Initial Comments:
A focused fundamental survey visit was completed on September 8 and 9, 2022.
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 eight, and the sample consisted of five individuals.
Plan of Correction:
483.420(a)(7) STANDARD
PROTECTION OF CLIENTS RIGHTS
Name - Component - 00
The facility must ensure the rights of all clients. Therefore, the facility must ensure privacy during treatment and care of personal needs.
Observations:
Based on observation and interview with facility and administrative staff, the facility failed to ensure privacy during treatment and care of personal needs for one sample Individual. This practice is specific to Individuals #3.
Findings include:
Observations completed on 09/08/2022 from approximately 7:15 AM to 7:45 AM, revealed
that at 7:17 AM survey staff entered the living room of the home and observed
Individual #3 sitting on the toilet in the half bathroom, which is located on the left as you enter the living room from the hallway of the home. He was observed with his pants and underwear pulled down to his knees. There was a staff person in the bathroom with Individual #3 and another staff sitting on the sofa in the living room, which is positioned directly in front of the bathroom door. This surveyor observed a nurse walking in and out of the living room are and, passing the open bathroom door on at least three different occasions with no intervention to close the bathroom door or prompt staff in the bathroom to do so.
Interview with the Program Director on 09/08/2022 at approximately 10:00 AM, confirmed that the staff should have closed the bathroom door to ensure privacy for this Individual during his personal care activities.
Plan of Correction:W-130: As soon as notification came to management that a violation of privacy was observed, an incident report was completed and an investigation was initiated by the Quality Management Department. Target date: 9/8/2022
All staff working in the facility were re-trained on 9/8/22 (includes individual #3 as well as the remaining individuals' that reside in the home) when using the bathroom while receiving care including personal hygiene, the staff must ensure the door is closed for privacy. Target Date: 9/8/22-9/15/2022
The Qualified Intellectual Developmental Professional (QIDP) held an Interdisciplinary Team meeting for Individual #3was held on 9/27/22 to review privacy, while receiving treatment and care of personal needs according to individual #3's Individual Program Plan (IPP), and to ensure the documentation is consistent throughout the record. Target Date: 9/29/2022
All staff working in the facility will be re-trained on 10/7/22 on individual #3's IPP to ensure understanding of the current privacy, of individual #3 are met. Training sheets will be completed and recorded in the training log of the facility and forwarded to the Training Department. Target Date: 10/5/2022
Interdisciplinary team meetings were held 9/27/227 and 9/30/22 for all other individual's that reside at the facility to review privacy, while receiving treatment and care of personal needs according to the individual's Individual Program Plans (IPP). All staff working at the facility were re-trained on the individual's IPP to ensure the understanding of the current privacy, while receiving treatment and care of personal needs of the individuals are met. Training sheets will be completed and recorded in the training log of the facility and forwarded to the Training Department. Target Date: 10/15/2022
The Program Director will re-trained the facility staff on visitation practices on 9/28/22 to ensure that the staff are preserving the privacy of all individual that reside in the home. Training sheets will be completed and recorded in the training log of the facility and forwarded to the Training Department. Target Date: 10/15/2022
The House Manager will complete weekly privacy audits (varying days and times) to ensure staff are preserving individual's privacy during treatment and care of personal needs. This includes but is not limited to; dressing, bathing, personal hygiene, toileting and medical treatments. All audits will be documented and reviewed by the Director of Operations within 7 days and forwarded to the Administrator for review. All items of non-compliance will be addressed immediately by Administrator within 5 days and will include corrective action for all staff found not in compliance with policy(s) The audits will be weekly for 6 months and then monthly thereafter. Target Date: 9/22/2023
The Residential Coordinator will complete monthly privacy audits (varying days and times) to ensure staff are preserving individual's privacy during treatment and care of personal needs. This includes but is not limited to; dressing, bathing, personal hygiene, toileting and medical treatments. All audits will be documented and reviewed by the Director of Operations and forwarded to the Administrator for review. All items of non-compliance will be addressed immediately by Administrator within 5 days. The audits will be monthly for 6 months and then quarterly thereafter. Target Date: 9/22/2023
The Quality Management Department will complete quarterly privacy audits (varying days and times) to ensure staff are preserving individual's privacy during treatment and care of personal needs. This includes but is not limited to; dressing, bathing, personal hygiene, toileting and medical treatments. All audits will be documented and forwarded to the Administrator for review. All items of non-compliance will be addressed immediately by Administrator. Target Date: 9/22/2023
Responsible persons: Assistant Administrator, Administrator and Quality and Risk Administrator
483.430(e)(1) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
The facility must provide each employee with initial and continuing training that enables the employee to perform his or her duties effectively, efficiently, and competently.
