Initial Comments:
A focused fundamental survey was conducted May 13-16, 2024, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was 22 and the core sample consisted of four individuals.
Plan of Correction:
483.420(a)(2) STANDARD
PROTECTION OF CLIENTS RIGHTS
Name - Component - 00
The facility must ensure the rights of all clients. Therefore the facility must inform each client, parent (if the client is a minor), or legal guardian, of the client's medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment.
Observations:
Based on record review and interview, it was determined the facility failed to ensure restrictive interventions were implemented only after informed consents were obtained for one (#2) of four individuals in the core sample. Findings included:
A record review was completed for Individual #2 on May 16, 2024. This review revealed a physician's order dated February 29, 2024, for Individual #2 to receive diazepam, 5 mg tablet; take one tablet by mouth one hour prior to chest x-ray scheduled for March 14, 2024.
Review of the medication administration record (MAR) for Individual #2 revealed Individual #2 received the pre-sedation medication on March 14, 2024. This review of the MAR further revealed that on November 2, 2023, and December 1, 2023, Individual #2 also received pre-sedation medications. On November 2, 2023, Individual #2 received lorazepam, 1 milligram (mg) tablet; take one tablet by mouth two hours prior to procedure and lorazepam, 1 mg tablet; take one tablet by mouth 20 minutes prior to procedure. On December 1, 2023, Individual #2 received lorazepam, 1mg tablet; take two tablets by mouth two hours prior to procedure, and then take one tablet 20 minutes prior to procedure.
This record review failed to reveal that consents were obtained for the above three restrictive interventions involving pre-sedation medications.
An interview was conducted on May 16, 2024, at 9:10 AM, with the qualified intellectual disabilities professional (QIDP). The QIDP confirmed there were no consents for Individual #2's restrictive interventions on November 2, 2023, December 1, 2023, or March 14, 2024.
Plan of Correction:Regarding Individual #2, the physician's orders for the pre-sedation medications (for appointments on 11/2/23, 12/1/23 and 3/14/24) which the program failed to obtain consents for were one time orders in each occasion. The QIDP notified Individual #2's guardian on 6/10/24 and informed her of the 11/2/23, 12/1/23 and 3/14/24 incidents.
The Director of Nursing trained all of the nursing staff on the process for obtaining consents for one time orders on 6/3/24. All of the nursing staff signed off on the process moving forward. Effective immediately, all scheduled appointments requiring any type of pre-sedation or other medication related interventions requiring guardian and Human Rights consent will be discussed in the daily 9:15am staff meeting. As part of this meeting, the status of consents will be discussed and documented in the minutes of these meetings. No appointments/procedures will occur until all required consents are received; once received, this will also be documented on the 9:15am meeting minutes.
The BLARS Lead Nurse and QIDP will monitor this area for compliance and assure that no appointments or procedures requiring pre-sedation type medications occur without the necessary consents being obtained and Human Rights approval. This is monitored daily during the 9:15am meeting which includes documentation/record keeping of the meeting content.
483.440(b)(5)(i) STANDARD
ADMISSIONS, TRANSFERS, DISCHARGE
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At the time of the discharge the facility must develop a final summary of the client's developmental, behavioral, social, health and nutritional status.
Observations:
Based on record review and interview it was determined that the facility failed to ensure that a discharge final summary was completed. This applied to one (#5) of one individual discharged from the facility in the past year. Findings included:
A review of facility provided documentation was completed for Individual #5 on May 16, 2024. This review revealed that Individual #5 was admitted to the hospital August 17, 2023. Individual #5 remained in the hospital until September 14, 2023, when he was transferred to a long term care faciltiy for rehabilitation services. Further review revealed that Individual #5's medical condition declined and it was determined based on current medical needs that Individual #5 be discharged from the facility on November 1, 2023, and admitted to long term care facility for skilled nursing care.
An interview was conducted with the executive director (ED) on May 16, 2024, at 8:21 AM. During this time the ED stated that the family and team determined that the placement at the long term care facility was necessary based on Individual #5's decline in medical condition. However, the ED confirmed at this time, that there was no final summary for discharge completed by the facility and there was no documentation on what information was shared with the new placement.
Plan of Correction:Regarding Individual #5, a final summary will be completed by 6/15/24. Additionally, the QIDP will reach out to the discharge facility for Individual #5 to inquire as to if they need any additional information or have run into any questions regarding his history or treatment during his tenure with our agency.
Moving forward, the QIDP will complete a discharge summary to be available for review to all potential discharge options. Additionally, notes will be kept on all discharge/planning meetings regarding individuals in the transition process. All notes including the discharge summary will be maintained in the individual's medical record.
The Executive Director will be responsible for monitoring this area and assuring the QIDP completes all aspects of the discharge planning documentation and collaboration with the discharge placement. This area will be monitored at the initiation of any discharge plan and immediately following the actual discharge date to ensure compliance in all aspects / documentation related to the discharge.
