Initial Comments:
A extended survey visit was completed on September 19 and 20, 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 nine, and the sample consisted of four individuals.
Plan of Correction:
483.410(a)(1) STANDARD
GOVERNING BODY
Name - Component - 00
The governing body must exercise general policy, budget, and operating direction over the facility.
Observations:
Based on observations and interview with the facility and administrative staff, the agency failed to exercise general policy, budget and operating direction over the facility to provide for the health and safety of Individuals in the provision of maintenance and repair of the facility.
Findings include:
Observations on 09/19/2024 from 7:35 AM to 8:00 AM revealed the following:
Bathroom at front end of the facility
-Caulking around the upper and lower edges of the shower stall is peeling.
-The rubber strip across the front base of the shower on the right side did not adhere to the base of the shower stall. This strip also had black spots located at various spots for the entire length of the strip.
-There were two bars of used soap in the soap dish on the back wall in the shower.
-There was a green and white long handled cleaning scrub brush hanging off the railing on the back wall of the shower. This brush a black substance on the handle, on the bristles and at the base of the bristles.
-There were 3 identical electric toothbrushes in their charging station located to the left of the sink. There wer not identifying markings on the toothbrushes indicating which toothbrush belonged to which individual. Interview with the house supervisor during this observation confirmed these items were not marked for ownership
-In what appeared to be water/urine getting under the flooring around the shower, and around the toilet, the flooring was pulling away from the edge of the shower and the toilet respectively.
-The corners of the floor and approximately 2 to 3 inches up the sides of the wall had a black substance.
Hallways
-The right inside wall located in the hallway to the right of the front door of the facility between the living room and the back hallway had approximately seven to eight dried on liquid drip marks running down the side of the wall approximately 4 to 9 inches in length
-The back hallway wall located near the back door of the facility had a brown substance smeared on the wall approximately three to four feet up the wall from the floor and approximately 7 to 9 inches in length
Bathroom at back end of the facility
-A urine collection bag filled approximately 3/8 to 1/2 way full of a yellow liquid hanging on the hand rail on the right side as you walk into the bathroom.
-Caulking around the upper and lower edges of the shower stall is peeling
-In what appeared to be water/urine getting under the flooring around the shower, and around the toilet, the flooring was pulling away from the edge of the shower and the toilet respectively.
-The corners of the floor and approximately 2 to 3 inches up the sides of the wall had a black substance.
Personal care bins
-All the personal care bins did not have any type of comb or brush.
-Each person car bin was missing at least one of the following items:
a. Soap and shampoo (or a combination of bodywash/shampoo)
b. Deodorant
c. Toothpaste
d. Toothbrush and covers for the toothbrushes
e. Shaving equipment and accessories (i.e. shaving cream or pre-shave or after shave)
f. Comb/brush
Interview with the house supervisor and the Director of IDD/ICF services on 09/19/2024 at approximately 7:45 AM to 8:00 AM acknowledged and confirmed:
-Personal care bins for each individual were missing at least one of the items noted above
-The condition of the bathrooms and hallway walls as described above.
-The house supervisor had extra supplies in the supply area but were not dispersed to the individuals.
Plan of Correction:CE 1 and 2
Immediately following survey, the team including: The house Manager (HM), Residential Coordinator (RC), Assistant Director of Nursing(ADON), Qualified Intellectual Disability Professional(QIDP), Director of Operations, two Health Care Coordinator (HCC), Behavior Specialist and Program Director met to review findings revealed during exit survey. The Administrator directed the team to immediately have physical plant concerns address. This would include but not limited to: Shower/bathrooms, toilet/sink fixtures, tiling, shower stalls and ceilings, all flooring, all corridor walls, individual bedrooms' furniture and interior. Environmental cleaning, sanitizing, painting and floor steamed cleaned or scheduled to be replaced was initiated.
Additionally, all personal care items and caddies should be stocked with necessary products and labeled. Each person should have a toothbrush either standard or electric and housed with label clearly.