Observations:
Based on observations and interview with administrative staff, the facility failed to ensure that staff were trained to effectively and competently perform duties to perform duties effectively, efficiently and competently for 2 of 4 sample Individuals. This practice is specific to Individuals #1 and #4.
Findings included:
1. Observations completed at the residence on 09/08/2022 from 7:45 AM to 8:30 AM revealed that Individuals did not have a full complement of utensils to inlcuded a knife at each place setting. Individuals were observed seated at the table, and eating breakfast at approximately 8:00 AM. Individual #4 had two whole pieces of french toast on his plate and was observed to stick his fork into the whole piece of french toast, pick it up and take a bite out of the whole slice of the french toast. The home manager proceed to go into the kitchen and retrieved a knife. The home manager then placed the knife next to Individual #4's plate. Individual #4 continued to stick his fork into his whole piece of french toast, pick it up and take a bite until his breakfast was finished. At no time, during this observation did staff prompt/assist Individual #4 to cut his french toast into bite size pieces.
Observations completed at the residence on 09/08/2022 from 4:55 PM to 5:45 PM revealed that Individual #1 arrived at the table approximately 4:55 PM and sat down. The table was set for four Individuals with two plastic cups, a plate, a fork, spoon and napkin at each place setting. There were no knives at each of the Individuals place setting.
Staff were observed to pour beverages, fruit juice and water., into the glasses in front of Individual #1. Staff were then observed to place a bowl of mashed potatoes next to Individual #1 and prompted him to take three spoonfuls. Staff then directed Individual #1 to take two pieces of meat from a bowl. Individual #1 declined the vegetables when presented. Individual #1 was observed picking up the whole piece of meat and taking a bite of it from his fork. After observing this action, staff went to the kitchen and returned with scissors and proceeded to cut Individual #1's meat.
As other Individuals arrived to the table, staff filled their cups with fruit juice and water, and placed mashed potatoes, meat and vegetables on their plates. The staff cut three of four Individuals meat with the scissors. Individual #4's meat was not cut for him and was observed picking up the whole piece of meat with his fork and taking several bites before being able to place the remainder of the portion of meat in his mouth.
2. A review of Individual #1's current functional assessment dated 03/28/2022, completed on 09/09/2022 between 11:00 AM and 11:30 AM reveals that Individual #1 is able to cut his food with a knife requiring a verbal prompt from staff.
A review of the record for Individual #4, on 09/09/2022 between 10:30 AM and 11:00 AM, revealed a Annual Assessment and Strengths and Needs List dated 05/23/2022. Under the Eating and Drinking section of this assessment it states that Individual #4 is able to use a knife with physical prompts.
Interview with the program director completed on 09/09/2022, at 12:00 PM, confirmed that Individuals should have a full complement of utensils and that both of these Individuals Individual #4 should have been prompted to cut their food before eating.
Plan of Correction:W-189: The Qualified Intellectual Developmental Professional (QIDP) held an Interdisciplinary Team meeting for Individual #4 on 9/27/2022, to review nutrition guidelines, diet orders and dietary recommendations and practices (via placemats) to ensure the items are consistent throughout the individuals individual Program Plan (IPP). Target Date: 10/15/2022
All facility staff will be trained on 10/7/22 individuals #4's IPP regarding the nutrition guidelines, diet orders and dietary recommendations which includes but not limited to; having a full complement of utensils (plate, cup, fork, knife, spoon and napkins at each place setting for each meal). The training also includes the prompting level for individual #4 to pour his own juice/water beverage, to cut his own food according to the dietary guidelines, portion size per dietary guidelines and family style dining. Prompting level will be verbal prompts, physical prompts and hand over hand starting with the least restrictive. Training sheets will be completed and recorded in the training log of the facility to ensure effective and competent skills for each staff at this facility and forwarded to the Training Department. Target Date: 10/15/2022
The Qualified Intellectual Developmental Professional (QIDP) held an Interdisciplinary Team meeting for Individual #1on 9/27/22, to review nutrition guidelines, diet orders and dietary recommendations and practices (via placemats) to ensure the items are consistent throughout the individuals individual Program Plan (IPP). Target Date: 10/15/2022
All facility staff will be trained on individuals #1's on 10/7/22 IPP regarding the nutrition guidelines, diet orders and dietary recommendations which includes but not limited to; having a full complement of utensils (plate, cup, fork, knife, spoon and napkins at each place setting for each meal). The training also includes the prompting level for individual #1 to pour his own juice/water beverage, to cut his own food according to the dietary guidelines, portion size per dietary guidelines and family style dining. Prompting level will be verbal prompts, physical prompts and hand over hand starting with the least restrictive. Training sheets will be completed and recorded in the training log of the facility to ensure effective and competent skills for each staff at this facility and forwarded to the Training Department. Target Date: 10/15/2022
