Initial Comments:
A focused fundamental survey was conducted August 29-31, 2023, 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(c)(5)(iv) STANDARD
INDIVIDUAL PROGRAM PLAN
Name - Component - 00
Each written training program designed to implement the objectives in the individual program plan must specify the type of data and frequency of data collection necessary to be able to assess progress toward the desired objectives.
Observations:
Based on record reviews and interview, it was determined that the facility failed to collect data with enough frequency to adequately measure progress toward residential program goals. This applied to three (#1, #2, and #3) of three individuals in the core sample. Findings included:
1. A record review was completed for Individual #1 on August 31, 2023. At that time, a review of the residential program goals and data collection for the months of June, July, and August of 2023, was completed. This review revealed that data collected for Individual #1's residential program goals were as follows:
- Will press the button to puree lunch, given hand-over-wrist assistance, for one of one trial per day. Documentation revealed that this goal was implemented nine out of 30 days in June, seven out of 31 days in July, and 15 out of 31 days in August of 2023.
- Will touch the pictures of the toothettes and the water faucet, given five physical prompts, for one of one trial per day, for 25 of 30 days each month. Documentation revealed that this goal was implemented eight out of 25 days in June, four out of 25 days in July, and eight out of 25 days in August of 2023.
-Will turn on water faucet in order to wash hands for dinner, given five physical prompts, for one of one trial per day. Documentation revealed that this goal was implemented 14 of 30 days in June, six of 31 days in July, and six of 31 days in August of 2023
-Will identify the color black, given six physical prompts, for one of one trial per day, for 25 of 30 days each month. Documentation revealed that this goal was implemented six out of 25 days in June, five out of 25 days in July, and six out of 25 days in August of 2023.
-Will tolerate wearing a mask over his nose and mouth for 45 seconds in the evening, for one of one trial per day, for 25 or 30 days each month. Documentation revealed that this goal was implemented 16 out of 25 days in June, nine out of 25 days in July, and eight out of 25 days in August of 2023.
2. A record review was completed for Individual #2 on August 31, 2023. At that time, a review of residential goals and data collection for the months of June, July, and August of 2023, was completed. This review revealed that data collected for Individual #2's residential program goals were as follows:
- Will press the correct button on the blender/chopper to puree breakfast, given hand to forearm assistance, for one of one trial per day. Documentation revealed that this goal was implemented seven out of 30 days in June, seven out of 31 days in July, and 15 out of 30 days in August of 2023.
- Will retrieve his toothbrush from hygiene bin, given hand to forearm assistance, for two of two trials per day. Documentation revealed that this goal was implemented 32 out of 60 opportunities in June, 25 out of 62 opportunities in July, and 24 out of 62 opportunities in August of 2023.
- Will sort four horseback riding pictures versus four swimming pictures, given hand to forearm assistance, for one of one trial per day, for 25 out of 30 days. Documentation revealed that this goal was implemented one out of one out 25 days in June, three out of 25 days in July, and 4 out of 25 days in August of 2023.
- Will activate the message, "Go" when ready for the shower, by pressing a switch, given hand over forearm assistance, for one of one trial per day. Documentation revealed that this goal was implemented two out of 30 days in June, two out 31 days in July, and one out of 31 days in August of 2023.
- Will sort pennies, nickels, dimes, and quarters, given five gestural prompts, for two of two trials per day, for 25 out of 30 days. Documentation revealed that this goal was implemented four out of 50 opportunities in June, five out of 50 opportunities in July, and 10 out of 50 days in August of 2023.
- Will point to where EBT card is to be swiped just prior to making a purchase, given hand to forearm assistance, two out of two trials per month, for three of four months. Documentation revealed that this goal was implemented zero out of two opportunities in June, zero out of two opportunities in July, and zero out of two opportunities in August of 2023.
3. A record review was completed for Individual #3 on August 31, 2023. At that time, a review of the residential program goals and data collection for the months of June, July, and August of 2023, was completed. This review revealed that data collected for Individual #2's residential program goals were as follows:
-Will utilize sensory water mat given hand-over-wrist assistance, for five minutes, for one of one trial per day. Documentation revealed that this goal was implemented 10 of 30 days in June, 10 of 31 days in July, and 18 of 31 days in August of 2023.
-Will activate a double switch message "walk" and "bed", given five physical prompt, for one of one trials per day, for 25 of 30 days. Documentation revealed that this goal was implemented four of 25 days in June, one of 25 days in July, and four of 25 days in August of 2023.
