Initial Comments:
A focused fundamental survey visit was completed on September 25 and 26, 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 five, and the sample consisted of three individuals.
Plan of Correction:
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 observation, a review of facility records and documention and interview with the facility staff, the facility failed to provide each employee with initial and continuing training that enables the employee to perform his or her duties effectively, efficiently and competently for three of four sample Individuals. This practice is specific to Individuals #1, #2, and 3.
Findings included:
Observations of the evening routine were completed at this residence on 09/25/2024 from 3:45 PM until 5:20 PM. At 4:44 PM, staff had Individual #3 come to the kitchen to assist in pureeing the meal. This surveyor observed staff prepare a plate with lasagna, mashed potatoes and spinach on a plate and cover with plastic lid and place on counter. Staff proceeded to put a serving of lasagna, mashed potatoes and spinach in the food processor and Individual #3 pushed the food processor button blending all three foods together. Staff again place a serving of lasagna, mashed potatoes, and spinach in the food processor and Individual #3 again pushed the food processor button blending all three food together. Staff placed the pureed food into a bowl and placed it on the counter. At 4:56 PM, staff placed the bowl of pureed meal (lasagna, mashed potatoes, spinach, pureed all together) in front of Individual #1. At 4:58 PM, staff escorted Individual #3 to the counter to retrieve his plate of lasagna, mashed potatoes and spinach and take it to the table. At 5:00 PM, Individual #2 was escorted to the table and staff placed the pureed together meal (lasagna, mashed potatoes, spinach) in front of him. Staff poured the drinks of juice for each Individual.
Interview with the Director of ICF on 09/26/2024 at approximately 9:00 AM confirmed that Individuals should not have all foods blended together and the food should be plated separately and Individuals should participate in serving themselves their meal.
Plan of Correction:CE #1: On 9-26-24, the ICF Program Director retrained the QIDP on the requirement that individuals with altered diets must have their food prepared and altered separately. Altered foods should never be blended together and must be plated separately. On 9-26-24, the QIDP retrained the Home Manager and all current staff on the requirement that individuals with altered diets must have their food prepared and altered separately. Altered foods should never be blended together and must be plated separately. Documentation will be the Meal Preparation and Family style staff retraining sign in sheet.
CE #2: By 10-11-24 the House Nurse will retrain the QIDP, House Manager, and staff on each individual that resides at this home's physician ordered diets, including the consistencies that food and drink are to be prepared and served for each individual. The training will include the requirement that each food item is prepared and served separately and not mixed together at any point. The training will include the use of a food substitution list for staff to follow when menus differ, an item is unavailable, or an item is not desired by an individual. Documentation will be the Catherine Specific Meal Training Sign In Sheet.
CE #3: Twice weekly the HM will do random and unannounced observations during the weekdays and the weekends to ensure that staff are following the proper procedures for meal preparation. Observations will occur during different mealtimes. The HM will document observances on the Mealtime Observation Notes and any feedback given to staff will be documented. Twice weekly the HM will submit the Mealtime Observation Notes to the QIDP for review within 5 days of the observation. Any feedback given by the QIDP to the HM will be documented on the Mealtime Observation form. Twice a week the QIDP will submit the Mealtime Observation Notes to the Program Director for review within 5 days after the observation. Any feedback given by the Program Director to the QIDP will be documented on the Mealtime Observation form.
CE #4: Twice a month the QIDP will do random and unannounced observations during the week to ensure that staff are following the proper procedures for meal preparation. Observations will occur during different mealtimes. The QIDP will document observations on the Mealtime Observation Notes and any feedback given to staff will be documented. The the QIDP will submit the Mealtime Observation Notes to the Program Director for review within 5 days of the observation. Any feedback given by the Program Director to the QIDP will be documented on the Mealtime Observation form.
CE #5: The Program Director will review all documentation associated with this plan of correction within 5 days of the observations to ensure that all training and reviews are occurring as required. Any missing documentation or incorrect documentation will be immediately addressed with the associate responsible and documented. Documentation will be the Program Director's signature on all forms.
483.430(e)(2) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
For employees who work with clients, training must focus on skills and competencies directed toward clients' health needs.
Observations:
Based on observation, record review and interview with administrative staff, the facility failed to ensure for employees who work with clients receive training that focuses on skills and competencies directed toward clients' health need for one of two sample individuals who were observed during the medication administration process. This practice is specific to Individual #3.
