Initial Comments:
A focused fundamental survey was conducted March 19 - 21, 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 five and the core sample consisted of three individuals.
Plan of Correction:
483.450(b)(2) STANDARD
MGMT OF INAPPROPRIATE CLIENT BEHAVIOR
Name - Component - 00
Interventions to manage inappropriate client behavior must be employed with sufficient safeguards and supervision to ensure that the safety, welfare and civil and human rights of clients are adequately protected.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure all interventions to manage inappropriate client behaviors were employed with sufficient safeguards. This applied to one (#1) of three individuals in the core sample. Findings included:
Record review for Individual #1 was completed on March 21, 2024. This review revealed that Individual #1 has current physician's order dated February 13, 2024, for "risperidone 1 mg tablet take by mouth one tablet (1mg) daily at 8 pm." Further review revealed psychiatric consult meetings, that included facility staff, listed risperidone as a psychiatric medication that was reviewed. Further record review failed to reveal that this medication was included in Individual #1's behavior plan that addressed aggression and depression. During an interview with the facility nurse on March 21, 2024, at 10:45 AM, the nurse provided past documentation from January and February 2019. This documentation revealed that risperidone was a recommendation from a neurologist for a tic disorder but was not ordered at that time. However during a psychiatric hospital stay in February 2019, Individual #1 returned to the facility with an order to receive risperidone 1 milligram (mg) two times per day. On February 11, 2019, medication order was reduced for Individual #1 to receive risperidone 1mg one time per day. The facility nurse confirmed that Individual #1 has been receiving that dose to date, and that the effectiveness was not documented.
Interviews with the qualified intellectual disabilities professional on March 21, 2024, at 9:40 AM and 10:53 AM, confirmed that the risperidone was included on Individual #1's psychiatric consults but was not a part of Individual #1's behavior plan or objectives for monitoring.
Plan of Correction:Valley Community Services (VCS) will ensure that all behavior plans, including behavioral goals and objectives are updated according to the individual's needs. Individual #1's behavior management plans have been reviewed to ensure they reflect her current needs. Individual # 1's BMP was revised to include the use of Risperidone for a Tic Disorder. A new behavior management pan will be developed to monitor her Tic Disorder. The QIDP will monitor effectiveness of the Risperidone by completing 28 day reviews of the behavioral data and compile quarterly reports which include incident rates for the quarter and revisions to plans and/or psychotropic medication changes. This process will be effective immediately and will be on-going for the duration of the behavior plan.
The QIDP will review all BMP's to ensure they reflect the current need of each individual. This includes reviewing the Behavioral Objectives to ensure that they accurately reflect the Individuals psychotropic medications. This will be completed by April 22, 2024. The QIDP will monitor effectiveness of each individuals psychotropic medications by completing 28 day reviews of the behavioral data and compile quarterly reports which include incident rates for the quarter and revisions to plans and/or psychotropic medication changes. This process will be effective immediately and will be on-going for the duration for each behavior plan.
To ensure that all behavior plans are updated according to the individuals needs and accurately reflect the individual's psychotropic medications, the COO will monitor the QIDP's quarterly reports containing incident rates for the quarter and revisions to plans and/or psychotropic medication changes. This will begin on May 1st 2024 and will end on April 30, 2025.
483.450(e)(2) STANDARD
DRUG USAGE
Name - Component - 00
be used only as an integral part of the client's individual program plan that is directed specifically towards the reduction of and eventual elimination of the behaviors for which the drugs are employed.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure the medication used to manage inappropriate behaviors is directed specifically towards the reduction and eventual elimination of the behaviors for which the medications are utilized. This applied to two (#1 and #3) of three individuals in the core sample. Findings included:
Record review for Individual #3 was completed on March 21, 2024. This review revealed that Individual #3 had a behavior plan and consents that target depression incidents with the use of the medication paxil. Review of Individual #3's current physician order for paxil revealed Individual #3 receives paxil, 10 milligrams (mg) at 8:00 PM. Further review revealed that the objective of the behavior plan for the evaluation of progress by the psychologist states, "to decrease the frequency of depression to 315 incidents or less for a 28-day review period while receiving Prozac 10mg/day."
Interview with the qualified intellectual disability professional (QIDP) on March 21, 2024, at 11:15 AM, confirmed that the incorrect medication was listed in the behavioral objective for Individual #3 from when it started on February 13, 2024.
Record review for Individual #1 was completed on March 21, 2024. This review revealed that Individual #1 had a behavior plan and consents that target depression incidents with the use of the medications lexapro and remeron. Review of Individual #1's current physician orders revealed Individual #1 receives lexapro, 20 mg per day. Further review revealed that the current objective of the behavior plan for the evaluation of progress by the psychologist states, "to decrease the frequency of depression to 18 incidents or less for a 28-day review period while receiving Lexapro 20mg/day and Remeron 15mg/day." Review of prior objective steps indicates that these two medications were used in the objective for reduction of the incidents of depression for Individual #1 for the past year. Further record review revealed that beginning April 12, 2023, the psychiatrist reduced and then in two weeks discontinued the use of remeron for Individual #1.
Interview with the QIDP on March 21, 2023, at 9:40 AM confirmed that remeron was discontinued but remained in the behavioral objective for Individual #1 to date, and that the objective was not revised.
Plan of Correction:
Valley Community Services (VCS) will ensure that all behavior plans, including behavioral goals and objectives are updated according to the individual's needs. The behavioral objective for individual #3's BMP for depression was revised to accurately reflect her current psychotropic medication. This was completed on 4/2/24. The behavior objective for individual #1's BMP for depression was revised to accurately reflect her current psychotropic medication. This was completed on 4/2/24.
The QIDP will ensure the BMP's reflect the current needs of each individual. This includes reviewing the behavioral objectives to ensure they accurately reflect the individual's psychotropic medication. This will be completed in all ICF's by April 22nd 2024.
Individual #3's, Guardian was made aware of the psychotropic medication error, and she was sent an updated copy of Individuals #3's Symptoms of Depression plan and the corrected psychotropic medication of Paxil, not Prozac on 4/5/24. This QIDP requested written verification that she read and understood the symptoms of depression plan with the corrected medication for Paxil.
To ensure that all behavioral objectives accurately reflect the individual's psychotropic medications, the QIDP will review all BMP revisions and check for accuracy of psychotropic medications. This process will be effective immediately and will be on-going for the duration of the behavior plan. The Chief Operations Officer will review all ICF BMPs on a quarterly basis to monitor the QIDP and ensure each BMP reflects the current needs of the individual. This process will begin May 1, 2024 and end on November 1, 2024.
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