Initial Comments:
A focused fundamental survey visit was completed on December 9 and 10, 2024. 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 three individuals.
Plan of Correction:
483.460(k)(2) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.
Observations:
Based on observation, interview with facility and administrative staff, and review of facility records, the facility failed to ensure that drugs are administered without error for one of three sample Individuals. This practice is specific to Individual #3.
Findings include:
1. During morning observations completed on 12/09/2024 between 7:30 AM until 9:00 AM revealed that Individual #3 returned from her bloodwork appointment at approximately
8:45 AM. Indivdual #3 walked to the dining room table to take her medication and eat her breakfast. Staff proceed to the closet in the living room, next to the front door, and unlocked the closet door to remove both the medication blister packs and the medication administration record. Staff then walked into the kitchen and retrieved two glasses and a pitcher of water and a sepereate pitcher of milk. Staff assisted Individual #3 with pouring water and milk into separate glasses, and then the staff proceed to punch out this Individual's medication of Levothyroxin [synthroid] from the blister pack.
Staff was observed to spoon fed this medication to Individual #3 at 8:55 AM.
Staff then went into the kitchen and retrieved a box of cereal, a bowl and utensils and placed the items in front of Individual #3. Individual #3 poured her cereal and milk into the bowl with staff assistance and proceeded to independently eat her breakfast at 8:58 AM, three minutes after taking her medication.
2. A review of Individual #3's record was completed on 12/10/2024 between 9:00 AM and 10:00 AM. this review noted a 90 day Physician's order dated 9/13/2024 which stated the following ; Levothyroxin [synthroid] tablet 17.5 mcg - take 1 tablet by mouth six times a week (Monday-Saturday). Take on empty stomach 30-60 minutes before food.
Interview with facility nurse on 12/10/2024 at approximately 10:30 AM confirmed that the medication of Levothyroxin [synthroid] is ordered to be given on a empty stomach 30 - 60 minutes before eating. This interviewee also confirmed that the administration of this medication on 12/09/2024 was not in accordance with the current Physician's order as written.
Plan of Correction:CE1 By 12/23/2024, the Director of Nursing contacted the pharmacy to change the medication administration time from 8:00am to 6:30am, so that the medication is administered 30-60 minutes prior to breakfast. The Nurse Case Manager re-trained all staff on the special instruction for the medication, including if the medication is held for morning blood work, that the individual #3 does not eat until 30-60 minutes after the medication is administered. This training occurred by 12/30/2024.
CE2 By 12/23/2024, the Nurse Case Manager checked all medications for all individuals in the home and no one has special instructions to hold breakfast for 30-60 minutes after administering a medication or any other special instructions.
CE3 On 12/10/2024, all staff were retrained by the Nurse Case Manager to follow medication special instructions and to hold Individual #3 breakfast for 30-60 minutes after administering the medication, including when medications are held for bloodwork. By 12/23/2024, the Nurse Case Manager posted special instructions in the front of the Medication Administration Record, explaining the need to hold food for 30-60 minutes after taking the medication, including when medications are held for blood work . If any medications has a special instruction, the Nurse Case Manager will post the special instruction in the front of the Medication Administration Record to alert staff to the Special Instruction.
The Director of Case Management will add to Individual #3 Personal Training Plan the special instruction for the medication by 12/26/2024. The new Training Plan will be trained to all staff by the Qualified Intellectual Disability Professional by 1/6/2024.
CE4 The Operations and Qualified Intellectual Disability Professional Team will complete medication observation weekly for 6 weeks to ensure medications are given at the correct time and following special instructions. The observations will be documented on the Medication Administration Observation form. Quality Improvement and leaders will complete unannounced Rounding. At the Rounding, medications may be observed to ensure that they are administered according to the label and following any special instructions. If any mistakes are noted when administering medications either during an observation or a rounding, the leader will stop the person administering medications and provide immediate feedback to correct the situation . The feedback will be documented on the Medication Administration Observation or Rounding Form. The Medication Administration Observation and Rounding Forms will be sent to the Sr. Director for review. The Sr. Director will forward the Forms to the Quality Improvement Director who will place the Forms in electronic files in Teams for tracking.