-Will roll a ball back and forth with staff (and/or a housemate) given one physical prompt, for three of three trials per day, for 25 of 30 days. Documentation revealed that this goal was implemented ten of 75 opportunities in June, zero of 75 opportunities in July, and 12 of 75 opportunities in August of 2023.
An interview was conducted with the administrator on August 31, 2023, at 10:25 AM. The administrator confirmed that data collection was lacking for Individuals #1, #2, and #3 and further confirmed that data was not collected with enough frequency to measure the individuals progress in their residential goals.
Plan of Correction:It is the policy of Valley Community Services to implement training objectives with data collected at a frequency that allows assessment of progress as agreed upon by the interdisciplinary team and as outlined in the individual program plan. By September 18, 2023, all DSPs will be retrained on the following goal plans:
*Individual #1- Will press the button to puree his lunch given 3 physical prompts.
*Individual #1- Will touch the pictures of toothettes and water faucet given 3 physical prompts.
*Individual #1- Will identify the color black when given a distractor color (white) given 3 physical prompts per trial.
Individual #1- Will tolerate wearing a mask over his nose and mouth for five minutes.
Individual #2- Will point to where his EBT card is to be swiped just prior to making a purchase given hand over forearm assistance.
Individual #2- Will sort pennies, nickels, dimes, and quarters to their appropriate bins.
Individual #2- Will activate the message "GO" when he is ready for his shower, by pressing a switch, given 3 physical prompts.
Individual #2- Will sort 4 horseback riding pictures versus four swimming pictures given hand to elbow assistance.
Individual #2- Will retrieve his toothbrush from his hygiene bin given hand over elbow assistance.
Individual #2- Will push the button on the blender/chopper to puree his breakfast given hand over elbow assistance.
Individual #3- Will independently roll a ball back and forth with staff (and/or a housemate).
Individual #3- Will activate a double switch message "walk" and "bed" given 3 physical prompts.
Individual #3- Will participate in sensory stimulation, by utilizing his sensory water mat, given 3 physical prompts.
By September 18, 2023, all DSPs will be retrained on Documenting Goal Plans on Therap.
The Program Manager will run weekly ISP Data reports for the individuals' goal plans to ensure documentation compliance for 6 months beginning October 1, 2023, and ending on September 30, 2024. The QIDP will run monthly ISP Data reports for the individuals' goal plans and document the individuals' progress on Monthly Summary Forms.
The Program Manager and the QIDP will complete bi-weekly observations of goal plan implementation to ensure compliance for 6 months beginning October 1, 2023, and ending on September 30, 2024.
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, review of physician's orders, and interview, it was determined that the facility failed to ensure that medications were administered without error. This applied to three (#1, #2, and #5) of four individuals observed during morning medication administration.
Findings included:
1. Morning observations were completed at the residence on August 29, 2023, from 5:55 AM to 8:20 AM. At 6:33 AM, staff were observed to serve Individual #1 breakfast. At 6:51 AM, the registered nurse (RN) prepared the medication omeprazole to administer to Individual #1. This medication was crushed and placed in applesauce, and then administered to Individual #1 at 6:56 AM.
A review of Individual #1's current physician's orders, dated August 17, 2023, was completed on August 29, 2023. This review revealed that Individual #1's physician's orders state, "Omeprazole 20 mg OTC tablet crush 1 tablet & mix with applesauce and take by mouth before a meal at 7 AM daily."
2. Morning observations were completed at the residence on August 29, 2023, from 5:55 AM to 8:20 AM. At 6:35 AM, staff were observed to serve Individual #2 breakfast. At 7:01 AM, the RN prepared the medication omeprazole to administer to Individual #2. The medication label indicated that this medication was to be administered before meals. This surveyor notified the RN that Individual #2 had already been served breakfast. The RN then stopped the medication pass and went to contact the physician. At 7:05 AM, the RN confirmed that Individual #2 should receive their omeprazole before their morning meal and that a medication error had occurred. At 7:32 AM, the RN received a call from the physician and stated that they were told to proceed with administering the medication.
A review of Individual #2's current physician's orders, dated July 5, 2023, was completed on August 29, 2023. This review revealed that Individual #2's physician's orders state, "Omeprazole 20 mg capsule ...take one capsule by mouth at 7 AM before meals daily."
3. Observation of the morning medication pass was completed on August 29, 2023, from 6:13 AM to 7:27 AM. At 7:11 AM, the RN prepared Individual #5's medications, which included the medication fiber-lax. The medication label indicated that this medication was to be given with eight ounces of water. At 7:25 AM, the RN was observed to administer the fiber-lax tablet and then offer Individual #5 approximately two ounces of water, stating, "take a sip for me." Individual #5 was then observed to take a small sip and walk away. This surveyor then questioned the RN about amount of liquid Individual #5 was to receive with their fiber-lax. The RN stated that it is often difficult to get Individual #5 to drink water. The RN then offered Individual #5 a full glass of water and Individual #5 drank the full glass.
