Initial Comments:
A focused fundamental survey visit was completed on December 30 and 31, 2020. The prupose 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:
483.440(f)(2) STANDARD
PROGRAM MONITORING & CHANGE
Name - Component - 00
At least annually, the comprehensive functional assessment of each client must be reviewed by the interdisciplinary team for relevancy and updated as needed.
Observations:
Based on a a review of facility records, and interview with the Director of Quality Improvement, the facility failed to review the comprehensive functional assessment (CFA), at least annually, for relevancy and update for one of two sample Individuals. This practice is specific to Individual #2.
Findings include:
A review of the record for Individual #2 was completed on 12/31/2020 between 7:00 AM and 9:00 AM revealed that Individual #2 had a Individual Program Plan (IPP) dated 04/16/2020, and a functional assessment dated 05/19/2019. Further review of
Individual #2's record revealed that the CFA was not reviewed or updated by the interdisciplinary team since that time.
Interview with the Director of Quality Improvement on 12/31/2020 at approximately 8:50 AM confirmed that the CFA was not reviewed and updated, at least annually.
Plan of Correction:CE#1:
The QIDP will review and update the comprehensive functional assessment (CFA) for Individual #2 by 1/15/21 to bring the paperwork into compliance.
-Responsible Person: Director of Case Management
-Date of Completion: 1/15/21
After updating the comprehensive functional assessment for Individual #2, the QIDP will submit the documentation to the Director of Case Management for review and approval.
-Responsible Person: Director of Case Management
-Date of Completion: 1/15/21
Once the Director of Case Management approves the comprehensive functional assessment for Individual #2, a copy will be submitted to the Quality Improvement Department and placed in the POC binder.
-Responsible Person: Director of Quality Improvement
-Date of Completion: 1/22/21
CE#2:
The IPP and comprehensive functional assessment for the other individuals in the home will be reviewed to determine if their documentation were updated appropriately. If any of the documentation is found to be out of compliance, they will be updated as required.
-Responsible Person: Director of Case Management
-Date of Completion: 1/8/21
The Director of Case Management will email the Quality Improvement Department to attest the comprehensive functional assessments for the other individuals in the home were reviewed and the outcome of the review.
-Responsible Person: Director of Quality Improvement
-Date of Completion: 1/8/21
If the comprehensive functional assessments for the other individuals in the home are found to be non-compliant, copies of the updated paperwork will be submitted to the Quality Improvement Department and placed in the POC binder.
-Responsible Person: Director of Quality Improvement
-Date of Completion: 1/15/21
CE#3:
The Director of Case Management created a Master IPP Schedule which is shared with all members of the interdisciplinary team. The IPP Schedule includes a column for the IPP meeting date and the date the IPP paperwork is due to the Director of Case Management for review. The QIDP must submit copies of all IPP packets to the Director of Case Management for review by the date noted on the IPP Schedule (within 14 days after the meeting date).
-Responsible Person: Director of Case Management
-Date of Completion: ongoing
The Director of Case Management reviews all documents in the IPP packet to assure the documentation is in compliance. If the documentation is not in compliance, the Director of Case Management returns the paperwork to the QIDP for correction.
-Responsible Person: Director of Quality Improvement
-Date of Completion: ongoing
The QIDP must return the corrected documents to the Director of Case Management within one business day. If the corrected documents are not returned within one business day, disciplinary action may occur, if warranted.
-Responsible Person: Director of Case Management
-Date of Completion: ongoing
CE#4:
The Director of Case Management enters the date the IPP paperwork packet was received on a tracking document in order to account for all documentation.
-Responsible Person: Director of Quality Improvement
-Date of Completion: ongoing
If the IPP paperwork is not submitted to the Director of Case Management by the due date noted on the Master IPP Schedule, the Director of Case Management follows up with QIDP and issues disciplinary action if warranted.
-Responsible Person: The Director of Quality Improvement
-Date of Completion: ongoing
The Director of Case Management submits an updated copy of the IPP tracker with completed dates received to the Quality Improvement Department on a monthly basis.
-Responsible Person: The Director of Quality Improvement
-Date of Completion: ongoing
CE#5:
The Executive Director of ICFs/IID & Quality Initiatives is responsible for monitoring this corrective action.
-Responsible Person: Executive Director
-Date of Completion: ongoing
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