Initial Comments:
A focused fundamental survey visit was completed on February 22-23, 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 two individuals.
Plan of Correction:
483.420(d)(4) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
If the alleged violation is verified, appropriate corrective action must be taken.
Observations:
Based on record review and interview with administrative staff, the facility failed to
take appropriate corrective action post the completion of an investigation for one of one individual who required medical treatment after falling out of a wheelchair. This practice is specific to Individual #1.
Findings include:
1. A review of the facility incident reports for the period from 11/01/2023 through 02/21/2024 was completed on 02/22/2024 at approximately 9:30 AM to 10:00 AM. This review revealed the following incident concerning Individual #1:
- "On 01/29/2024 at around 12:50 PM, [ staff person] was in the kitchen cooking. I heard a loud noise. When I went to look, I found [Individual #1] on the floor with her wheelchair slightly on top of her. House manager was notified. Nursing called and 911 called....
She is bleeding from above her left eye."
-Under the section titled Follow-up/corrective action, the following statement was listed, "No corrective action needed."
Two additional documents attached to this report included the following:
-Progress and Order Record dated 01/30/24: Individual #1's primary care physician noted this individual had received 3 non-visible stitches to the laceration above her left eye in the emergency room from the above noted fall.
- [Agency name] Mini IDT (Interdisciplinary Team) Fall Reduction Plan dated 02/01/2024: This document reiterated the incident of 01/29/2024 and noted a fall risk assessment was completed on 01/30/2024 which identified Individual #1 was at high risk for falls. This Mini IDT further states "No other concerns noted."
A review of Individual #1's record completed on 02/23/2024 from approximately 9:00 AM to 11:00 AM revealed there was no indication that the IDT had addressed the identified condition of high risk for falls noted in the assessment completed on 01/30/2024.
When asked if there were any preventive measures put into place to safeguard Individual #1 post the assesment tthat she was identified as a high risk for fall, interview with the Associate Executive Director and the Eastern Region Social Services Director on 02/23/2024 at
11:10 AM confirmed that no preventative actions had been put in place by the IDT to address the identified conditions.
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Plan of Correction:The facility will ensure that appropriate corrective action is taken.
#1
On 2/23/24 a Team meeting was held for individual #1 to rereview the incident that occurred on 1/29/24 to address the identified condition of high risk falls that were previously noted in fall risk assessment completed on 1/30/24 which were reviewed with the team on 2/1/24. The addended Mini Interdisciplinary Team (IDT) meeting assuring additional safeguards were put in place. Once additional safeguards have been put into place the team will reconvene to ensure that the safeguards are adequate at this time. Mini Interdisciplinary Team a will be documented and forwarded to the AED for verification of completion.
#2
On or before March 22, 2024, the Associate Executive Director (AED) will meet with the Performance and Quality Improvement Department (PQI) to review all incidents reported in the month of December 2023 through February 2024 to ensure appropriate corrective actions were taken. Any noted concerns were addressed at the meeting. If further review into an incident is needed, the AED will contact PQI department to initiate the investigatory process if needed.
On or before March 29, 2024, the facility Manager will be retrained on documentation of appropriate follow-up and corrective action to ensure that all corrective measures were put into place to avoid further incidents. Training will be forwarded to AED for verification of completion.
On or before March 29, 2024, the Eastern Region Social Services Supervisor (ERSS) will retrain all QIDP's on increased awareness regarding significant events and documentation of those events and documentation of appropriate follow-up and corrective action. Training will be forwarded to AED for verification of completion.
On or before March 29,2024 the Eastern Region Social Services Supervisor will review reports for remainder of the facility individuals tracking significant events to ensure that documentation of appropriate follow-up and corrective action was taken. Situations of concern will be reviewed and individually addressed and documented by the team at an interdisciplinary team meeting within 7 days.
#3
Upon notification the House Manager will review the incident with staff to ensure all events leading up to the incident are documented to include who, what, when, where how and why. In addition, the Manager will ensure that all staff who may have witnessed the incident also complete an incident report. Once the incident report is completed the house manager will ensure that they complete the follow up corrective action section of the incident report to include focusing on measures that were put into place to avoid further incidents as well as any additional corrective actions that are needed. Upon receipt of incident reports PQI will review and contact House Manager/Designee for further follow up if needed.
When applicable a team will be held to review the incident further to ensure that all corrective measures are put into place to avoid further incidents. The team may also recommend additional follow-up which may include but not limited to a review of medications, adaptive equipment, environmental settings, or any support needed.
#4
On or before March 31, 2024, the PQI Department will conduct an incident review meeting once a week with the House Manager, and various department heads to review incidents to ensure that all components of the incidents were completed and any additional follow up that was needed was completed. If there is any need for additional follow-up it will be noted on the meeting minutes and sent to the attendees for completion.