On 9/26/2024, Administrator met will facility Directors which included above mentioned and Director of Social Service, Director of Training and Director of Nursing. During this meeting the 2567 report was reviewed and beginning plans for sustained correction were initiated.
The plans for correction includes a systematic, multi-tiered auditing, enhanced management training focused on not only physical plant but all areas of person-centered care and the importance of maintaining a safe and healthy environment.
Completion date: 11/15/2024
CE 3
Development of an audit tool was drafted and specific responsibilities for areas of concern were assigned. Flooring for each bathroom was sent to outside contractor and facility is awaiting date for installation, however in meantime, all floors were steamed cleaned and will remain on a daily basis until replaced. Interior hallways were cleaned and repainted. All personal care caddies were replenished and will be maintained daily. All standard/electric toothbrushes were labeled with individual's name and cover.
An audit tool will be used to ensure proper compliance and upholding standards related to physical plant and health and safety.
Additionally, prior to change of shifts (7a-3p, 3p-11p and 11p -7a) managers on duty will complete a walk-thru together and document on the daily shift report it was completed and will note any area of concern.
Completion date: 11/15/2024
CE 4
The Environmental Audit will be completed as follows varying days and times.
House Manager weekly for next 6 months and monthly thereafter
Residential Coordinator every 2 weeks for 6 months and monthly thereafter
Director of Operations will review the above audits and forward to Administrator including any areas of non-compliance and date of correction
The Quality Management team will complete monthly audits for the next six months and notify Administrator immediately of any areas on non-compliance.
All audits will be recorded and kept on file.
Completion date: 4/1/2025
CE 5
Responsible persons: House Manager(s), Residential Coordinator, Director of Operations, Nurse, ADON, DON, Quality Management team, Administrator
The Administrator is responsible for all areas of correction.
483.410(d)(3) STANDARD
SERVICES PROVIDED WITH OUTSIDE SOURCES
Name - Component - 00
The facility must assure that outside services meet the needs of each client.
Observations:
Based on observation and interview with day program staff, day program administrative staff, facility nurse and the qualified intellectual disabilities professional (QIDP), the facility failed to ensure that outside services meet the needs of each individual for one of one sample individual who attends the agency's day program. This practice is specific to Individual #1
Finding include:
Observations completed on 09/19/2024 at approximately 10:15 AM to 10:55 AM revealed the following:
Upon entering the "Pink" class, Individual #1 was sitting in his wheelchair in the middle of classroom facing the wall that had a TV. Individual #1's eyes were closed and there was no staff interacting with him nor were the other individuals in close proximity to him. Approximately 10:45 AM, a staff person turned Individual #4 around and faced him towards her at the rear of the classroom while remaining in the middle of the room. This staff person sat down at the table next to where Individual #1 sat and the staff did not interact with Individual #1, but instead the staff appeared to be watching the TV on the wall at the opposite end of the room. There was no interaction between this staff person and
Individual #1 after she turned Individual #1 to face her from 10:45 to 10:55 AM while the surveyor was in the room. This was pointed out to the program specialist at the time and the program specialist acknowledged the non-interaction.
Interview with the program specialist at approximately 10:16 AM regarding the activities and training plans for Individual #1 revealed Individual #1 started attending the day program on 7/11/2024. When asked what training programs Individual #1 was working on, this interviewee revealed Individual #1 does not have any current training programs. When asked if Individual #1 had any training plans at the residence that could be crossed trained in the day program, this interviewee stated that she believed there were. However, this interviewee was unable to identify what training plans could be cross trained and why cross training had not been implemented.
A review of Individual #1's residential record at the facility on 09/20/2024 from approximately 8:45 AM to 11:00 AM, revealed the following
A review of Individual #1's annual plan (IPP) dated 04/10/2024, revealed the following diagnoses:
-Quadriplegia, unspecified
-Cerebral Palsy, unspecified
-Congenital hydrocephalus, unspecified
-Unspecified convulsions.
