Initial Comments:
A focused fundamental survey visit was completed on October 5 and 6, 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 three, and the sample consisted of three individuals.
Plan of Correction:
483.410(a)(1) STANDARD
GOVERNING BODY
Name - Component - 00
The governing body must exercise general policy, budget, and operating direction over the facility.
Observations:
Based on observations and interviews with facililty and administrative staff, the governing body failed to exercise general operating direction over the facility to ensure the necessary environment to provide for the health, safety of Individuals at this residence.
Findings included:
Observations completed within the facility on 10/05/2023, from approximately 3:30 PM to 5:30 PM revealed the following:
Kitchen
-stove top had dried food in and around the burners and along the back of the stove, the oven had dried grease streaks on the inside and outside of the door
-corners of the cabinet doors are chipped, paint is peeling off, two door cabinets under countertop are loose/crooked
Individuals Bathroom
-bathtub had brownish black debris laying on the bottom.
Individuals #1 and #2 Bedroom
-Individual #2's closet shelving/rod had come off the wall. Some of Individual #2's clothing was piled on a chair, the remainder was placed in two large black plastic trash bags next to the chair.
-carpet stained from doorway around the beds, a trail of brown spots approximately 4" by 4" in diameter
-dirt was built up on the carpet along baseboard
Individual #3's Bedroom
-carpet stained from doorway to bed, five approximately 2" to 3" brown spots, carpet is discolored around the stains
Family Room
-rug in family room is fraying at the entrance from kitchen, stained and dirty marks approximately 8 to 12 inch circular stains.
Interview with the associate director conducted on 10/06/2023, at approximately
11:00 AM, confirmed the above observations and acknowledged that general repairs were needed throughout the residence.
Plan of Correction:C1
The Governing Body will exercise general policy, budget and operating direction over the facility. All maintenance and cleanliness issues will be evaluated by the Senior Executive Director and Associate Executive Director and the Director of Facilities on or before November 17, 2023. Where applicable, items identified will be repaired and/or replaced (see specific items below).
On 10/19/23 a walk through was Completed by Associate Executive Director and House manager and an action plan was developed to address concerns. Upon completion of the action plan the House Manager will submit to Associate Executive Director to verify the completed target dates.
Closet of Individual #2 was repaired on 10/7/23 and all clothes were placed and organized back into the closet.
Bathtub was Cleaned on 10/6/23.
All Bedroom carpets were cleaned on 10/10/23 to remove stains that were on the carpets.
The stove was cleaned and replaced on 10/18/2023.
Rug in the family Room will be removed and replaced by 11/10/23.
A Work order to repair Kitchen Cabinets was placed on 10/19/23.
C2
On or before November 3, 2023, the House Manager will re-train all staff on the Shift Routines to include cleaning responsibilities for each shift to maintain the cleanliness of the home. Training will be documented on a Staff Attendance Sheet (SA) and will be sent to the Associate executive Director for verification.
On or before November 10, 2023, Weekly, the Manager of the house will complete a walkthrough of the home to ensure shift cleaning routines are being completed. The House Manager will submit a Weekly Update form to the Associate Executive Director to include the outcome of the walk throughs and corrective actions if needed and if /when maintenance reports are filed and status of existing maintenance reports. These Weekly Update forms will be completed by the House Manager once a week for three consecutive months and forwarded to the Community Director for verity completion. Thereafter the House Manager will complete electronic maintenance work order whenever maintenance repairs and or concern occur and maintain copies of all work order forms in a binder which will be kept at the site.
C3
House Managers are responsible for ensuring that the staff have all the tools they need to maintain the cleanliness of the home. Each shift has the responsibility of maintaining the cleanliness of the home. House Managers have the responsibility to review the cleanliness of the home daily and to address any issues with the responsible staff. If repairs are needed Staff are to notify the Manager and the Manger is to place a work order for the repair and follow up within 10 days unless it is a Health and Safety Risk within the shift.