#5
PQI Director will present an incident trending report at the monthly Executive Operations meetings, chaired by the Sr. Executive Director. Outstanding issues will be addressed via systemic corrective action.
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
and under varied conditions to-
Observations:
Based on record review and interview with administrative staff, the facility failed to hold quarterly evacuation drills under varied conditions of time. This practice is specific to the
first shift and second shift of personnel during the time period of January, 2023 thorough December, 2023.
Findings include:
A review of the facility's evacuation drills for the period from 01/2023 through 12/2023 was completed on 08/17/2023 from approximately 7:50 AM to 8:05 AM. This review revealed that evacuation drills were not varied throughout the extent of the shift as follows :
First Shift Evacuation Drills: Shift time identified as 7:00 AM to 3:00 PM
03/18/2023 1:30 PM
06/13/2023 7:30 AM
09/17/2023 10:45 AM
12/14/2023 2:00 PM
Second Shift Evacuation Drills: Shift time identified as 3:00 PM to 11:00 PM
01/13/2023 4:00 PM
04/20/2023 10:30 PM
07/14/2023 3:30 PM
10/17/2023 8:15 PM
Interview with the Associate Executive Director completed on on 02/22/2024 at approximately 9:15 AM, confirmed the above evacuation drills were not varied throughout the shift of personnel.
Plan of Correction:The facility will ensure that evacuation drills are held under varied conditions of time.
C1
On or before March 12, 2024, the facility House Manager will be retrained on the Evacuation Drills Scheduling Guidelines. The training emphasized conducting evacuation drills at least quarterly for each shift of personnel and under varied conditions. The training provided general guidelines and examples of varying the timeframe that each evacuation drill is conducted across each shift of personnel.
On or before March 12, 2024, the Community Director or designee will retrain all House Managers (HM) on the Evacuation Drills Scheduling Guidelines. The training will emphasize conducting evacuation drills at least quarterly for each shift of personnel and under varied conditions of time. The training will provide general guidelines and examples of varying the timeframe that each evacuation drill is conducted across each shift of personnel. The training will be documented on a Staff Attendance Sheet to verify completion. The Staff Attendance Sheet will be uploaded to each HM training transcript and electronically stored in the Learning Management System. A copy of the completed training will be forwarded to the Associate Executive Director to verify completion.
C2
On or before March 15, 2024, the HM will conduct an evacuation drill in accordance with the Evacuation Drill Scheduling Guidelines. The HM will use the fire drill form to collect, document, and maintain the required elements of the evacuation drill. The HM will then submit the fire drill form via the electronic Evacuation Drill Verification System (EDVS) for further review/audit by the Community Director/designee. The review/audit will confirm that the HM conducted the evacuation drill in accordance with State and Federal regulations and the agency's Evacuation Drills Scheduling Guidelines.
C3
The EDVS will be used to collect, review, and maintain the required elements of the evacuation drill. Upon completion of the evacuation drill and by the 15th day of the month, the HM will submit a copy of the evacuation drill to the EDVS for review. The Community Director (CD) will receive an automated email from the EDVS notifying him of a new evacuation drill submission. Upon receipt and by the 20th of the month, the CD will review the evacuation drill to ensure all required elements have been met including verifying that the evacuation drill was conducted at different times of the day and under varying conditions as set forth in the Evacuation Drills Scheduling Guidelines. After review, the CD will either approve or reject the submitted evacuation drill. If the evacuation drill is found to be unsatisfactory, it will be rejected, and the CD will direct the HM to repeat the evacuation drill within seven days and until it meets the requirements in accordance with State and Federal regulations in addition to the agency policies and protocols. Any concerns noted will be addressed with further training and/or employee counseling and corrective action. The EDVS audits will serve as the means to monitor that the corrective actions remain effective.
C4
On a monthly basis by the 28th of the month, the Associate Executive Director (AED) or designee will audit all approved evacuation drills within the EDVS. The audit will confirm that all approved evacuation drills are conducted under various conditions and timeframes pursuant to the Evacuation Drills Scheduling Guidelines, and in accordance with State and Federal regulations. During the AEDs review, if concerns are identified with the varied conditions and/or the Evacuation Drills Scheduling Guidelines were not followed, the AED will require that another drill is conducted to maintain compliance with State and Federal regulations and agency policy. Any anomalies will be addressed with training and employee counseling and corrective action.
C5
The AED will present a summary of all audit outcomes to the Senior Executive Director at the monthly executive operations meeting chaired by the Senior Executive Director, who will address any outlying issues with systemic corrective actions.
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