CE5 The Executive Director is responsible for monitoring the corrective actions starting 12/26/2024 and ongoing. If the corrective action is not implemented the Executive Director will follow-up with any leaders not meeting expectations. Training and progressive disciplinary action will be implemented if needed.
483.480(a)(1) STANDARD
FOOD AND NUTRITION SERVICES
Name - Component - 00
Each client must receive a nourishing, well-balanced diet including modified and specially-prescribed diets.
Observations:
Based on observations, record review and interview nursing staff, the facility failed to ensure that each individual receive a nourishing, well-balanced diet including modified and specially-prescribed diets for one of three sample individuals who is on a 1200 calorie diet to promote weight loss. This practice is specific to Individuals #2.
Findings include:
1. Observations completed on 12/09/2024 at 5:30 PM, revealed dinner included chicken parmesan patties, spaghetti and broccoli. Staff placed the bowl of spaghetti next to Individual #2 and handed her the tongs to use to pick up the spaghetti. Individual #2 took two servings of spaghetti, placing it on her plate, filling two thirds of the plate with the spaghetti. Staff present did not instruct Individual #2 to take less spaghetti. Next,
Individual #2 was given the bowl of broccoli and she took three scoops using the serving spoon and placed the broccoli on her plate. Next, the bowl of chicken parmesan patties was placed next to Individual #2. Staff directed her to take two pieces which were approximately three inches in diameter. After the last Individual at the table served themselves the chicken parmesan patties, the bowl was placed on the table to the right of Individual #2.
Individual #2 was observed picking up the serving spoon in the bowl with the two remaining pieces of chicken parmesan after the Individuals had served themselves. Without being seen by the four staff in the dining room, Individual #2 picked up the serving spoon and took a third piece of chicken parmesan pattie, placing it on top of her spaghetti with the yet uneaten pieces from the first two chicken patties remaining on her plate. Approximately five minutes later, Individual #2 removed the last piece of chicken parmesan from the bowl with the serving spoon. This surveyor informed the Supervisor that Individual #2 had just served herself a third and fourth piece of chicken Parmesan. Staff did not direct Individual #2 to remove the fourth piece of chicken Parmesan from her plate. This surveyor observed Individual #2 consuming the four chicken parmesan patties and broccoli on her plate leaving the spaghetti.
2. A review of the menu on 12/09/2024 at approximately 4:30 PM, revealed a document titled Fall/Winter, House, Cycle 2, 2000 Calorie Menu. This chart included the period Sunday Breakfast, Lunch and Dinner through Saturday Breakfast, Lunch and Dinner and also include an Alternate for breakfast, lunch and dinner should an Individual want something other than what was being served on that day. For Monday dinner on the date of 12/09/2024, the following food and drink items were on the menu:
-3 ounce chicken parmesan
-1 cup whole wheat spaghetti with red sauce
-1 cup zucchini
-1 cup low-fat milk
-decaf coffee/tea
-1 piece of fresh fruit or 1/2 cup canned fruit
-water
Interview with the direct care staff preparing the dinner meal on 12/09/2024 at approximately 4:35 PM, revealed broccoli was substituted for zucchini. Additionally, this interviewee confirmed that this menu is followed for all Individuals in the home. In further interview, there was no other information available for diets that were of a lesser caloric value then 2000 calories.
3. A review of Individual #2's record was conducted on 12/10/2024 from approximately 8:45 AM to 10:00 AM. This review revealed a 90 Day Physician's Order dated 09/13/2024 which included the following diagnosis: Obesity, Type 2 Diabetes, and Hyperlipidemia (high cholesterol). This document also revealed the following prescribed diet: 1200 Calorie, thin liquids, regular house diet (heart healthy), diabetic (carbohydrate controlled), no concentrated sweets (limit juice, no extra sugar), 100 calorie bedtime snack with sugar-free beverage.
