Initial Comments:
A focused fundamental survey was conducted March 5-7, 2024, to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was six and the core sample consisted of three individuals.
Plan of Correction:
483.440(f)(3)(ii) STANDARD
PROGRAM MONITORING & CHANGE
Name - Component - 00
The committee should insure that these programs are conducted only with the written informed consent of the client, parents (if the client is a minor) or legal guardian.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that human rights committee (HRC) approval was given with the written informed consent of the client, parents or legal guardian. This applied to one (#2) of three individuals in the core sample. Findings included:
A record review for Individual #2 was completed on March 7, 2024. This review revealed that Individual #2 is currently on a behavior plan dated June 7, 2023, that utilizes the medication Zoloft to target depression that manifests by difficulty concentrating, remembering, decreased energy and sleep problems. Individual #2 signed the consent for this plan with the medication Zoloft on June 7, 2023. The HRC signed for approval of this plan on June 6, 2023.
An interview was conducted with the operations director/qualified intellectual disabilities professional (OD/QIDP) on March 7, 2024, at 9:15 AM. The OD/QIDP confirmed that the HRC did not ensure the individual's consent was obtained prior to the HRC giving approval for Individual #2's plan.
Plan of Correction:Valley Community Services will ensure that Human Rights Committee approval is given with the written informed consent of the individual, parent(s), or legal guardian. Individual #2 signed the consent for her behavior plan that uses the medication Zoloft to target depression manifested by difficulty concentrating, remembering, decreased energy and sleep problems. Consent for individual #2's behavioral support plan that has been obtained will be reviewed by the Human Rights Committee by 3/19/24. Consents were reviewed for all other individuals with behavioral supports plans to ensure that Human Rights Committee approval was given with the written informed consent of the individual, parent(s), or legal guardian. To ensure no further infractions occur on 0263, the QIDP will monitor consents for all individuals monthly for one year starting 4/1/24 and ending 3/31/25 to ensure Human Rights Committee approval is given with the written informed consent of the individual, parent(s), or legal guardian. The Quality Management Director will monitor consents quarterly for all individuals for one year to ensure Human Rights Committee approval is given with written informed consent of the individual, parent(s), or legal guardian starting 4/1/24 and ending 3/31/25.
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 observations and interviews, it was determined that the facility failed to ensure that all medications were administered without error. This applied one (#4) of two individuals observed during morning medication pass. Findings included:
Observations of the morning medication pass were completed on March 5, 2024, from 6:22 AM to 6:59 AM. At 6:36 AM, the nurse was observed to prepare the medications for Individual #4. These medications included Vitamin B12 250 micrograms (mcg), and according to the label on the pharmacy pre-packaged medication pack, the nurse was to prepare for Individual #4 to "Take by mouth 1/2 tablet (125 mg) daily at 7AM." The nurse was observed to place a whole tablet from the medication pack into a cup, along with the other medications for Individual #4. At 6:49 AM, the surveyor asked the nurse if Individual #4's medications were ready to be administered, to which the nurse responded, "yes." The surveyor then asked the nurse if Individuals #4's Vitamin B12 250 mcg medication was in a whole tablet form or if it was half of tablet. The nurse examined Individual #4's pharmacy prepackaged Vitamin B12 250 mcg medication and confirmed that it was a whole tablet. The surveyor then asked if the facility nurse is expected to cut the individuals tablets in half, if the physican's order specifies that it be half tablet to which the nurse responded, "no." The nurse then notified on-call and was advised to contact the physician to obtain a medication hold until the facility could clarify the medication order. The medication was held at 6:59 AM.
An interview was conducted with the health services officer (HSO) on March 5, 2024, at 9:35 AM. The HSO reported that she had just spoke with the director of nursing who stated that the pharmacy had packaged the Vitamin B12 for Individual #4 incorrectly. The HSO further stated that Individual #4 had been receiving 250 milligrams of their Vitamin B12 daily since approximately February 15, 2024. The HSO confirmed that had the surveyor not interceded during the morning medication pass, Individual #4's Vitamin B12 would have been administered in error.
Plan of Correction:Valley Community Services' policy is to ensure that all medications are administered as ordered. On 3/5/24 during a Department of Health medication pass observation, the surveyor noted an incorrect dosage was contained in a bubble of a blister packet for individual #4. The medication pass was immediately stopped for this medication for Individual #4 and the physician was notified of the discrepancy. The medication was placed on hold until verification from the pharmacy regarding correct dosage. The dosage was verified as incorrect, and the physician was then immediately notified of the administration of the incorrect dose since February 15th, 2024, further instructions from the physician included monitoring and resuming correct dose on 3/6/24, an investigation was initiated. All nurses involved in the medication error were immediately pulled from passing medications and had a medication pass observation performed to ensure proper medication administration, this was completed by the Director of Nursing by March 7th, 2024. In addition, starting immediately pharmacy policy change will now include placing an orange alert sticker on any blister packet that should contain a one-half tablet in the bubble. The orange alert sticker will state "NOTE ½ TABLET" if indicated. Also, a new procedure was put into place for receiving monthly bulk shipments. All monthly bulk shipments must be checked and initialed by two nurses before being used to ensure accuracy, this will begin with all bulk shipments for March 15, 2024. A training will be done with all nurses on the new protocols for bulk shipments by 3/14/24 by the Director of Nursing. Also a training will be done with all nursing and medication trained staff in regard to the additional orange sticker to be placed on blister packets that should contain one-half tablet as an additional alert when performing the five rights for medication administration. This training will be done by the Director of Nursing and will be completed by 3/31/24. The Director of Nursing will complete monthly monitoring checks for the proper use of the orange alert sticker and the checking of the bulk shipments by 2 nurses for six months ending 9/30/24.