-Urinary incontinence
-Full incontinence of feces
-Epilepsy
-Prone to pressure ulcers
-Sensorimotor hearing loss
-Non-ambulatory
Continued review of Individual #1's IPP dated 04/10/2024, under the section titled, Supports needed to be Successful, page 2 of 3, revealed the following information:
-Individual #1 needs day program services
-Individual #1 needs to complete his goals
Further review of Individual #1's record revealed, Individual #1 is working on the following training programs at the residence:
-Sensory Stimulation: Individual #1 will have different parts of his face and hands massaged for 5 times for 2 minutes for 10:12 sessions.
-Apply Lotion: Individual #1 will tolerate staff applying lotion to various parts of his body due to dry skin for 10:12 sessions.
-Fine Motor skills: Individual #1 will hold the "hand carrots" in his hands for a total of 5 hours during the day for 10:12 sessions.
Interview with the QIDP on 09/20/2024 at approximately 10:50 AM confirmed that the training plans noted above could be implemented across both the day program and the residential settings. Further interview noted that this interviewee was unable to indicate why these training plans were not implemented within the day program setting.
Plan of Correction:CE1
The Qualified Intellectual Disability Profession (QIDP) will conduct a meeting for individual #1 which will include day program service representatives on 10/11/24 to review individual #1 individual Program Plan (IPP). During this meeting the QIDP and day program staff will identify at least 2 day program training programs that individual #1 will work on during his hours of participation, as well as, preferred activities and meaningful programming supporting his residential IPP. The QIDP will ensure a method of data collection and review at least monthly.
Completion date : 10/9/2024
CE 2
The QIDP will review all other program services offered to all other facility individuals attending outside community program. The QIDP will review individual's IPP and ensure that day services programming has appropriate objectives and a means to document participation showing benefits of participation and if necessary coordinate necessary changes. The QIDP will complete monthly program observations and have routine dialog with day services staff.
Target date: 11/30/2024
CE 3 / 4
The QIDP will be responsible to complete 2 observations a month for individual #1 for the next 3 months. These observations will be recorded of "Day Program Observation" form. The observation should include: level of participation on training objectives, participation in group activities, use of adaptive equipment if applicable, lunch/snack times and any behavioral concerns. If QIDP finds concerns it will be noted on observation form and necessary correction with responsible party identified.
The observation form will be signed by Director of Day Services at completion of each visit.
Upon completion of observation form, the QIDP will forward to Program Director for review. The Program Director will guide QIDP in initiating any corrective actions. The Program Director will inform Administrator of any areas of non-compliance.
The Program Director will complete 4 additionally observation on days different than QIDP for the next 4 months and review results with Administrator.
Target date: 2/1/2025
CE 5
Responsible: QIDP, Program Director, Program Specialist and Administrator
The Administrator will oversee plan and direct all necessary action.
483.430(a) STANDARD
QIDP
Name - Component - 00
Each client's active treatment program must be integrated, coordinated and monitored by a qualified intellectual disability professional who-
Observations:
Based on record review and interview with the Qualified Intellectual Disabilities Professional (QIDP) and administrative staff, the QIDP failed to integrate, coordinate and monitor each individual's active treatment program for one of one sample Individual who attends the agency's day program.. This practice is specific to Individual #1.
The findings included:
The facility failed to ensure that outside services meet the needs of each individual for one of one sample individual who attends the agency's day program. This practice is specific to Individual #1. Refer to W-120.
Plan of Correction:CE1
The Qualified Intellectual Disability Profession (QIDP) will conduct a meeting for individual #1 which will include day program service representatives on 10/11/24 to review individual #1 individual Program Plan (IPP). During this meeting the QIDP and day program staff will identify at least 2 day program training programs that individual #1 will work on during his hours of participation, as well as, preferred activities and meaningful programming supporting his residential IPP. The QIDP will ensure a method of data collection and review at least monthly.
Completion date : 10/9/2024
CE 2
The QIDP will review all other program services offered to all other facility individuals attending outside community program. The QIDP will review individual's IPP and ensure that day services programming has appropriate objectives and a means to document participation showing benefits of participation and if necessary coordinate necessary changes. The QIDP will complete monthly program observations and have routine dialog with day services staff.