The Qualified Intellectual Developmental Professional (QIDP) will hold an Interdisciplinary Team meeting for all other individuals that reside in the facility on 9/27/22 and 9/29/22, to review nutrition guidelines, diet orders and dietary recommendations and practices (via placemats) to ensure the items are consistent throughout the individuals individual Program Plan (IPP). Target Date: 10/15/2022
All facility staff will be trained on all individuals that reside in the facility on nutrition guidelines, diet orders and dietary recommendations which includes but not limited to; having a full complement of utensils (plate, cup, fork, knife, spoon and napkins at each place setting for each meal). The training also includes the prompting level for the individuals to pour their own juice/water beverage, to cut their own food according to the dietary guidelines, portion size per dietary guidelines and family style dining. Prompting level will be verbal prompts, physical prompts and hand over hand starting with the least restrictive. Training sheets will be completed and recorded in the training log of the facility to ensure effective and competent skills for each staff at this facility and forwarded to the Training Department. Target Date: 10/15/2022
The Training Department will complete dietary and nutrition training for all staff at this facility which includes; Meal preparation, Kitchen safety-appliances, cross contamination, utensils to use during food preparation/serving, Diets/Diet modifications, menus, placemats, portion sizes etc. Target Date 10/15/2022. The House Manager will complete weekly audits at varying times and days. All audits will be documented and reviewed by the Director of Operations within 7 days and forwarded to the Administrator for review. All items of non-compliance will be addressed immediately by Administrator within 5 days and will include corrective action for all staff found not in compliance with policy(s) The audits will be weekly for 6 months and then monthly thereafter. Target Date: 9/22/2023
The Residential Coordinator will complete monthly meal audits varying time and days and forward to Director of Operations. All audits will be documented and reviewed by the Director of Operations within 7 days. Director of Operations will then forward to the Administrator for review. All items of non-compliance will be addressed immediately by Administrator within 5 days. The audits will be monthly for 6 months and then quarterly thereafter. Target Date: 9/22/2023
Responsible persons: Director of Training, Assistant Administrator, Administrator
483.460(c)(4) STANDARD
NURSING SERVICES
Name - Component - 00
Nursing services must include other nursing care as prescribed by the physician or as identified by client needs.
Observations:
Based on observations, record review and interview with administrative staff the facility failed to provide nursing care for one of one sample Individuals with identified health needs. This practice is specific to Individual #1.
Findings include:
Observations completed at the residence on 09/08/2022 from 4:55 PM to 5:45 PM revealed that dinner included mashed potatoes, beef patties in gravy and a vegetable medley.
Staff was observed verbally prompting Individual #1 to take three large heaping serving sized spoonfuls of mashed potatoes and two pieces of meat from a serving dish. He declined to take vegetables when prompted by staff.
A review of Individual #1's record on 09/09/2022 from approximately 8:45 AM to 11:45 AM, revealed an annual nutritional evaluation dated 03/22/2022. The Nutritionists noted a heart healthy, low oxalate diet. The nutritionist reported that Individual #1 gained 20 pounds in three months, indicating this as his highest weight in a long time of 268.6 pounds with a body mass index of over 40. Individual #1 is 68.5 inches in height with a listed body weight of 128 to 166 pounds.
The Nutritional Assessment includes the following information in the section titled "Nutritional Needs":
Calorie Needs: 2917 Kcal for maintenance
Other: under 2400 Kcal+ daily for desired weight loss
Nutritional Needs Are Being Met: No
Comments: He is gaining weight despite limits on snacking and condiments
The section titled Plan of Care includes the following information:
- Assessment: "[Individual #1] is now morbidly obese. He is back at program, but weight is up further. Goal was 235# or less, which is not realistic at this time. He has co-morbidities including diabetes, HTN (Hypertension), and OSA (obstructive sleep apnea). His A1C is up as well and Endo (endocrinologist) counseled him on snacking."
- Nutrition Diagnosis: "Unplanned weight gain related to pandemic and decreased activity as evidenced by 20 pound gain over the last year and a half."
- Nutrition Plan of Care/Goals/Interventions: "Will meet with Team at [Individual #1's] IPP (Individual Program Plan meeting) to discuss weight gain and goals. He needs to exercise daily and goal is 18 pound loss to 250 or less in the next 6 months. Goal is to lower A1C."