Findings include:
Two medication administration observations for Individual #3 on 09/25/2024 revealed the following:
1. Observations from 7:14 AM to approximately 7:18 AM, revealed, Individual #3 was moved in his wheelchair into the office area by a staff person. This area serves as the medication administration room This staff person turned Individual #3 towards the desk/computer area and then staff proceeded to the closet in which the medications are stored. The staff person located Individual #3's medication bin containing the medications for Individual #3 and brought the medication bin to the desk/computer area. Without speaking to Individual #3, the staff person removed the medication blister packs containing the following five medications: Geodon 20 mg.; Zestril 5 mg.; Norvasc 2.5 mg.; Vimpat 200 mg.; and
Ativan 1 mg.
The staff person then scanned each medication blister pack individually, punched out the medication from the blister pack into a plastic dosing cup and turned towards Individual #3 with the medications in the cup. Individual #3 opened his mouth and the staff person poured the five medications into Individual #3's mouth. The staff person then handed Individual #3 a metal thermal cup with a straw placed in a hole in the plastic lid. Individual #3 drank through the straw. The staff person removed the thermal cup, threw the plastic dosing cup away, and returned the blister packs and medication bin to the office closet.
2. Observations at the afternoon medication administration on 09/25/2024, between 4:00 PM and 4:30 PM, revealed that at approximately 4:05PM, Individual #3 wheeled himself into the office for his medications. Staff removed a locked box from the medication closet. Staff unlocked the box and Individual #3 lifted the box lid, identified his afternoon blister pack containing his medications, removed the blister pack from the box, and punched out his medication of Lorazepam into a plastic medication cup. Individual #3 independently placed the pill into his mouth and independently drank his water. After this medication administration Individual #3, wheeled himself out of the office.
3. A review of Individual #3's annual self medication assessment completed on 11/30/2023 revealed:
with 1 physical guidance, Individual #3 is able to:
-Obtain the key to the medication cabinet
-Unlock medication cabinet
-Lock and close the cabinet
With 1-2 verbal prompts, Individual #3 is able to:
-Take out the medication box
-Locate the correct medications
-Take out the required medications
-Take the medications required
-Return the medications to the medication box
-Return the medication box to the cabinet
-Return the key to staff
-Indicate or say the name, dosage, reason and state the side effects of the medication
A review of Individual #3's training programs revealed that Individual #3 had a self medication training plan dated 02/07/2024 in which Individual #3 was presented the medication blister pack of Ativan and given the verbal cues:
- "[Individual #3], what medication is the name of this medication?", Individual #3 was able to to answer "Ativan" with 1 verbal prompt or less for 4 of 5 sessions. Criteria met 02/19/2024.
-"[Individual #3], how many times a day do you take Ativan?", Individual #3 responds, "Four times a day", with 1 verbal prompt or less for 4 of 5 session. Criteria met on 03/08/2024.
--"[Individual #3], why do you take Ativan?", Individual #3 was able to answer "to feel better" with 1 verbal prompt or less for 4 of 5 sessions. Criteria met on 03/22/2024.
Interview with the Program Director of ICF/ acting Qualified Intellectual Disabilities Professional, confirmed that Individual #3 is able to participate in his medication administration with one verbal prompt or less and was unsure why the morning staff person did not include Individual #3 in his medication administration pass by recognizing and encouraging Individual #3 to use his self-medication skills.
Plan of Correction:CE #1: By 10-11-24 a performance Management will be completed for the worker on shift who did not provide active treatment during the medication administration process. Documentation is the file for this worker. By 10-11-24 The Program Director will train the QIDP on individual #3 specific medication administration program focusing on skills individual #3 is currently working on, and skills individual #3 has worked on in the past. By 10-11-24 the QIDP will re-train all staff on individual #3 specific medication administration program focusing on skills individual #3 is currently working on, and skills individual #3 has worked on in the past. Documentation will be the individual's self-medication program sign off form.
CE #2: By 10-11-24 The Program Director will train the QIDP on all individuals specific medication administration program focusing on skills each individual is currently working on, and skills each individual has worked on in the past. By 10-11-24 the QIDP will re-train all staff on individuals' specific medication administration program focusing on skills each individual is currently working on, and skills each individual has worked on in the past. Documentation will be the individual's self-medication program sign off form.
CE #3: Twice weekly the Home Manager will observe randomly selected medication passes during weekdays and weekends. An observation will be conducted to ensure active treatment and individual involvement is occurring during each and every medication pass. Any procedures not being followed will be documented and performance management steps will be taken. Twice weekly the HM will submit the medication observation form to the QIDP for review within 5 days of the observation. Any feedback given by the QIDP to the HM will be documented on the medication observation form. Twice a week the QIDP will submit the medication observation form to the Program Director for review within 5 days after the observation. Any feedback given by the Program Director to the QIDP will be documented on the Mealtime Observation form.