When Qualified Intellectual Disability Professionals (QIDP's) are monitoring the homes and note any anomalies such as repairs needed or cleanliness of the home, they are to notify the House Manager within 24 hours. The anomalies are noted on an Observation form and sent to the House Manager as well as the Community Director to address. Cleanliness should be addressed within the shift and Work orders should be submitted within 24 hours unless Health and Safey issues are noted.
C4
On or before November 6, 2023, the Associate Executive Director or designee will complete a bi-monthly walk through of the home to ensure issues of cleanliness and repairs are addressed. Any issues will be addressed with the Manager with the expectation that the cleanliness issues will be addressed within 24 hours. The Maintenance report binder will be reviewed, and any outstanding issues will be addressed with the Maintenance Supervisor for resolution.
On or before November 6, 2023, the QIDP or designee will complete a monthly walk through of the home to ensure issues of cleanliness and repairs are addressed. Any issues will be addressed with the Manager with the expectation that the cleanliness issues will be addressed within 24 hours. All Observations will be documented on observation form and sent to the House Manager, Social Services Supervisor, Community Director and Associate Executive Director for review within 5 days of the review unless it is a health and safety risk it will be reported immediately to the House Manager to address.
C5
The Associate Executive Director will provide summary of all audit outcomes to the Senior Executive Director at the monthly executive meeting regarding home/facility maintenance/cleaning issues.
483.430(a) STANDARD
QIDP
Name - Component - 00
Each client's active treatment program must be integrated, coordinated and monitored by a qualified intellectual disability professional who-
Observations:
Based on record review and interview with the administrative staff, the Qualified Intellectual Disabilities Professional (QIDP) facility failed to ensure that each client's active treatment program is integrate, coordinated and monitored for three of three sample Individuals. This practice is specific to Individual #1, #2 and #3.
Findings include:
A review of the records of Individual #1, #2 and #3 was completed on 10/06/2023 from 9:00 AM to 11:00 AM. This review revealed that the QIDP failed to address Individuals #1, #2 and #3's refusals to participate in their training plans.
Individual #1 is exemplary of this practice.:
A review of the Individual #1's record revealed the following training plans and documentation;
a. To improve tolerance in oral hygiene skills, implemented on 07/02/2023. Individual #1 is currently working on step #2 of this training plan where she is required to allow staff to brush her upper left inner quadrant of teeth using her battery operated toothbrush for 7 seconds on 20/28 days. This training plan is implemented and documented Monday - Friday. A review of the data from 08/01/2023 - 10/05/2023 revealed the following;
August 2023
-Refused to complete this training plan for 10 sessions out of a 24 sessions implemented.
September 2023
-Refused to complete this training plan for 11 sessions out of 21 sessions implemented.
Oct 1 -5, 2023
-No data.
b. To improve bathing skills, implemented on 05/01/2023. Individual #1 is currently working on step #2 of this training plan, where she is required to rinse her right thigh for 30 seconds given hand over forearm assistance on 20/28 days. This training plan is implemented/documented daily. A review of the data from 08/01/2023 - 10/05/2023 revealed the following;
August 2023
-Refused to complete this training plan for 8 sessions out of 31 sessions implemented.
September 2023
-Refused to complete this training plan for 15 sessions out of 29 sessions implemented.
October 1-5, 2023
-Refused to complete this training plan for 1 sessions out of 4 sessions implemented.
c. To improve kitchen skills, implemented on 11/02/2022. Individual #1 is currently working on step #2 where she is required to clean the outer parts of the refrigerator door for 25 seconds with hand over elbow assistance on 15/20 days. This training plan is implemented/documented 3 times a week. A review of the data from 08/01/2023 - 10/05/2023 revealed the following;
August 2023
- Refused to complete this training plan for 5 sessions out of 13 sessions implemented.
September 2023
- Refused to complete this training plan for 9 sessions out of 13 sessions implemented.