A review of the Physician's orders dated 08/05/2022 revealed the following diet:
heart healthy, soft to chew, thin/regular fluid consistency, dime sized, low oxalate/low sodium diet, encourage low calorie snacks, vegetables only for second at meals.
On 08/30/2022, a interdisciplinary team meeting was held to address Individual #1's weight gain. At this meeting, the Nutritionist reported to members of the Interdisciplinary Team including the Qualified Intellectual Disability Professional, Program Director and Residential Coordinator, the following information: "the whole house started on a heart healthy diet, limiting salt and calories, feeling that the heart healthy diet will aid [Individual #1] with his weight loss."
A review of staff training documentation post the above team meeting noted that there was no staff training completed regarding the institution of a heart heathy diet.
Interview with the Program Director on 09/09/2022 at approximately 10:30 AM confirmed that despite Individual #1 being morbidly obese, no further changes to Individual #1's diet were made.
Plan of Correction:W-339: The Qualified Intellectual Developmental Professional (QIDP) held an Interdisciplinary Team meeting for Individual #1 on 9/27/22, to review physician orders, specialist recommendations, diagnosis, lab values, nutrition guidelines, diet orders and dietary recommendations and practices (via placemats) to ensure the facility is providing nursing care for individual #1's identified health needs. This special IDT meeting will include the following members; QIDP, Health Care Coordinator, Assistant Director of Nursing, Program Director, Director of Operations, Residential Coordinator, Nutritionist, House Manager and the Administrator who will be the substitute decision maker because individual #1 does not have active family involvement. Revisions will be made to the indivduals individual program plan with recommendations from the IDT. Within 2 weeks of the IDT, an updated nutritional evaluation, a new diet, menu and meal time guidelines along with an exercise program will be written into the IPP. Target Date: 10/15/2022
All facility staff will be trained on 10/7/22 individual's #1's updated nutritional evaluation, diet, menu, meal time guidelines and exercise program. Training sheets will be completed and recorded in the training log of the facility to ensure effective and competent skills for each staff at this facility and forwarded to the Training Department. Target Date: 10/30/2022
The Health Care Coordinator will complete a monthly medical file review to ensure nursing care is being provided for individual #1. Audits will include but not be limited to, review of specialist visits, weight, lab values that occurred within the month, and results of meal audits from the House Manager/Residential Coordinator in relation to individual #1. These audits will be forwarded to Administrator within 5 days and Administrator will direct corrective action as needed within 5 days. Nursing documentation via Point Click Care will be reviewed with the IDT to determine progress on a monthly basis. The QIDP will conduct an IDT quarterly for the complete team to review progression/regression. Team meetings will be documented and filed in PCC and shared with Administration for review within 5 days of meeting. Administrator will direct corrective action or instruct modification to changes if needed within 5 days. Target Date: ongoing monthly/quarterly.
The Assistant Director of Nursing will conduct an audit of individual #1s record quarterly to ensure the nursing care is being provided for individual #1's identifies health care needs. The audits will be forwarded to the Director of Nursing and Administrator for review within 5 days. Any recommendations will be reported to the team for further discussion and planning with the IDT. The team will reconvene as needed following Administrator's instruction. Target Date: 9/23/2023
As nursing changes occur with any other indivdual that reside in the facility, the Health Care Coordinator will bring changes to the QIDP to hold IDT meeting for the individual within 7 days . The IDT will be documented and shared with Administration. Revisions to the IPP and training and documentation will be ongoing as nursing needs change from indivdual to individual. Audits will be completed semiannually by the Assistant Director of nursing to ensure nursing care continues to be provided for the remaining indivduals at the facility. The audits will be forwarded to the Director of Nursing and Administrator for review within 5 days. Any recommendations will be reported to the team for further discussion and planning with the IDT as directed by Administrator. The IDT must meet within 5 days and any changes to the IPP must be completed within 7 days. Target Date: 9/23/2023
Responsible persons: Assistant Director of Nursing, Director of Nursing and Administrator. Administrator will have oversight of POC.
483.460(j)(1) STANDARD
DRUG REGIMEN REVIEW
Name - Component - 00
A pharmacist with input from the interdisciplinary team must review the drug regimen of each client at least quarterly.
Observations:
Based on record reviews and interview, the facility failed to ensure that each individual's medication regimen is reviewed by a pharmacist at least quarterly by the pharmacist. This practice is specific to Individual #3.
