Initial Comments:
A focused fundamental survey visit was completed on July 31 through August 2, 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 38, and the sample consisted of 17 individuals.
Plan of Correction:
483.440(b)(2) STANDARD
ADMISSIONS, TRANSFERS, DISCHARGE
Name - Component - 00
Admission decisions must be based on a preliminary evaluation of the client that is conducted or updated by the facility or by outside sources.
Observations:
Based on record review and interview with the qualified intellectual developmental professional (QIDP) and administrative staff, the facility failed to ensue admission decisions are based on a preliminary evaluation of the individual that is conducted or updated by the facility or by outside sources for one of one sample Individual who was a new admission to the Melissa A building. This practice is specific to Individual #1.
Findings include:
A review of the record of Individual #1's record was completed on 08/02/2023 from approximately 9:00 AM to 11:15 AM. This review indicated that Indvidual #1 was admitted to this residence on 11/03/2022. In further review it was discovered that there was no evidence that the facility had either preadmission materials from the discharging facility nor any preliminary evaluation completed by the admitting faiclity that were utilized to make an admission decision regarding Individual #1.
Interview with the QIDP on 08/02/2023 at approximately 10:00 AM confirmed that she did not receive any preadmission materials from the discharging facility prior to Individual #1 referral to this facility for potential admission. This interviewee also acknowledged that this facility did not complete assessments of Individual #1's skills in order for the interdisciplinary team to make an admission decision.
Interview with the Senior Director of Adult Services on 08/02/2023 at approximately
11:30 AM confirmed that preadmission materials were not received from the discharging facility prior to Individual #1's admission to this facility at the Melissa A residence building..
Plan of Correction: 1. How corrective actions will be accomplished for those individuals identified in deficiency statements: Due to individual #1 being previously admitted to Melissa A house, this deficiency cannot be retroactively corrected. The Melissa A House Interdisciplinary Team members consisting of the Qualified Intellectual Disability Professional (QIDP) and other professionals responsible for assessing the needs of individuals in the ICF/ID programs, will complete an evaluation for individual # 1 to ensure that individual # 1 is appropriate for placement in Melissa A house.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice: The Assistant Director of the facility will complete an audit of all admissions that occurred in the past year (07/2022 to 08/14/2023) to ensure that preliminary evaluations were completed prior to individual admission as per the ICF/ID regulatory manual regarding admission decisions. If any individual admissions are discovered to have occurred without preliminary evaluations, the QIDP and the Interdisciplinary Team members will initiate evaluations within 24 hours to ensure any identified individuals admitted without a preliminary evaluation are appropriate for their respective placements. This process will be completed by 08/31/2023.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur: All Interdisciplinary Team members consisting of the QIDP and other professionals responsible for assessing the needs of individuals in the ICF/ID programs, will be trained on the regulation as per the ICF/ID regulatory manual regarding admission, that decisions must be based on a preliminary evaluation of the individual prior to admission to any ICF/ID facility. This training will be conducted by the Director of the facility or designee by 08/31/2023 and will be documented on a Melmark Training log.
Additionally, the ICF/ID Admissions checklist will be used by the Interdisciplinary Team for any future referrals to ensure a preliminary evaluation is completed for any individual who is being considered for admission to any of the ICF/ID Programs.
Once the preliminary evaluation is completed, the outcome of the evaluation will be forwarded to the admissions review committee for a second level review. If the admissions review committee determines that the referred individual meets the ICF/ID admissions criteria the Team will proceed with admission. If the Admissions Review Committee determines that the individual does not meet the ICF/ID admission criteria based on the assessments completed, The Director of the facility or designee will notify the referral source (i.e. county, supports coordinator) of this decision within 2 business days.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: All future referrals for admissions will be reviewed by an admissions review committee that will consist of a healthcare representative, a rehabilitative services representative, a clinical team member, the Director of Adults Programs and the Director of Quality Improvement. The admissions committee will review the ICF Admissions Checklist to ensure the Interdisciplinary Team members completed a preliminary evaluation of the individual being referred for ICF/ID placement. The admissions review committee will document their findings on an admissions review committee recommendation form. If the admissions review committee determines that preliminary evaluations were not completed as per the ICF/ID regulations, the Director of Quality Improvement or designee will notify the same to the IDT members for completion. This process will be initiated beginning 08/14/2023 onwards.
