Initial Comments:
A fundamental recertification survey visit was completed on July 20 and July 21, 2023. 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:
483.410(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 a review of facility incident reports and investigation documents, the governing body of the facility failed to exercise general policy, budget and operating direction to provide for the health and safety of individuals in the provision of medication acquisition and administration for one of one sample Individual who received a reduced dose of a prescribed medication for a period of seven days. This practice is specific to Individual #3.
Findings include :
1. A review of incident report documention was completed on July 20 between 9:45 AM and 11:30 AM, A review of the record of the physician orders for Individual #3 dated
June 2023 noted that this Individual received Trazadone, 50 mg. at bedtime for the treatment of his diagnosis of bi-polar psychosis, and insomnia.. On 7/1/2022, due to an increase in manic behavior as reported by staff, an order was written by the psychiatrist for an increase in the dosage of Trazadone form the current 50 mg. to 150 mg tablet administered as (1) 50 mg tablet and (1) 100 mg tablet as prescibed .
2. A review of a subsequent investigation report was completed on July 21. 2023 between 10:00 Am and 11:00 AM. This report noted the following:
"Medication error incident report 7/18/22 ; This incident report was written by the
program supervisor [name] on 7/18/22. [program supervisor] wrote that on 7/16.22, while administering [Individual #3's ] medications, she discovered that his Trazadone 100 mg blister pack was not on site. A review of the MAR [medication administration record] demonstrated that [Individual #3] only received Trazadone 50 mg and not his full dose of 150 mg from 7/11/22 to 7/17/2022. [ program supervisor]documented".
This investigation established that the Program Supervisor who picked up Individual #3's medications packets from the pharmacy on 07/01/2022 did not report to the pharmacy that the blister pack for Trazadone, 100 mg, contained only 6 tablets instead of a full month of medication dosages. The Program Supervisor who picked up this medication did not check the package before leaving the pharmacy indicating that this person was following Covid protocol where staff who picked up medications were not opening the bag at the pharmacy.
This investigation reports that having received the correct dosage between 7/1/2022 and 7/10/2022, there were no other 100mg Trazadone dosage in the residence due to the short supply provided on 07/01/2022 at pharmacy pick up. Although monthly medication replenishment was received on 7/11/2022, it was replenished at 50 mg which was the previous physician's order written on 6/1/2022, and did not dispense the 100 mg tablet as outlined in the revised physicians order dated 07/01/2022.
Staff at the residence continued to administer 50 mg of trazodone but signed the MAR indicating that Individual #3 was given 150 mg Trazadone. Staff did not notify the appropriate supervisory personnel to report the missing medication dosages.
This investigation discovered that the circumstances leading to the lack of available medication of Trazadone in the correct dosage involved " procedural issues related to medication receipt at the pharmacy, medication transcription in the MAR, and appropriate follow-up and reporting by members of [Individual #3's] team.
Corrective actions resultant from this investigation included"
- re-train Program Supervisor of need to take blister pack to pharmacy for any re-labeling for charge of dosage or timing.
- Protocol for medication pick up to resume previous actions to check medication blister packs against the packing slip while at the pharmacy to be sure the contents match the packing slip.
- re-train staff to notify the supervisor and the nurse on call with any potential medication errors or confusion about dosage, medication counts or doucmentation to receive immediate guidance.
- nightly medication checks have been implemented in the residence in order to check MAR for documention errors and the check that medication counts are accurate.
The trainings that are listed above did not occur until 9/2/2022.
This investigation also indicated that a new poilicy and/or procedure would be developed to address the issue of medication management that were identified within the investigations. In further review, there was no policy/procedure relevant to this topic that had been developed as a result of this investigation.
Interview with the Associate Director of Quality Assurance on 07/21/2023 at approximatley 11:30 AM indicated that this policy was unavailable at this time. Subsequent interview with the Executive Director Supports for living on this same date at approximately12:00 PM confirmed that the poilicy was in the final stage of review and approval at this time.
Plan of Correction:CE1The corrective action specific to Individual #3 cannot be corrected as the incident occurred in 7/2022. On 8/8/2023, the CRS (Community Residential Services) Medication Prescription Storage, Administration and Recording policy was approved by the Sr. Vice President. The new policy was distributed by the Executive Director of Quality Improvement to the Sr. Director.