Target date: 11/30/2024
CE 3 / 4
The QIDP will be responsible to complete 2 observations a month for individual #1 for the next 3 months. These observations will be recorded of "Day Program Observation" form. The observation should include: level of participation on training objectives, participation in group activities, use of adaptive equipment if applicable, lunch/snack times and any behavioral concerns. If QIDP finds concerns it will be noted on observation form and necessary correction with responsible party identified.
The observation form will be signed by Director of Day Services at completion of each visit.
Upon completion of observation form, the QIDP will forward to Program Director for review. The Program Director will guide QIDP in initiating any corrective actions. The Program Director will inform Administrator of any areas of non-compliance.
The Program Director will complete 4 additionally observation on days different than QIDP for the next 4 months and review results with Administrator.
Target date: 2/1/2025
CE 5
Responsible: QIDP, Program Director, Program Specialist and Administrator
The Administrator will oversee plan and direct all necessary 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 one of one sample Individuals with medications on their nightstand. This practice is specific to
Individual #4.
Findings included:
Observations on 09/19/2024 at approximately 9:20 AM revealed a nightstand in
Individual #4's bedroom with a tube of Desitin 13% Rapid Relief Cream with a pharmacy label. This pharmacy label stated, "Refer to medical record for administration". Also located on this individual's nightstand was a brown square bottle with a white lid. This bottle had a m label located on one of the sides of the bottle which stated, "Hydrogen Peroxide 3 %".
A review of Individual #4's current 90 Day Physician's Orders dated 08/15/2024, revealed there are two written orders for the Desitin 13% Rapid Relief Cream. The first order is for the Desitin 13% Rapid Relief Cream to be applied topically to posterior scrotal areas as needed for incontinence care and the second order is for Desitin 13% Rapid Relief Cream to be applied topically to posterior scrotal area every shift for incontinence care. Both orders were initially ordered on 10/19/2023 with no end dated identified. There was no indication on these physician orders for the use of hydrogen peroxide 3% for this Individual.
Interview with the facility nurse on 09/19/2024 at approximately 9:30 AM confirmed Individual #4 has an order for the Desitin 13% Rapid Relief Cream and that the cream should not be left in Individual #4's bedroom; the medication should be returned to the medication cabinet after use and the cabinet should be locked. This interviewee also confirmed that there is no current physician order for the use of Hydrogen peroxide 3% for Individual #4 and indicated that this item should not be stored in the bedroom area.
Plan of Correction:CE 1
On 9/30/2024, 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. The ADON specifically reviewed physician orders for individual # 4. Clarification of orders specific to use, schedule for use and application of Desitin 13% Rapid Relief cream was reviewed.
Completion date: 9/30/2024
CE 2
ADON/DON will review all other individual orders. Facility nursing staff will be reminded/retrained to follow orders as written and following medication administration all medications and topical treatments must be returned to locked medication cabinet.
The ADON developed a checklist that will be used by nursing staff daily prior to the end of each for their shift. This checklist will be kept in a nursing binder within the nursing office.
HealthCare Coordinators (HCC) will use the same checklist weekly. This checklist will record bedroom and medication areas with attention given to, but not limited to; beds frames/rails, enteral feeding equipment, medical equipment, trash container and bedroom nightstands/tables.
The ADON/DON will review completed checklist weekly for 3 months.
Completion date: 12/1/2024
CE 3 / 4
The Healthcare Coordinator (HCC) will complete an "Environmental Audit" weekly, varying days and times for the next 3 months and monthly thereafter. Any area of non-compliance will be noted. These audits will be forward to Administrator and kept on file. The Administrator will direct all necessary corrective actions.
The ADON/DON will complete monthly "Environmental Audits" for the next 6 months and notify Administrator immediately of areas of non-compliance.
Completion date: 4/1/2025
CE 5
Responsible persons: Nurse, HCC, ADON, DON and Administrator
Administrator will oversee plan and ensure necessary corrective action
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