Oct 1-5, 2023
- Refused to complete this training plan for 4 sessions out of 4 sessions implemented.
d. To improve hair care implemented on 03/24/2022. Individual #1 is currently working on step #5 where she is required to rinse her entire hair for 60 seconds given 7 verbal prompts on 20/28 days. This training plan is implemented/documented Monday - Friday. A review of the data from 08/01/2023 - 10/05/2023 revealed the following;
August 2023
- Refused to complete this training plan for 8 sessions out of 20 sessions implemented.
September 2023
- Refused to complete this training plan for 9 sessions out of 21 sessions implemented.
Oct 1-5, 2023
- Refused to complete this training plan for 2 sessions out of 4 sessions implemented.
3. Further review of the monthly data sheets, for Individual #1. #2, #3, for the months of August 2023 - October 5, 2023 revealed that the QIDP reviewed the data on 08/15/2023 and again on 09/15/2023. There is no documented evidence within Individual #1, #2, and
#3 that the QIDP has addressed refusals to complete their training plans.
Interview with the QIDP on 10/06/2023 at approximately 10:30 AM confirmed that Individual #1, #2 and #3's refusals to participate in their training plans were not addressed although she reviewed the data on 08/15/2023 and again on 09/15/2023..
Plan of Correction:The facility will ensure that each client's active treatment program is integrated, coordinated and monitored by a qualified intellectual disability professional.
#1
On or before 10/30/23 a mini–Interdisciplinary Team Meeting (IDT) will be held for all individuals in the facility to address their total IPP. This meeting will be documented on a mini-IDT form and forwarded to the Associate Executive Director (AED) to verify completion. Any recommendations will be noted and implemented accordingly. Following that, for a period of two months, individual's team will meet bi-weekly to review individual progress related to their goal plans and their total IPP. Following the two months, the teams will meet as necessary. These meetings will be documented on a Bi-Weekly Review form and forwarded to the Associate Executive Director (AED) to verify completion. Any recommendations will be noted and implemented accordingly.
#2
On or before 11/10/23, the Eastern Region Social Services Supervisor (ERSSS)/Designee will re-train the Qualified Intellectual Disabilities Professional (QIDP)/Program Specialist (PS) on the monitoring of progress and lack of progress with active treatment. The training will include whenever there are refusals for over 7 consistent days, the QIDP reviews the data sheet to investigate why there may be refusals or lack of progress and conducts observations to get a clearer picture of why there may be lack of progress or refusal to perform the goal and provide additional training to the staff if needed or a revision to the goal. The training will be documented on an SA sheet and forwarded to the Associate Executive Director for verification.
On or before 11/10/2023 The Social Services Department will in-service all facility staff on the implementation and documentation of the training plans noting that whenever there are refusals, the date, reason, and staff initial should be documented on the back of the data sheets to give the explanation of the refusals for the QIDP review. The training will be documented on an SA sheet and forwarded to the Associate Executive Director for verification.
#3
The QIDP is responsible for monitoring the amount of progress or lack of progress of active treatment. During the monitoring process using the form, "Active Treatment Monitoring" whenever there are refusals for over 7 consistent days, the QIDP reviews the data sheet to investigate why there may be refusals or lack of progress and conducts observations to get a clearer picture of why there may be lack of progress or refusal to perform the goal and provide additional training to the staff if needed or a revision to the goal.
#4
Beginning 11/05/23 and for a period of three months, the House Manager (HM) will audit the current goals for all individuals once a week for three months to address any refusals or lack of progress. Any noted concerns will be addressed accordingly by the appropriate discipline within 7 days. These audits will be completed on Data Flow sheets and initialed by each discipline and forwarded to the Associate Executive Director to verify completion.
Beginning 11/10/23, the QIDP will complete Weekly residential observations for all individuals at the facility for a period of three months. Thereafter bi-monthly for the next 3 months. These will include the review of goal plans as well as the implementation and documentation of individual goal plans. Any issues noted during the observations will be immediately corrected. Copies of the observations will be forwarded to the ERSSS for review and then sent to the AED to verify completion. Copies of the observations will be forwarded to the ERSSS for review and then sent to the AED to verify completion.
#5
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. All corrective actions will be monitored by the positions identified in the above sections which are incorporated herein by reference.
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