483.440(c)(4) STANDARD
INDIVIDUAL PROGRAM PLAN
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The individual program plan states the specific objectives necessary to meet the client's needs, as identified by the comprehensive assessment required by paragraph (c)(3) of this section.
Observations:
Based on observations, record review and interview, it was determined that the facility failed to ensure client's needs in the area of daily living skills were met. This applied to one (#2) of four individuals in the core sample. Findings included:
On May 13, 2024, the evening meal was observed in Cottage 1 from 4:48 PM to 5:30 PM. Individual #2 was seated at the dining room table with a divided plate filled with spaghetti, two meatballs and garlic toast. All food items were cut up in quarter size pieces. Individual #2 was not given any silverware and was observed to begin eating immediately with their fingers. The staff stated to this surveyor that Individual #2 does not use silverware and is known to throw silverware away immediately. They further stated Individual #2 has never used silverware.
On May 14, 2024, the morning meal in Cottage 1 was observed from 6:55 AM to 8:30 AM. Individual #2 was seated at the dining room table with a divided plate filled with cereal, banana, and grapes. Individual #2 was not given any silverware and was observed to begin eating immediately with their fingers. The morning staff stated to this surveyor, similar to evening staff, that Individual #2 does not use silverware and is known to throw silverware away immediately. They further stated Individual #2 has never used silverware.
A record review for Individual #2 was completed on May 15, 2024. Individual #2's comprehensive functional assessment dated December 20, 2023, revealed Individual #2 has no skills in the use of mealtime utensils and requires assistance from staff. Individual #2's annual individual program plan dated December 20, 2023, revealed a report from the residential manager that states Individual #2 is known to throw silverware and dishes.
This review failed to reveal a training program for Individual #2 for the use of silverware during a meal.
An interview was conducted with the qualified intellectual disabilities professional (QIDP) on May 15, 2024, at 9:12 AM. The QIDP confirmed that Individual #2 has no formal plan in place to teach the proper use of utensils and mealtime equipment.
Plan of Correction:Regarding Individual #2, the QIDP will complete a formal training program for use of silverware during mealtimes. This plan, including the training of staff on the program, will be completed by 6/15/24.
The QIDP will complete a review of the priority needs list of all other individuals in the programs to identify if there are additional programs that need initiated moving forward or areas that need moved up the priority list. The Executive Director will be responsible for assuring this review is completed by 7/1/24.
While preparing the annual Individual Program Plan (IPP's) on each of the individuals and during the actual IPP meetings, the priority needs list will be evaluated and discussed to assure there is a plan for priority areas so as to maintain active treatment protocols for all individuals.
The Executive Director will be responsible for assuring the QIDP is prioritizing the needs lists and training programs for all of the individuals and will adhere to existing processes to assure compliance in this area. The Executive Director and the QIDP will meet following each IPP to review that the priority lists were reviewed and updated (if necessary).
483.460(k)(1) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that all medications were administered according to physician's orders. This applied to one (#2) of four individuals in the core sample. Findings included:
1. Review of the medication administration record (MAR) for Individual #2 was completed May 16, 2024. This review revelaed that Individual #2 received the following on November 2, 2023: "Lorazepam 1mg take one tablet by mouth two hrs. prior to procedure" and "Lorazepam 1mg take one tablet by mouth 20 min. prior to procedure." Record review completed on May 16, 2024, failed to revealed physician orders for lorazepam as stated above.
An interview was conducted on May 16, 2024, at 9:40 AM with the RN. The RN confirmed there was no physician order for the lorazepam given to Individual #2 on November 2, 2023.
2. Record review and review of medication administration record (MAR) for Individual #2 was completed on May 16, 2024. This review of MAR revealed that on December 1, 2023, Individual #2 received "Lorazepam tab 1mg take 2 tablets (= 2mg) by mouth 2 hours prior and to procedure take 1 tablet 20 minutes prior to procedure." Further review revealed a physician's order for Individual #2 dated, November 20, 2023, for Individual #2 "Lorazepam 2 mg tab take one (1) tablet by mouth 2 hours prior to CT procedure. Take another (1) tablet 20 minutes prior to CT procedure.
An interview was conducted on May 16, 2024, at 9:40 AM with the registered nurse (RN). The RN confirmed the physicians order did not match the MAR of what Individual #2 was given on December 1, 2023, prior to the procedure. The RN further confirmed that the lorazepam was not given according to physician orders.
Plan of Correction:Regarding Individual #2, the physician's orders for the pre-sedation medications (for an appointment on 11/2/23) was a one time order; the agency was able to locate this order on 6/10/24; an order entry clerk at Vantage Care Apothecary was able to locate the order. Regarding the instance on 12/1/24 with Individual #2, there was a transcription error when the nursing staff wrote the order on the MAR for this particular medication.