CE2 By 8/22/2023, all leadership at the home will be trained on the new Medication policy by the Sr. Director, who is a member of the committee that wrote the policy.
CE3 The new CRS Medication Prescription Storage, Administration and Recording policy includes instructions on the protocol for obtaining the prescription from the pharmacy and administering medications, including that the staff administer the right dosage. The policy states to "stop if you have any doubt that you have the right...dose." This policy will be trained to all Direct Support Professionals by the Operations Manager by 9/2/2023.
The Risk Management Team collects the completion dates for all investigation follow-ups. If the follow-up does not occur within a timely manner (generally less than 30 days after the closure of an investigation), the Risk Management Team will notify the Sr. Director and Quality Improvement Director for the follow-up to occur.
CE4 The Risk Management Team and Director or Quality Improvement will keep detailed notes and emails of all correspondence to close the loop and obtain requested documents, such as a policy change with monthly updates emailed to the Sr. Director and Executive Director, until the task is completed.
CE5 The Executive Director is responsible to oversee that policies are updated in a timely manner. Failure to do so will lead to documented requests from the work team who are producing the document to establish and meet deadlines as instructed by the Executive Director. Failure to meet the deadlines could lead to additional training and counseling of the team member.
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
and under varied conditions to-
Observations:
Based on a review of facility fire drill documentation, and interview with facility staff, the facility failed to hold evacuation drills at least quarterly for each shift of personnel under varied condition of time. This practice is specific to the third shift of personnel during the time period of July 2022 thorough June 2023.
Findings include the following:
A review of facility fire drill documentation for the period from July 2022 to June 2023 was completed on July 20, 2023 between approximatley 9:00 to 9:30 AM. This review revealed that quarterly evacuation drills conduced for the third shift of personnel during this time period were not varied beyond a 2.25 hour period within that shift as follows:
Quarter 1 - July 2022 inclusive of September 2022
- Evacuation drill conducted on July 7, 2022 at 4:45 AM.
Quarter 2-October 2022 thorough December 2022
- Evacuation drill conducted on October 21, 2022 at 6:00 AM.
Quarter 3- January 2023 through March 2023
- Evacuating drill conducted on January 14, 2023 at 6:00 AM.
Quarter 4 - April 2023 through June 2023
- Evacuation drill conducted on April 4, 2023 at 3:45 AM
Interview with facility personnel on July 20 , 2023 at approximatley 10:00 AM noted that this interviewee was unable to indicate why the times of the evacuation drills were not varied during this time period.
Plan of Correction:CE1 The Quality Improvement Director reviewed the times for drills. An old version of the schedule for fire drills was utilized, causing an overlap of time slots for Fire Drills. A corrected schedule to be created by the Quality Improvement Department and shared with the Operations leadership by 8/18/2023.
CE2 There is only 1 building on this license. The building leadership will be instructed to discard any older fire drill schedules, so that varied times of drills occur. The Operations Manager will destroy the old schedules by 8/30/2023.
CE3 The Operations Manager will retrain staff and Supervisor to: 1. complete fire drills per the most up-to-date schedule and 2. all drills need to occur at various times on the shift, following the schedule. 3. The Fire Drill Log will be completed by the Supervisor within 3 days after the drill occurred. The Fire Drill Log lists date and time of each drill. When completing the log, if the Supervisor notes the drills are not varied by time, the drill will be repeated within 24 hours within the same month at a varied time. This repeated drill will then be documented on the Fire Drill Log. This training will occur by 8/30/2023.
CE4 The Operations Manager will review the Fire Drill Log checking that varied drills occur. If a drill is not varied, it will be repeated to make-up for the incorrect drill. Any repeated non-varied drills will be reported to the Director of Operations for immediate correction. If drills continue to occur at the same time on any shift, the issue will be brought to the attention of the Sr. Director for re-training, counseling, or possible disciplinary action. The use of the Fire Drill Log will be implemented 9/1/2023 and ongoing.
CE5 The Sr. Director will take appropriate action to address any personnel who fail to meet this corrective action with re-training, counseling or disciplinary action starting 9/1/2023 and ongoing.
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