Findings included:
A review of the record for Individual #3 completed on 09/09/2022 between 9:00 and
11:30 AM revealed that Individual #3's drug regimen reviews were completed by the pharmacist on 09/10/2021, 03/15/2022, and 06/10/2022. There was no documented evidence that the pharmacist reviewed the drug regimen in 12/2021 (4th quarter).
An interview with the Health Care Coordinator on 09/09/2022, at approximately 11:30 AM confirmed that the pharmacist did not review Individual #3's drug regimen during the forth quarter of 2021 on a quarterly basis.
Plan of Correction:W-362 The Director of Nursing conducted a meeting with the consulting pharmacist on 9/12/22. The meeting included procedures and schedules for ensuring that all drug regimens are reviewed for each individual, on a quarterly basis, signed and dated by the reviewing pharmacist. The Pharmacist records the review and receives input from the Interdisciplinary team (IDT) and makes recommendations. Upon the completion of the review (that day), the consulting pharmacist will forward the reviews to the Director of Nursing.
The Director of Nursing forwards the recommendations to the assigned Health Care Coordinator (HCC)within 5 days of review and the HCC forwards the recommendations to the prescribing physician for consideration and documentation within one week of the completion date of the review. The prescribing physician notes the receipt of recommendations in the medical record, within one week. The HCC forwards the completed pharmacy review to the Qualified Intelluctional Development Professional (QIDP) to share with the IDT. All original pharmacy reviews will be kept in the medical record/scanned into Point Click Care (PCC) system.
The Director of Quality Assurance/Director of Nursing will complete a audit of pharmacy reviews within 3 weeks following the pharmacy recommendations to ensure the reviews are completed, the reviews are within the current quarter, the prescribing physician notes the receipt of recommendations in the medical record and that the QIDP received a completed pharmacy review to share with the IDT. Audit findings will be forwarded to Administrator, within two days of the audit. The Administrator will direct any correction needed within 5 days. Target date: 9/2023.
Responsible Persons: Director of Nursing, Administrator and Quality and Risk Administrator
483.460(l)(2) STANDARD
DRUG STORAGE AND RECORDKEEPING
Name - Component - 00
The facility must keep all drugs and biologicals locked except when being prepared for administration.
Observations:
Based on observation and interview with administrative staff, the facility failed to ensure that all drugs and biologicals are locked except when being prepared for administration for one of three sample Individuals. This practice is specific to Individual #1.
Findings include:
1. Observations of the medication administration process completed on 09/08/2021 from approximately 4:00 PM until 4:15 PM revealed a staff person sitting at a small table in the medication room with the door open. The staff removed Individual #1's 4:00 PM medications from a plastic container located on the shelf, punched the pills from the blister packs into a small plastic cup, and added applesauce. The staff then signed off the medications electronically on an ipad and placed the blister packs back in the plastic container and placed it back on the shelf. These medications included:
-Clonazepam 1mg tablet
-Potassium CHL 20MEQ three tablets
-Potassium Citrate 30mg three tablets
At 4:05 PM, prior to administering Individual #1 his medications, the direct care staff walked out of the medication room, across the family room to the bedroom hallway, leaving the the door open for approximately one minute. At this time, there were three Individuals in the family room at and one staff who was assigned to be with one of the three Individuals at all times. When the medication door was open, this surveyor observed the medications for the eight Individuals located in plastic containers without lids, on the shelves, with the Individuals name on them. There was a small table and chair next to the shelves.
Interview with the program director on 09/08/2019 at approximately 4:15 AM, confirmed that the medication room should be kept locked except when preparing medications to administer.
Plan of Correction:W-382
All facility staff will receive and refresher course on proper medication administrator practices and policies. This training will be completed by training department by 11/15/22 following the Pennsylvania Medication Administrator Training.
Target date: 11/15/22
All facility staff will receive instructions to never leave medication room door opened or unlocked at any time except when preparing medications for dispensing.
These trainings will be recorded on training logs. In addition, a copy forwarded to Administrator.
Target date: 11/15/22
The House Manager will be responsible to conduct monthly medication administration observations at varying times, days and staff to ensure compliance. These audits will be forwarded to Administrator for review within 5 days, who will direct corrective action as needed.
Target date: 9/23/2023
The Residential Coordinator will conduct monthly medication administration observations at varying times, days and staff to ensure compliance. These audits will be forwarded to Administrator for review within 5 days, who will direct corrective action as needed.
Target date: 9/23/2023
The Director of Operations will complete an unannounced quarterly medication observation at varying times, days and staff. These observations will be forwarded to Administrator within 5 days. The Administrator will direct any corrective action need within 5 days.
Target date: 9/23/2022
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