Initial Comments:
A fundamental survey visit was completed on August 17 and August 18, 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 four, and the sample consisted of two 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 record review and interview with the qualified intellectual disabilities professional (QIDP) and administrative staff, the governing body failed to exercise general policy and operating direction over the facility in the provision of necessary services to provide for the health of Individuals for one of one sample individual who requires extensive dental services
as documented by dental services. This practice is specific to Individual #1.
Findings include:
1. A review of the record of Individual #1 was completed on 08/18/2023 from approximately 8:45 AM to 11:00 AM. In a review of dental reports and services administered to Individual #1, the following information was noted:
a. A review of a dental appointment reports for the period from 02/2022 through 06/2023 revealed the following information:
- 02/04/2022 ;
"Needs to perform scaling/root planning; likely fillings also. Refer to Surgi-center for comprehensive care under [general anesthesia]."
- 05/18/2022: Consultation: Dental screening: " Needs dental prophylaxis in a hospital setting."
-08/10/2022: " [Individual #1] did not allow exam. Did X-rays then uncooperative. Recommend medical consult with cardiologist and Primary Care Physician (PCP). Depending on results he will either go to Surgi-center or in office visit."
-10/18/2022: "Seen at cardiology. Plan: Okayed for dental cleaning...under routine anesthesia, no restrictions."
-06/06/2023: " Dental Intake Appointment cancelled. Unable to obtain consents from family."
-06/21/2023: " New Patient Evaluation cancelled due to still not receiving consents from mother. ( 2nd cancellation due to same reason ). Next appointment to be announced. "
Interview with the facility nurse was completed on 08/18/2023 at approximately 9:30 AM. This interview revealed that at this time, there have been no further dental appointments scheduled for dental services fort this Individual due to lack of consent from
Individual #1's mother.
b. In a review of a document titled, Mini Interdisciplinary Team (IDT) dated 02/21/2022, the following is listed:
" Individual #1's chair side dental appointment on 02/02/2022 revealed this individual has mild gum inflammation and caries to teeth (specifics as to which and how many teeth were not reported or available)" This report continued by noting this Individual' dental cleaning appointment six months ago indicated fair to poor condition of gums and fair condition of teeth.
c. A review of a document titled, Mini IDT dated 05/25/2022, the following is listed
"On 07/21/2021, it was recommended to schedule a follow up dental appointment with anesthesia in a hospital setting due to medical precautions related to CHARGE syndrome
[ genetic syndrome resulting in heart deficits in addition to area of eyes, heart, nose and intellect].
2. Interview with the Qualified Intellectual Disabilities Professional on 08/18/2023 from approximately 10:00 AM to 10:10 AM revealed that the facility has made multiple attempts to contact Individual #1's mother who is the designated contact, but not legal guardian for Individual #1. In a review of email documents for the period from 05/30/2023 to the date of the survey, 08/18/2023 the following information regarding attempts to secure consent from Individual #1's mother, either by mail, phone calls or visits to house are as follows: are as follows :
-05/30/2023- Individual #1's mother attended an IDT meeting by telephone. There was no indication that the topic of consent for dental treatment for her son was discussed during this meeting.
-06/06/2023 ; no response
-06/13/2023: no response
-06/20/2023 ; no response
-07/17/2023 ; no response
-07/17/2023 : no response
-08/14/2023 : no response
3. Subsequent interview with the Associate Executive Director on 08/18/2023 at approximately 10:15 AM confirmed the above attempts. When asked what is the agency policy when consents are not obtainable, this interviewee provided the agency policy titled, Consent for Emergency Hospital Admission Authorization; Consent for Routine Surgical Diagnostic Evaluation and Treatment Procedures. Under the section titled, Purpose, it states: "To ensure consents are in place for medical treatment."
-Point 1 states: "...forms [for consents] are sent to the designated contact person(s) for signature approximately one (1) month prior to the IDT service plan meeting."
-Point 2 states: "The verbal consent portion of the Consent for Routine Surgical Diagnostic Evaluation and Treatment Procedures forms is used when there is sufficient time to obtain written consent. Two (2) witnesses are required for their verbal consent."
-Point 3 states: "If these consents are not received with in one (1) month from the time they were sent, the QIDP will contact the person verbally and follow up by sending another set of consents.
-Point 4 (a) states: "If the above procedures have proven unsuccessful, QIDP will forward the forms to the Administrator for signature."