483.470(b)(4)(iv) STANDARD
CLIENT BEDROOMS
Name - Component - 00
The facility must provide each client with individual closet space in the client's bedroom with clothes racks and shelves accessible to the client.
Observations:
Based on observations and interviews, it was determined that the facility failed to ensure all individuals had access to closet space. This applied to one (#4) of six individuals residing at the facility. Findings included:
Observations were conducted at the residence on March 5, 2024, from 3:05 PM until 6:25 PM. An interview was conducted with Individual #2 in their bedroom at 5:45 PM. At this time it was observed that the shared closet in the bedroom was partially blocked on the left side by the headboard of a bed and not fully accessible to the individuals. Individual #2 stated that they were able to access their clothing hanging in the closet on the right side of the closet, but the roommates clothes were located in the closet behind the headboard. Individual #4 was observed to utilize a wheelchair and would be unable to access any of their clothing hanging in the left side of the closet.
An interview was conducted with the program manager (PM) on March 5, 2024, at 6:05 PM. The program manager stated that the beds were recently moved around in that bedroom to accommodate two individuals (Individuals #2 and #4) that utilize wheelchairs. The PM confirmed that Individual #2's clothes are hanging on the right side of the closet and Individual #4's clothes are hanging on the left side of the closet. The PM further confirmed that the bed is partially blocking access to the closet and Individual #4 is not able to access their clothing hanging in the closet.
Further interview conducted with the operations director/qualified intellectual disabilities professional on March 7, 2024, at 9:10 AM confirmed Individual #4 did not have access to their closet.
Plan of Correction:Valley Community Services will ensure that each client is provided with individual closet space in the client's bedroom with clothes racks and shelves accessible to the client. Individual #4 was unable to access her belongings due to the headboard of Individual #2's bed blocking the left side of the closet where her clothes are kept. On 3/11/24 the furniture in the bedroom belonging to Individual #2 and Individual #4 was rearranged so that the closet is now fully accessible to both individual #2 and Individual #4.
On 3/7/24, the Program Manager of Mount Pleasant ICF/ID was trained on ensuring that closets are free from obstructions and accessible to the client. On 3/12/24, all ICF managers were trained on ensuring that closets are free from obstructions and accessible to the client. All staff will be trained on ensuring that closets are free from obstructions and accessible to the client; this training will be completed by 3/31/24. To ensure future infractions do not occur, the ICF Program Managers will be completing monthly closet checks to confirm the closet's accessibility beginning 4/1/24 and ending 3/31/25. The QIDP/OD will monitor the monthly closet checks beginning 4/1/24 and ending 3/31/25.
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
and under varied conditions to-
Observations:
Based on facility provided fire evacuation drill documentation and interview, it was determined that the facility failed to ensure that evacuation drills were completed under varied conditions for staff training purposes. This applied to two of four exits at the residence. Findings included:
A review of the fire evacuation drill documentation for the previous 12 months was completed on March 6, 2024. This review failed to reveal that two exits, the front door exit and kitchen door exit, at the facility were practiced during a fire evacuation drill within the past 12 months.
Interview with the operations director/qualified intellectual disabilities professional (OD/QIDP) on March 7, 2024, at 9:06 AM, confirmed that the individuals living at the residence utilize both the front and kitchen doors at the residence. The OD/QIDP further confirmed that these exits should have been practiced during fire evacuation drills and that two of the four exits at the residence had not been practiced within the past 12 months.
Plan of Correction:It is the duty of Valley Community Services to ensure that evacuation drills are completed under varied conditions for staff training purposes; this includes use of all exits at least one time per calendar year during fire evacuation drills. A retraining with the Mount Pleasant ICF Program Manager was completed on 3/7/24 regarding the need to use all exits at least once per calendar year during fire evacuation drills. The Mount Pleasant ICF Program Manager conducted a fire drill on 3/15/24 using the front door as an exit. The Mount Pleasant ICF Program Manager will conduct an additional fire drill by 3/31/24 using the kitchen exit as an evacuation route.
All ICF managers were retrained on 3/12/24 regarding the need to use all exits at least once per calendar year during fire evacuation drills. VCS Form 19-B titled Fire Drill Report Record was revised to include an area to document exit(s) used during a fire evacuation drill. All ICF Program Managers were trained on 3/12/24 to complete the revised Fire Drill Report Record monthly upon completion of the monthly fire drill. This process will begin April 2024 and will end March 31, 2025. The QIDP/OD will monitor the Fire Drill Report Record monthly beginning April 1, 2024 and ending March 31, 2025.
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