CE #4: Twice monthly the QIDP will observe randomly selected medication passes. An observation will be conducted to ensure active treatment and individual involvement is occurring during each and every medication pass. Any procedures not being followed will be documented and performance management steps will be taken. The QIDP will submit the medication observation sheet to the Program Director for review within 5 days of the observation. Documentation will be the MEDICATION OBSERVATION sheet.
CE #5: The Program Director will review all documentation associated with this plan of correction within 5 days of the observations to ensure that all training and reviews are occurring as required. Any missing documentation or incorrect documentation will be immediately addressed with the associate responsible and documented. Documentation will be the Program Director's signature on all forms.
483.480(d)(4) STANDARD
DINING AREAS AND SERVICE
Name - Component - 00
The facility must assure that each client eats in a manner consistent with his or her developmental level.
Observations:
Based on observation and interview with administrative staff, the facility failed to ensure that
Individuals are actively encouraged to eat in a manner consistent with his or her developmental level including family style dining practice for four of four sample Individuals.
Findings include:
Observations on 09/25/2024 between 4:44 PM and 5:17 PM revealed that staff had prepared each Individual's plate using either a palate or their adaptive feeding equipment, at the kitchen counter near the kitchen range. Once all Individuals plates were prepared, staff placed the plates on the kitchen counter near the dining room table.
Individual #1 placed the placemats at each Individuals place setting on the table. Staff gathered all utensils, cups and napkins for the meal and placed them at each Individuals place settings. At 4:55 PM , the Individuals came to the dining table. At 4:56 PM, staff placed Individual #1's prepared meal in front of him, At 4:58 PM, staff escorted Individual #3 to the kitchen counter to retrieve his prepared meal plate and take it to the table. Staff proceed to escort Individual #4 to the kitchen counter to retrieve his meal plate. At approximately,
5:00 PM, Individual #2 was escorted to the dining room table and staff placed his prepared plated meal in front of him. Staff poured the Individuals' juice into their cups.
All Individuals were observed to eat/drink independently. There were no serving bowls on the table to afford the Individuals the opportunity to serve themselves or obtain second helpings as in family style dining. Staff made no attempt to involve any of the Individuals in putting food on the table, or having the individuals serve themselves.
Interview with the Director of ICF on 09/26/2024 at approximately 9:15 AM confirmed that the Individuals are able to participate in family style dining and should be involved with serving themselves their meals.
Plan of Correction:CE #1: On 9-26-24, the ICF Program Director retrained the QIDP on the requirement that all individuals are served a family style meal. Individuals will be involved to the best of their abilities to prepare and serve themselves. Meals will be served at the dining room table in serving bowls and each individual will participate in serving themselves. Documentation will be the Meal Preparation and Family Style staff retraining sign in sheet.
CE #2: By 10-11-24 the Program Director will train the QIDP on Active treatment. By 10-11-24 the QIDP will retrain the House Manager and staff on active treatment and how to implement during mealtimes. All associates working in the homes will be trained on the procedure to provide active treatment at all times including during the preparation, serving, and eating of meals. Documentation will be the Catherine Ave Active treatment training sign off.
CE #3: Twice weekly the HM will do random and unannounced observations during the weekdays and the weekends to ensure that staff are providing active treatment during mealtimes and the individuals are served a family style meal. The HM will document their observations and feedback on the Mealtime observation: Family style meal form. Twice weekly the HM will submit the mealtime observation: Family style meal form to the QIDP for review within 5 days of the observation. Any feedback given by the QIDP to the HM will be documented on the mealtime observation: Family style meal form. Twice a week the QIDP will submit the mealtime observation: Family style meal form to the Program Director for review within 5 days after the observation. Any feedback given by the Program Director to the QIDP will be documented on the Mealtime Observations: Family Style meals.
CE #4: Twice a month the QIDP will do random and unannounced observations to ensure that staff are providing active treatment during mealtimes and the individuals are served a family style meal. The QIDP will document observances on the Mealtime Observations: Family Style meals form, and any feedback given to staff will be documented. The QIDP will submit the Mealtime Observation: family style meals form to the Program Director for review within 5 days of the observation. Any feedback given by the Program Director to the QIDP will be documented on the Mealtime Observations: Family Style meals form.
CE #5: The Program Director will review all documentation associated with this plan of correction within 5 days of the observations to ensure that all training and reviews are occurring as required. Any missing documentation or incorrect documentation will be immediately addressed with the associate responsible and documented. Documentation will be the Program Director's signature on all forms.
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