician.
Plan of Correction:The facility will ensure that the system for drug administration is administered without error.
#1
An incident report was written for individual #1 on 3/18/2024 to address the medication error that occurred due to late administration. The incident was put into EIM.
On 3/18/2024 facility nurse retrained all staff on Individual #1's physician's orders for medication administration process to include the way the medication should be administered. A copy of the training was sent to the Associate Executive Director to verify completion.
The staff who was observed administering medications in the morning was observed on 3/25/2024 and 3/26/2024 by a Pennsylvania Department of Public Welfare (DPW) Practicum Medication Observer administering medications to ensure that dosages administered properly according to the physician's order. The Observations were recorded on a DPW Observation Check list and sent to the Associate Executive Director to verify competition.
#2
On 4/15/2024the facility nurse retrained all staff on Individual's #2through #4 physician's orders for medication administration and how their medications should be administered. A copy of the training will be sent to the Associate Executive Director to verify completion.
On 4/15/2024 the House Manager will retrain all facility med- certified staff on the on the completion of a proper AVS medication pass protocol to include right time and proper administration according to the physician's order. The training was documented on a Staff Attendance (SA) sheet. A copy of the training was also sent to the Associate Executive Director to verify completion within 7 days of completion.
#3
The House Manager completes Monthly MAR reviews and Medication observations for each medication certified staff member. This process must include review of the MAR indicating what proper way the medication should be administered and observation of the administration to verify that staff are administering medication properly. Monthly MAR reviews will be initialed by the House Manger and sent to Nursing upon completion of the MAR cycle. Medication Observations will be Maintained in the employee file. Any anomalies during medication observations will be immediately addressed during the observation and will require another observation within 7 days. Any MAR anomalies will be reported and addressed within 7 days.
C4
Beginning April 15, 2024, the House Manager and Region Nurse will conduct medication administration observations once a week for one month (alternating medication passes at 8a-4p-8p) primarily focusing on the proper way in which the medication should be delivered. The Medication Administration Pass will be documented on a Medication Administration Observation form. Beginning on May 15,2024, the House Manager and Region Nurse will conduct random medication administration pass audit twice during the month (alternating medication passes at 8a-4p-8p) primarily focusing on the consistency in which the medication should be delivered. Thereafter the House Manager will complete random monthly Medication Administration observations for three consecutive months focusing on the consistency in which the medication should be delivered. Any concerns will be addressed through further training or a progressive discipline process.
C5
The Associate Executive Director will be responsible for monitoring the process and reporting any discrepancies and corrective actions taken to the Senior Executive Director at the monthly Director's meetings.
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
and under varied conditions to-
Observations:
Based on record review and interview with administrative staff, the facility failed to hold quarterly evacuation drills under varied conditions of time. This practice is specific to the
first shift of personnel during the time period of 01/2023 through 12/2023.
Findings include:
A review of the facility's evacuation drills for the period from 01/2023 through 12/2023 was completed on 03/18/2024 from approximately 8:50 AM to 9:05 AM. This review revealed that evacuation drills were not varied throughout the extent of the shift as follows:
First Shift Evacuation Drills: Shift time identified as 7:00 AM to 3:00 PM
03/11/2024 1:30 PM
06/16/2024 7:55 AM
09/17/2024 10:33 AM
12/30/2024 2:10 PM
Interview with the Associate Executive Director completed on 03/18/2024 at approximately 9:45 AM, confirmed the above evacuation drills were not varied throughout the first shift of personnel.
Plan of Correction:The facility will ensure that evacuation drills are held under varied conditions of time.
C1
On or before April 15, 2024, the facility House Manager will be retrained on the Evacuation Drills Scheduling Guidelines. The training emphasized conducting evacuation drills at least quarterly for each shift of personnel and under varied conditions. The training provided general guidelines and examples of varying the timeframe that each evacuation drill is conducted across each shift of personnel.
On or before April 15, 2024, the Community Director or designee will retrain all House Managers (HM) on the adherence to Evacuation Drills Scheduling Guidelines. The training will emphasize conducting evacuation drills at least quarterly for each shift of personnel and under varied conditions of time. The training will provide general guidelines and examples of varying the timeframe that each evacuation drill is conducted across each shift of personnel. The training will be documented on a Staff Attendance Sheet to verify completion. The Staff Attendance Sheet will be uploaded to each HM training transcript and electronically stored in the Learning Management System. A copy of the completed training will be forwarded to the Associate Executive Director to verify completion.
C2
On or before April 15, 2024, the HM will conduct an evacuation drill in accordance with the Evacuation Drill Scheduling Guidelines. The HM will use the fire drill form to collect, document, and maintain the required elements of the evacuation drill. The HM will then submit the fire drill form via the electronic Evacuation Drill Verification System (EDVS) for further review/audit by the Community Director/designee. The review/audit will confirm that the HM conducted the evacuation drill in accordance with State and Federal regulations and the agency's Evacuation Drills Scheduling Guidelines.
C3
The EDVS will be used to collect, review, and maintain the required elements of the evacuation drill. Upon completion of the evacuation drill and by the 15th day of the month, the HM will submit a copy of the evacuation drill to the EDVS for review. The Community Director (CD) will receive an automated email from the EDVS notifying him of a new evacuation drill submission. Upon receipt and by the 20th of the month, the CD will review the evacuation drill to ensure all required elements have been met including verifying that the evacuation drill was conducted at different times of the day and under varying conditions as set forth in the Evacuation Drills Scheduling Guidelines. After review, the CD will either approve or reject the submitted evacuation drill. If the evacuation drill is found to be unsatisfactory, it will be rejected, and the CD will direct the HM to repeat the evacuation drill within seven days and until it meets the requirements in accordance with State and Federal regulations in addition to the agency policies and protocols. Any concerns noted will be addressed with further training and/or employee counseling and corrective action. The EDVS audits will serve as the means to monitor that the corrective actions remain effective.
C4
On a monthly basis by the 28th of the month, the Associate Executive Director (AED) or designee will audit all approved evacuation drills within the EDVS. The audit will confirm that all approved evacuation drills are conducted under various conditions and timeframes pursuant to the Evacuation Drills Scheduling Guidelines, and in accordance with State and Federal regulations. During the AEDs review, if concerns are identified with the varied conditions and/or the Evacuation Drills Scheduling Guidelines were not followed, the AED will require that another drill is conducted to maintain compliance with State and Federal regulations and agency policy. Any anomalies will be addressed with training and employee counseling and corrective action.
C5
The AED will present a summary of all audit outcomes to the Senior Executive Director at the monthly executive operations meeting chaired by the Senior Executive Director, who will address any outlying issues with systemic corrective actions.
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