A review of Individual #5's physician's orders, dated June 14, 2023, was completed on August 29th, 2023. This review revealed that Individual #5's physician's orders state, "fiber-lax captabs take 1 tablet by mouth daily at 8 AM with 8 oz of water."
An interview with the chief health officer (CHO) was completed on August 29, 2023 at 10:05 AM. At this time the CHO confirmed that Individual #1 and Individual #2's omeprazole should have been administered before their morning meal and that medication errors had occurred. The CHO further confirmed that Individual #5 should be offered eight ounces of water when the fiber-lax is administered and that a medication error had occurred when the RN failed to do this. The CHO confirmed that all medications should be administered in accordance with the physician's orders.
Plan of Correction:Valley Community Services' policy is to ensure all medications are administered as ordered. On 8/29/23 the physician was immediately notified of the administration error for individuals #1,#2 and #5. No further instructions were given by the physician. The nurse was immediately pulled from passing medications on 8/29/23 and was re-trained on the specific physician orders for medication administration for individuals #1,#2, and #5. In addition, a full medication pass observation on nurse was completed by the Director of Nursing on 8/30/23 to ensure proper administration. The Director of Nursing will perform a monthly medication pass observation on the nurse in September and October of 2023 to monitor performance. Also beginning with October 2023 monthly medication bulk shipments from the pharmacy all medications that are ordered by the physician, to be administered prior to meals, will have additional sticker labeling applied to blister packet stating "Before meals" as an additional alert. All nurses and medication trained staff will be retrained on the additional labeling and specific meal physician orders by 9/30/23.
483.480(b)(2)(iii) STANDARD
MEAL SERVICES
Name - Component - 00
Food must be served in a form consistent with the developmental level of the client.
Observations:
Based on observation, a focused record review, and interviews, it was determined that the facility failed to provide food in a form consistent with the developmental level and identified need of the individuals. This applied to one (#4) of six individuals living at the residence. Findings included:
Evening observations were conducted at the residence on August 29, 2023, from 3:00 PM to 6:30 PM. During this time, Individual #4 was observed to be served cereal with milk that appeared to be prepared with unthickened milk. At 4:28 PM, Individual #4's thickener container was observed placed on the dining room table, and remained in this location throughout the meal. At 4:46 PM, Individual #4 declined to eat the meal that was served, and requested cereal as an alternative. Staff was observed to prepare Individual #4's cereal in the kitchen, adjacent to the dining room. Staff then brought the cereal with milk into the dining room and placed it in front of Individual #4 for consumption. Individual #4 declined to eat the cereal, so staff placed the bowl of cereal in the refrigerator. Individual #4 was not observed to eat the prepared cereal during the observations at the residence. At 6:20 PM, the surveyor questioned the staff regarding the consistency of the milk that was placed in the cereal. Staff confirmed that the milk in the cereal had not been thickened.
A focused record review for Individual #4 was completed on August 30, 2023. This review revealed a current physician's order, signed on June 15, 2023, with diet a diet order that stated, "regular diet, no calorie restrictions allow second with mechanical soft consistency and nectar thick liquids."
An interview was conducted with the chief health officer (CHO) on August 30, 2023, at 10:00 AM. The CHO confirmed that Individual #4 did not receive their food in a form consistent with their identified need or developmental level. The CHO further confirmed that all liquids for Individual #4 should have been nectar thickened, including the milk used for Individual #4's cereal.
Plan of Correction:Valley Community Services policy is that all food is served in a manner consistent with the individual's developmental level. On 8/30/23, the staff who served Individual #4 cereal with un-thickened milk earlier that evening (8/30/23) was verbally retrained by the QIDP/OD regarding Individual #4's dietary orders stating, "regular diet, no calorie restrictions, allow seconds with mechanical soft consistency, and nectar thick liquids". By 9/18/23, All DSPs will be retrained on the individuals' diet orders including food consistencies and accurate food preparation with a required return demonstration. The Program Manager will observe meal preparation at least 4 times a month for compliance using the Meal Observation Form for one year beginning October 1, 2023, and ending September 30, 2024. The QIDP will monitor every month via the Meal Observation Forms to identify and address areas of concern and compliance, beginning on October 1, 2023, and ending on September 30, 2024.
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