Initial Comments:
A focused fundamental survey was conducted July 17, 18, and 19, 2023, to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I, Requirements for Intermediate Care Facilities. The census during the survey was eight and the sample consisted of four individuals. One deficiency was identified as a 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 investigation report review, it was determined facility staff failed to report two allegations of potential neglect in a timely manner to facility administration for two individuals residing at the facility. (Individuals #1 and #2).Findings included:A. Individuals #1 and #2
1. Review of a facility investigation and staff interview revealed an incident of a potential neglect had occurred on January 13, 2023, on third shift. The allegation was not discovered by facility administration until January 16, 2023, three days after the alleged incident had occurred. Investigation revealed that two Direct Support Professional (DSP) staff working third shift on January 13, 2023, did not complete overnight checks as required.
2. Individual #1's Individual Habilitation Plan states she requires 20-minute checks when out of her wheelchair and 1-hour checks when she is in her wheelchair. Overnight notes/checks were completed by DSPs at 11:20 PM, 1:23 AM, and 7:31 AM. Nurse notes/checks were completed at 11:04 PM, 1:29 AM, and 3:23 AM. 20-minute checks were not completed as required by the DSPs or nurse on duty.
3. Individual #2's Individual Habilitation Plan states she can be left in a room by herself for up to 20 minutes. Overnight notes/checks were completed by DSPs at 12:04 AM, 12:06 AM, and 1:20 AM. Nurse notes/checks were completed at 11:09 PM, 1:33 AM, 2:27 AM, and 6:09 AM. 20-minute checks were not completed as required by the DSPs or nurse on duty.
4. Review of the investigation findings revealed the alleged neglect was confirmed.
5. Facility staff involved were retrained on call procedures as it relates to the Incident Management Bulletin for timely reporting of incidents, potential abuse, and potential neglect.
B. The Qualified Intellectual Disability Professional (QIDP) was interviewed on July 18, 2023, at 11:00 AM. During the interview the QIDP confirmed that the facility staff failed to ensure that all allegations of mistreatment, neglect, or abuse, were reported immediately to the administrator.
Plan of Correction:Plan of Correction:
The incidents of failed reporting in a timely matter noted on Individual #1 and #2
were discussed with responsible staff members.
The Policy and Procedures for Incident Reporting and Management was reviewed and training was
completed by the Program Supervisor. Emphasis on the importance of reporting an incident immediately
when observed to the ON-Call Supervisor and procedural management.
The staff members responsible for the incident of Individuals #1 and #2 are no longer employed with
Community Services Group as a result of our policy and procedures for Incident Reporting and
Management .
The Policy and Procedures for Incident Reporting and Management will be reviewed with all staff
members working at the ICF. The staff will have an updated on- call phone number list of Program
Managers and Program Directors available. In addition, the supervision levels as stated in the IHP for
each individual will be reviewed by all staff members. This review and training will be completed by the
Program Supervisor and monitored by the Program Manager.
Completion Date 07/25/2023
The continual review of the importance of immediate reporting and management at monthly staff
meetings will prevent future incidents on the indicated two individuals', as well as, the rest of the
individuals that reside in the ICF.
The Program Supervisor will be responsible to ensure all 8 Individuals are free of these types of
incidents. The PM is responsible to ensure this process is followed.
CSG will implement the corrective action form when indicated, this will be followed by the Program
Supervisor and monitored by the Program Manager.
Completion Date 07/25/2023
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