In further interview with the Associate Executive Director on 08/18/2023 at approximately 10:15 AM, this interviewee indicated that the Administrator designated within the above policy, is the Vice President of the agency. When asked if that Administrator has been given the forms to sign for dental procedures for Individual #1, this interviewee stated, "No"..
There was no further information regarding the agency attempt to secure alternate consent as outlined in agency policy/procedure in the absence of consent from his mother. for long standing dental treatment needed for Individual #1
Plan of Correction:The governing body must exercise general policy, budget, and operating direction over the facility.
The governing body of the facility will ensure to exercise general policy and operating direction over the facility in the provision of necessary services to provide for the health of individuals. This will be accomplished through the following:
CE#1
On or before September 15, 2023, a protocol will be developed by the governing body to address failure to obtain consent when there are family members or legal guardians who sign on behalf of an individual for dental procedures. Governing Body will be trained on the new protocol once developed. Training will be sent to the Associate Executive Director to verify completion.
On August 29, 2023, the Eastern Region Social Services Director requested consent on behalf of individual #1 from the VP of IDD for dental services. Once consent is obtained Individual #1 will be scheduled within a week for dental services.
CE#2
On or before September 15,2023 the Qualified Intellectual Disabilities Professional (QIDP)will review all the remaining individuals in the facility for current obtained consents to ensure in compliance. Any anomalies will be addressed within 7 days of discovery.
CE#3
Family members and Legal Guardians are sent initial dental consents and clearances by the Nursing Department prior to previous exam's expiration. If not returned the nursing department within 2 weeks, they will resend dental consents and clearances a second time and a call will be placed to the family or legal guardian by the nursing department in conjunction with the QIDP to verify receipt of consents and a case note will be written to document the attempt to obtain the consent.
The QIDP will reach out to the Supports Coordinator to assist with obtaining consents if unsuccessful.
If consents are not received within one week of second attempt the nursing department will send out a certified letter containing consents for signature. If the consents are not received in one week the nursing department will get two opinions from the dentist and the PCP indicating that the individual needs the dental exam and still unsuccessful the QIDP has a team meeting and then forwards the documented attempts, and documents/consents to the Merakey legal team for review and then to the VP for IDD services to sign on behalf of the individual.
CE#4
As of August 23, 2023, the Dental Coordinator/Medical Administrative Assistant will conduct a monthly meeting with the Nursing Department, Social Services Department and Residential Services for the next 6 months. Meetings will include, but are not limited to, Reason for out of compliance, status and plan. Any noted concerns will be addressed accordingly by the appropriate discipline within 7 days. Meeting minutes will be sent to the Associate Executive director for verification.
CE#5
The Health Services Supervisor/designee and the Associate Executive Directors will review meeting minutes to monitor the process. Any anomalies will be brought to the attention of the Sr. Executive Director at the monthly Director's meeting.
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 and third shift of personnel during the time period of July 2022 thorough June, 2023.
Findings include:
A review of the facility's evacuation drills for the period from 07/2022 through 6/2023 was completed on 08/17/2023 from approximately 7:50 AM to 8:05 AM. This review revealed that evacuation drills were not varied throughout the extent of the shift as follows :
First Shift Evacuation Drills: shift time 7:00 AM to 3:00 PM
09/11/2022 10:50 AM
12/10/2022 2:28 PM
03/11/2023 10:25 AM
06/12/2023 7:20 AM
Third Shift Evacuation Drills: Shift time 11:00 PM to 7:00 AM
08/01/2022 4:30 AM
11/10/2022 5:10 AM
02/08/2023 11:21 AM
06/07/2023 1:55 AM
Interview with the House Manager on 08/17/2023 at approximately 8:00 AM confirmed
the times were not varied as noted above.
Subsequent interview with the Associate Executive Director completed on on 08/17/2023 at approximately 9:25 AM confirmed that these evacuation drills were not varied throughout the shift of personnel.
Plan of Correction:The facility will ensure that evacuation drills are held under varied conditions of time.
C1
On August 30, 2023, the facility House Manager was 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 September 12, 2023, the Community Director or designee will retrain all House Managers (HM) on the 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 September 15, 2023, 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. Beginning January 1, 2023, the HMs will receive monthly automated email alerts of upcoming evacuation drills for their respective location(s). These alerts will provide HMs with all relevant information about the evacuation drill such as the date due, recommended shift, and suggested timeframe pursuant to the Evacuation Drills Scheduling Guidelines. Since all individuals were affected, these corrective actions stand for both potential and affected individuals.
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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