5. Identify by position, who will be responsible for monitoring the corrective action: The Director of the Facility is responsible for the oversight of all corrective action being completed in the appropriate timeline as outlined in the plan of correction. The Director of the facility will be responsible for ensuring the corrective action as outlined above are completed in a timely manner. Additionally, the Director of the facility will ensure continued compliance and oversight of all admission processes moving forward. This process will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, Melmark's disciplinary action policy will be followed.
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 observations and interview with the facility nurse, the facility failed to keep all drugs and biologicals locked except when being prepared for administration for seven of eight individuals. This practice is specific to Individuals # 1, 11, 12, 13, 14, 16 and 17.
Findings include:
Observations completed on 08/01/2023 from approximately 4:16 PM until 4:41 PM revealed that the door to the office where the individuals' medications are kept was fully open. Upon entering this office it was noted that the top double door cabinet, with locks on each door and with keys in the locks, were unlocked. The right cabinet door was open allowing full view of bins filled with medications. The bins were labeled for Individuals #1,
#12, #16 and a bin labeled PRN.
When this surveyor checked the closed left door of the cabinet, this door was also unlocked allowing access to medications in bins labeled for Individual #11, #13, #17 and a forward facing bin with no name.
Examples of medications located in each individual's medication bins are as follows:
Individual #11
-Trazadone HCL 100 mg. for insomnia
-Prozac 20 mg/5ml for anxiety disorder
Individual #12
-Briviact 50 mg for seizures
-Zonisamide 100 mg for seizures
-Hydrochlorothiazide 12.5 mg for blood pressure, edema
Individual #13
-Abilify 15 mg for psychotic disorder
-Klonopin 0.5 mg for unspecified mood disorder
-Aricept 10 mg for downs associated with dementia
Individual #14
-Klonopin 1 mg for seizures
-Lamictal ER 300 mg. for seizures
Individual #16
-Zoloft 100 mg. for generalized anxiety
-Zoloft 25 mg. for generalized anxiety
Individual #17
-Topamax 200 mg. for seizures
-Topamax 50 mg. for seizures
Individual #1
-Tegretol ER 200 mg. for seizures.
This surveyor remained in the area for approximately eight minutes during which only one staff person entered the room during this time period. When that staff person was asked if he was the nurse, he stated, "No". He then picked up a notebook and left the office again leaving the door open, and cabinets unlocked.. At 4:24 PM, this surveyor went to the kitchen area where the individuals and staff were located. Upon entering the kitchen area, the supervisor came into the kitchen area and approximately one minute later, 4:25 PM, the supervisor went to the office where the unlocked medication cabinets were open and shut the door.
At approximately 4:41 PM, when the facility nurse returned to this residence, the surveyor informed the nurse about the medication cabinets being unlocked. The nurse and surveyor walked back to the office and the nurse unlocked the office door. Upon entering the office, the medication doors were locked. The supervisor stated that she had just shut them.
The facility nurse then stated, "OK".
Interview with the facility nurse on 08/01/2023 at approximately 4:43 PM, confirmed that she is aware that medications need to be locked at all times.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements: All nurses in Melissa A House assigned with the task of medication administration will be trained on the standard drug storage expectation to keep all drugs and biologicals locked except for when being prepared for administration to the individuals served.
This training will be conducted by the Director of Nursing or designee and will be documented on a Melmark Training log. This training will be completed for all nurses assigned with the task of medication administration by 08/31/2023.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice: This deficient practice affected all residents of Mellissa A. All nurses and staff in the other facilities with the task of medication administration will be trained on the standard drug storage expectation to keep all drugs and biologicals locked except for when being prepared for administration to the individuals served. This training will be completed by the Director of Nursing or designee and will be documented on the Melmark Training log. The training will be completed by 09/30/2023.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur: The medication administration process will be monitored at varied and random times, twice weekly for the month of August 2023 starting 08/20/2023, then once weekly at varied and random times for the month of September 2023 to assure the standard expectation of all prescribed medications to be kept locked except for when being prepared for administration to the individuals served is adhered to. During the monitoring, in the moment feedback will be provided if needed. Increased observations, at minimum once a week will be maintained at varied and random times for the specific nursing staff who fail to adhere to the standard expectation of all prescribed medications remaining locked at all times except when being administered. If expectations are met consistently, the observations will be faded to a monthly basis and will be completed at varied and random times to ensure continued compliance. This monitoring will be conducted by the Director of the facility or designee and documented on a Melmark Clinical note.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The medication administration process will be monitored on a varied and random schedule at least once a month to assure the standard expectation of all prescribed medications are kept locked except for when being prepared for administration to the individuals served is being adhered to on an ongoing basis. In the moment feedback will be provided during the monitoring if needed and increased observation for any nursing staff who fails to adhere to this expectation. This monitoring will be completed by the Assistant Director of the facility and documented on the Melmark Clinical note. This process will begin by 10/01/2023.
