Initial Comments:
A focused fundamental survey visit was completed on November 6 and 7, 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 seven, and the sample consisted of
three individuals.
Plan of Correction:
483.460(a)(3) STANDARD
PHYSICIAN SERVICES
Name - Component - 00
The facility must provide or obtain preventive and general medical care.
Observations:
Based on facility record review and interview with administrative staff, the facility failed to
provide or obtain preventative and general medical care for one of one sample Individual
who was identified by specialized studies for increased surveillance for colon cancer. This practice is specific to Individual #3.
Findings include:
A review of Individual #3's record was conducted on 11/07/2024 from approximately
8:45 AM to 10:30 AM. This review revealed the following information:
Individual #1 had a colonoscopy completed on 09/23/2019. As a result of this procedure, the gastroenterologist noted that during the studies, the presence of tubular adenoma [ pre-cancerous polyp] was identified in various areas. As a result of these results, this specialist recommended a follow-up study be completed on 04/13/2020.
However, in further record review, there was no documentation that a follow-up colonoscopy was not completed until 01/28/2022. At that time, the test was not completed due to poor preparation and evacuation of the colon. The recommendation post this encounter was to repast this study in three months.
It was not until 10/6/2022, that a follow-up visit with the gastroenterologist was completed
At that time, this specialist requested that the facility should make a decision to either consider another colonoscopy or complete a Cologurad test which is a non-invasive surveillance method for colon screening .
Further record review revealed that there has been no further effort by the facility to secure or complete a Cologuard test as recommend by the gastroenterologist on 10/06/2022 as a non-invasive method for screening of colorectal cancer which had been potentially identified in the colonoscopy completed for this Individual on 09/24/2019.
Plan of Correction:
Individual # 3' s , interdisciplinary team (IDT) met to review physician findings for colon cancer surveillance. The team recommended that the primary care physician obtain a "Cologuard" screen and ordered and gastroenterologist follow up consult. The order for "Cologuard" screening was obtained 11/20/24 and an appointment with gastroenterologist is scheduled for 12/11/24. The team will follow up once test results are obtained. The IDT also reviewed all physician orders and specialist recommendations needing follow-up and any preventative medical care indicated.
The IDT will convene when a new diagnosis is given and ensure follow-up care is given. The IDT will monitor all preventative care guidelines in accordance with established standards.
Completion date: 1/24/2025
CE 2
The Qualified Intellectual Disability Professional (QIDP) will schedule IDT meetings for the six other individuals residing at this residence. These reviews will include review of physician orders, preventative care plans and any specialist recommendation for necessary follow-up or preventative screenings. These meetings will be documented and include responsible party for needed follow-up, date follow-up needed by and responsible person for the follow-up.
The IDT will convene when a new diagnosis is given and ensure follow-up care is given. The IDT will monitor all preventative care guidelines in accordance with established standards.
CE 3 / 4
The Administrator and Director of Training will train the Director of Nursing (DON), Assistant Director of Nursing (ADON) and Health Care Coordinator (HCC) code 483.406 Physician Services emphasizing the importance of ensuring preventative and medical care ordered by primary care physician or specialist. The training also highlighted the need for notification to the IDT of these services.
In any situation where it is found that recommended care is not attainable whether from lack of physician availability, testing roadblocks or other unexpected circumstances, the Administrator must be notified. This notification should occur within 72 hours of discovery.
Training acknowledgement sheets will be available at the facility.
Completion date: 1/24/25
A Medical Chart Audit will be used to monitor. Thes audits will be conducted monthly by DON/ADON for the next six months and quarterly until 12/31/25.
Audits will be forwarded to the Administrator upon completion and should note any non-compliance. The Administrator will direct corrective action needed.
Completion Date: 12/31/2025
CE 5
The Administrator is responsible for overseeing and executing all corrective action.
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 facility staff, the facility failed to ensure that all drugs and biologicals are locked except when being prepared for administration for three of three sample Individuals. This practice is specific to Individual #1, 2 and #3.