A review of Individual #2's nutrition assessment dated 11/11/2024 revealed Individual #2 weighed 134 pounds, is 4 feet 11 inches tall, ideal body weight is 97 pounds, with a body mass index of 27 (overweight). Nutrition diagnosis is overweight with intended weight loss. This report also reiterated the prescibed diet as 1200 calories.
In a of monthly weight documentation for Individual #2 for the period January 2024 through December 2024, this review revealed revealed an average weight of 134.4 for the twelve month period, fluctuating in weight from a low of 133 pounds to a high of 135.7 pounds.
4. Interview with the facility nurse on 12/10/2024 at approximately 9:30 AM revealed that staff are to monitor Individual #2's intake to ensure compliance with her prescribed diet. In further discussion, this interviewee did confirm that there was no measurable weight loss through the year of 2024. However, this interviewee was unable to explain why this information had not been reviewed or shared with either the primary care physician and/or the intuitionist in order to either change or evaluate the effectiveness of the current diet protocol.
Interview with the Director of Quality Improvement on 12/10/2024 at approximately
9:45 AM confirmed that staff are trained to monitor dietary intake during the course of the various meals in order to assure compliance with each Individuals prescribed diet. This interviewee was unable to indicate why staff who were observed during the evening meal on 12/9/2024, did not intervene when Indvidual # 2 had served herself multiple servings of various food items. This interviewee also confirmed that the diet menus in this residence do not contain an outline for the diet of 1200 calories specific to Individual #2.
Plan of Correction:CE1 The Operations Manager will retrain all staff on Individual #2s diet orders and menus starting 1/3/2025. The diet order will be added as a Support by the Qualified Intellectual Disability Professional by 12/27/2024. This new support will be in-serviced to all staff by 1/3/2025. The Support will include to encourage Individual #2 to make healthy choices. A Special Team Meeting will occur by 1/3/2025 to discuss if Individual #2 needs a Behavior Support Plan to address following her diet orders.
CE2 The Operations Manager will retrain all staff on all diets utilizing correct menus by 1/6/2025. The training will be documented on an In-service sign-in form.
CE3 The Dietician placed all menus with the corresponding diets/portion sizes in the electronic Teams file by 12/27/2024 so that leadership has access to the files if the original menus happen to get misplaced. The Site Supervisor was trained by the Director of Operations on the placement of the menus and the need to complete meal observations at least weekly by 12/27/2024. The Site Supervisor will observe 1 meal per week and document the observation on the Meal Observation form. If she observes that a prescribed diet is not being followed, she will correct the staff in the moment. Continued failure of staff to implement prescribed diets could result in progressive disciplinary action. The completed Meal Observation forms will be sent to the Director of Operations for review, then forwarded to Quality Improvement for further review and tracking.
CE4 Meal observations will be completed by the Operations Manager, the Director of Operations or the Qualified Intellectual Disability Professional at least weekly for 6 weeks to observe that the prescribed diets are being followed. This observation will be documented on the Meals Observation form. The meal observations will be sent to the Sr. Director for a review and Director of Quality Improvement to be filed in Teams for further review and tracking. If a diet is not followed, the leader will complete immediate corrective actions and re-training. Corrective disciplinary action may occur for continued non-compliance in this area. The Quality Improvement department completes a visit at least quarterly to observe the implementation of policies as written. If they observe that a prescribed diet is not being followed, they will document the incident on the Rounding Tool and correct the staff person in the moment. The Rounding Tool will be sent to the Sr. Director for further review and stored electronically in Teams by the Quality Improvement Director for tracking purposes.
CE5 The Executive Director is responsible for all individuals to obtain prescribed diets by 1/6/2025 and on-going Failure to comply with this plan of correction and providing the corresponding documentation may lead to retraining and progressive disciplinary action.
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