5. Identify by position, who will be responsible for monitoring the corrective action: The Director of the Facility is responsible for the oversight of all corrective action being completed in the appropriate timeline as outlined in the plan of correction. This will be accomplished through monthly meetings to review the status of corrective action completion and continued oversight of the process above. Updates on corrective actions and continued oversight of the above process will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, Melmark's disciplinary action policy will be followed.
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
at least quarterly for each shift of personnel.
Observations:
Based on a review of facility documention and interview with administrative staff,
the facility failed to ensure evacuation drills were conducted at least quarterly for each shift of personnel. This practice is specific to the first calendar quarter of 2023 in Melissa A building and the second calendar quarter of 2023 in Engle building.
Findings included:
A review of evacuation drills for the period July 2022 through June 2023 was conducted on July 31, 2023 from approximately 9:00 to 9:30 AM. This review revealed there were no evacuation drills completed in the following buildings:
-Melissa A building, the first shift of personnel defined as 7:00 AM to 3:00 PM during the first calendar quarter of 2023. .
-Engle building, the first shift of personnel defined as 7:00 AM to 3:00 PM
during the second calendar quarter of 2023
Interview with the Senior Director of Adult Services on August 2, 2023 at approximately 9:20 AM, confirmed the above findings of missing evacuation drills as outlined above.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
Engle and Melissa House will conduct a fire drill on the first shift, defined as 7:00 AM to 3:00 PM. The time of the fire drill will be varied from the previous fire drills conducted in the course of the year. The fire drill will occur any day in the month of October 2023 at 10:00 AM.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
This deficient practice affected all residents of Melissa A and Engle House.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
All Qualified Intellectual Disability Professionals (QIDP) and House Supervisors of both Melissa A and Engle House will be trained on the expectation of fire drills being conducted at least for each shift within a quarter, defined as 7am to 3pm, 3pm to 11pm and 11pm to 7am and held during varied times. This training will be conducted by the Director of the facility and documented on a Melmark Training log by 08/31/2023.
The above training will include a review of the fire drill schedule for the entire year for all facilities. The schedule will indicate the shift that each facility should conduct the monthly fire drill. Each fire drill will be scheduled to occur at varied shifts throughout the year. All QIDP and House Supervisors of the facility will be trained on the fire drill schedule. This training will be documented on the Melmark Training log by 08/31/2023.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: All Assistant Directors of the facilities will be trained on the expectation of fire drills being conducted at least for each shift within a quarter, defined as 7am to 3pm, 3pm to 11pm and 11pm to 7am and held during varied times. This training will be conducted by the Director of the facility and documented on a Melmark Training log by 08/31/2023.
The above training will include a review of the fire drill schedule for the entire year for all facilities. The schedule will indicate the shift that each facility should conduct the monthly fire drill. Each fire drill will be scheduled to occur at varied shifts throughout the year. All Assistant Directors of the facilities will be trained on the fire drill schedule. This training will be documented on the Melmark Training log by 08/31/2023.
The Assistant Director or designee will be trained on how to review fire drills once conducted. The review of completed monthly drills will need to be completed by the 15th date of each month to verify that the fire drill was completed at the scheduled shift and varied time as per the fire drill schedule. If the Assistant Director identifies a fire drill that was not conducted during the correct shift and time, the facility will conduct another fire drill as per the fire drill schedule by the end of the specific month in review. This practice will begin by 08/31/2023
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective actions being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings to review the status of corrective action completion, beginning 09/01/2023. This will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, Melmark's disciplinary action policy will be followed.