Findings included:
1. Observations on 11/06/2024 from 7:00 AM to 8:00 AM revealed that prescribed medications for the individuals who reside in this home are kept in an office adjacent to the kitchen area in this home. During this observation period , the office door to this area was propped open with a small wedge at the bottom of the door. From the doorway, this surveyor observed blister packs of various medications in an open, clear plastic gallon bag on the counter. On further examination, the 14 blister packs prescribed for Individual #1, #2
and #3 containing the following medications:
Individual #1
-Midodrine 10 mg, used to treat low blood pressure, had three pills in the blister pack
Individual #2
-Sulfasalazine [azulfidine] 500 mg, had five pills in the blister pack
Individual #3
-Gabapentin [neurontin] 800 mg, used to treat and prevent seizures in people with epilepsy, had four pills in the blister pack
-Gabapentin 800 mg, had five pills in the blister pack
-Gabapentin 600 mg, had five pills in the blister pack
-Lorazepam [ativan] 1 mg, a sedative used to treat seizure disorders, had 3 pills in the blister pack
-Lorazepam 1 mg, had four pills in the blister pack
-Lacosamide [vimpat] 200 mg, an anti-seizure medication, had five pills in the blister pack
-Simvastatin [zocor] 10 mg, used to treat high cholesterol and triglyceride levels, had five pills in the blister pack
-Famotidine [ pepcid] 40 mg, used to treat gastroesophageal reflux disease, had five pills in the blister pack
-Clonidine [catapress] 0.1 mg, used to treat high blood pressure, had five pills in the blister pack
-Citalopram [celexa] 20 mg, used to treat depression, had five pills in the blister pack
-Austedo [ingrezza] 6 mg, used to treat involuntary movements caused by tardive dyskinesia, had five pills in the blister pack
-Vitamin D 25 mg, had five pills in the blister pack
At approximately 7:10 AM, this surveyor observed in Bathroom A Individual #2's Desitin Diaper Rash 40% Paste and Calmoseptine Ointment, both with a pharmacy label, on the counter next to the sink which is prescribed for use during incontinence care.
2. A review of the facility's medication administration policy and procedure effective date 02/01/2023 on 11/07/2024 at approximately 9:00 AM revealed all medications will be kept in a locked/secured area. Unlicensed staff certified to administer medications will follow protocols in their program area to label discontinued medications and store in a locked area until the medication can be obtained and destroyed by the Licensed Healthcare Professional.
Interview with the facility nurse on 11/06/2024 at approximately 8:00 AM revealed the medications in the blister packs were discontinued. This interviewee confirmed that the discontinued medication is to be removed from the Individual's medication container, placed in a bag labeled discontinued medication and placed in the locked medication closet until picked up by the nurse.
Interview with the Program Director on 10/06/2024 at approximately 8:10 AM also confirmed that the topical medications as was observed in the bathroom A area, should not be left in the bathroom, but returned to the medication closet after each use.
Plan of Correction:CE 1
On 11/19/2024, the Assistant Director of Nursing (ADON) held a training with facility nursing staff to review the expectation that no medications or topical treatments maybe left unattended and not returned immediately to locked medication cabinet following administration. This training included medications prescribed for individuals # 1,2 and 3. The ADON reviewed the importance of all medications to never be unlocked, even momentarily in a common area and not locked in designated medication cabinet.
The Director of Training will provide all facility staff and nursing staff with a review of Medication Administration policy. Included in the policy are the procedure for medication storage and the importance of adherence to policy for medication storage of current or discontinued medications. The training will highlight that all creams and topical medications need to be returned immediately to storage area after use and when receiving medications, such as new delivery or discontinued medications being readied for return to pharmacy must always be in locked storage and never left on an office countertop.
Record of training will be kept at home.
Completion Date: 12/24/2024
CE 2
The Assistant Director of Nursing (ADON) held a training with facility nursing staff to review the expectation that no medications or topical treatments maybe left unattended and not returned immediately to locked medication cabinet following administration. This training included medications prescribed for all other individuals residing in home. The ADON reviewed the importance of all medications to never be unlocked, even momentarily in a common area and not locked in designated medication cabinet.
The Director of Training will provide all facility staff and nursing staff with a review of Medication Administration policy. Included in the policy are the procedure for medication storage and the importance of adherence to policy for medication storage of current or discontinued medications. The training will highlight that all creams and topical medications need to be returned immediately to storage area after use and when receiving medications, such as new delivery or discontinued medications being readied for return to pharmacy must always be in locked storage and never left out on an office countertop.
Record of training will be kept at home.
Completion Date: 1/24/25
CE 3 / 4
The DON/ADON will complete random observations at varying times every two weeks for the next three months. These observations will be recorded and forwarded to the Administrator for review. The House Manager will complete monthly medication observations at varying times and days for the next 6 months. These observations will be forwarded to the Administrator for review.
Completion Date: 6/1/2025
CE 5
Responsible person: Administrator will oversee and ensure all necessary corrective actions.
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