483.480(b)(2)(ii) STANDARD
MEAL SERVICES
Name - Component - 00
Food must be served at appropriate temperature.
Observations:
Based on observations and interview with facility staff, the facility failed to serve hot food items at appropriate temperature for seven of seven sample Individuals residing in Spruce A building. This is specific to Individual #2, #5, #6, #7, #8, #9 and #10.
Findings include:
Observations completed on 08/01/2023 from 4:00 PM to 5:45 PM revealed the following;
-At 4:00 PM, this surveyor entered the kitchen/dining room area. On the stove were two large pots, one filled with water and the other empty. To the right of the stove was a glass dish with ten breaded chicken patties piled on top of each other. The dish was not covered.
-At approximately 4:45 PM, the direct care staff person began to cook pasta in one pot and spinach in the other pot. The chicken patties remained next to the stove in the glass dish while the pasta and vegetable was cooking.
- At approximately 5:10 PM, all seven Individuals sat down at the table for dinner.
The breaded chicken patties, pasta and spinach was pureed for Individual #2 and #10 per their prescribed texture diet, and placed in a divided serving plate. Five breaded chicken patties, pasta and spinach were placed in serving dishes for Individuals #5, #6, #7, #8 and #9 with regular texture diets. The dish with the breaded chicken patties were observed sitting on the counter for over 70 minutes, and were not reheated prior to serving.
Interview with the direct care staff on 08/02/2023 at approximately 5:20 PM revealed that the breaded chicken patties had been baked in the oven earlier in the afternoon but did not indicate the time when they were cooked.
Interview with the associate director on 08/01/2023 at approximately 5:35 PM confirmed
that the food should be served hot and not be off the heat source for longer then 15 minutes.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
All Spruce A House staff will be trained that food must be served at the appropriate temperature; hot foods should be served hot. The training will include the need to cover food when food is removed from the heating surface, the expectation for food to be reheated if not immediately consumed and has been out of the heat source for longer than 15 minutes. This training will be conducted by the house supervisor of the facility and will be documented on the Melmark Training Log. This training will occur for all staff in Spruce A House by 08/31/2023.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
This deficient practice affected all residents of Spruce A House. All staff in the other facilities will be trained that food must be served at the appropriate temperature; hot foods should be served hot. The training will include the need to cover food when food is removed from the heating surface, the expectation for food to be reheated if not immediately consumed and has been out of the heat source for longer than 15 minutes. This training will be conducted by the house supervisor of the respective facilities and will be documented on the Melmark Training Log. This training will occur for all staff in the other facilities by 09/30/2023.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
All Qualified Intellectual Disability Professionals (QIDP), House Supervisors, and Assistant Directors will be trained by the Director of the facility to ensure that food is served to the individuals supported at the appropriate temperature; hot foods should be served hot. Food that is not immediately consumed need to be covered and reheated if it has been out of the heat source for longer than 15 minutes.
The QIDP, House Supervisor and Assistant Directors will also be trained to intervene and provide in the moment feedback and reiterate to staff that all meals should be served at the appropriate temperature if they identify a meal is about to be served and has been seating out for more than 15 minutes.
Meal Observations in the home will be conducted on a weekly basis and documented on a Melmark Meal Observation checklist. The QIDP, and House Supervisors will be trained on the meal observation expectations by 08/31/2023. This training will be completed by the Assistant Director of the facility and will be documented on the Melmark Training Log. The Meal observations will occur at minimum; one breakfast, one lunch, and one dinner on a monthly basis. These observations will be conducted by the Speech Language Pathologist (SLP), QIDP, and House Supervisor. This process will begin by 09/01/2023.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
The QIDP, SLP, and House Supervisor will complete random meal observations throughout the course of each month. The completed Meal observation checklist will be provided to the Assistant Director of the facility. The Assistant Director of the facility will then review the Meal Observation Checklist and if any need areas are identified, the Assistant Director of facility will initiate training within 48 hours of their review. This process will begin on 09/01/2023.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective action being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings to review the status of corrective action completion, beginning 09/01/2023. The above will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, Melmark's disciplinary action policy will be followed.
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