The Director of Nursing (DON) and or the lead nurse will review the DHS train the trainer course with all nursing staff and certified medication administrators on the proper transcription of orders to the MAR. Medication administration protocols will also be a part of this training. These trainings will address the issues (which lead to this citation) where the order did not match the MAR of what Individual #2 was given on December 1, 2023. In this case the medication was not given according to the physician's order. The Director of Nursing and or the lead nurse will conduct these trainings prior to 7/15/24. This training will include demonstration and observation of order transcription to the MAR.
Additionally, when one time pre-appointment orders are received from the physician, both a nurse and a certified medication administrator will check the MAR's to assure the physician's orders was transcribed to the MAR correctly prior to the date of medication appointment. Any discrepancies will be communicated to the contracted pharmacy, DON, Lead Nurse, and Executive Director each month. The BLARS Lead Nurse will be responsible for tracking any discrepancies to assure they were corrected on the following month MARS. Monthly checks will be conducted by the BLARS Lead Nurse to ensure accuracy of transcription and orders.
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
at least quarterly for each shift of personnel.
Observations:
Based on review of facility provided documentation of fire drills and interview, it was determined that the facility failed to ensure that fire drills occurred at least quarterly per shift of staff. This applied to one of four quarters. Findings included:
Review of facility provided documentation of the past year of fire drills in all three cottages was completed on May 15, 2024. This review failed to reveal that a day shift drill was completed in Cottage 2 during the fourth quarter of 2023.
Interview with the executive director on May 15, 2024, at 11:25 AM confirmed that there was no day shift fire drill in Cottage 2 in the fourth quarter of 2023.
Plan of Correction:The Executive Director will review the current 2024 fire drill schedule to assure that each of the cottages run at least one fire drill per shift per quarter. This review will be completed by 6/15/24. Additionally, a grid sheet will be developed which depicts compliance in this area which shows each fire drill per shift, per quarter. This will also be completed by 6/15/24.
The QIDP will be responsible for reviewing the monthly fire drills and assuring they were conducted at the appropriate times according to the master schedule. The QIDP will also monitor the grid which depicts that a drill was done for each shift, each quarter. The grid graphically depicts the fire drill schedules for each cottage. The QIDP will monitor this area monthly.
483.480(a)(3) STANDARD
FOOD AND NUTRITION SERVICES
Name - Component - 00
If a qualified dietitian is not employed full-time, the facility must designate a person to serve as the director of food services.
Observations:
Based on observations, record review, review of facility menus, and interview, it was determined that the facililty failed to ensure all the individuals were assessed and provided nutritional adequacy of meals and snacks. This applied to all individuals residing at the facility. Findings included:
1. Evening observations were completed in all three cottages on May 13, 2024, from 3:30 PM to 6:30 PM. Morning observations completed in all three cottages on May 14, 2024, from 7:00 AM to 8:30 AM. During these times dinner and breakfast were observed, with staff providing assistance to the individuals to portion meal items for their plates using measuring utensils. During these observations the posted menus were reviewed and there was no indication of how to portion the meal item according to caloric intake. During an interview with the staff in Cottage 1 on May 14, 2024, at 7:15 AM, the staff was able to show the surveyor a list of individuals and their corresponding diet order including caloric intake, however the staff were unable to demonstrate how to portion each meal in accordance with the diet orders.
2. Record review for Individual #1 was completed on May 15, 2024. This review revealed that Individual #1 was admitted to the facility on December 6, 2023. This review failed to reveal documentation that a nutritional assesment had occurred for Individual #1 during intake or since being admitted to the facility.
Interview with executive director (ED) was completed on May 16, 2024 at 7:58 AM. At this time the ED confirmed that Individual #1 had not received a nutritional assesment during intake or since being admitted to the facility. The ED further confirmed that neither the current contracted food service provider and the contracted dietician provided staff with guidance to ensure nutritional needs of the individuals' for every meal in accordance with their individual diet orders.
Plan of Correction:The acting Dietary Manager has reached out to the consulting dietician to provide portion sizes for the menus in the ICF program. The dietician has been directed to portion the meal items on the menus according to caloric intake and diet stipulations for the individuals.
Additionally, the Executive Director is going to reach out to the consulting dietician to have her complete a nutritional assessment on Individual #1 inasmuch as this was missed upon intake. The Executive Director will make this contact by 6/10/24.
In an effort to avoid similar issues in the future the acting dietary manager (and the fulltime dietary manager once hired) will hold regular, monthly meetings with representatives of all programs in the agency. The Ramsbottom representatives which include the Director of Nursing, the Executive Director, the contracted dietician, and the cottage/ADS managers will have a standing agenda items list which will include portion sizes, special diets, nutritional assessments or re-assessment due and any other dietary issues or topic of concern. Minutes of these monthly meetings will be taken as evidence of the meetings and content therein. Additionally, the Director of Nursing will review all menus and work (when needed) with the acting dietary manager and consulting dietitian to assure regulatory compliance. This review of the menus will occur at the time of each monthly meeting.
Regarding dietary assessments moving forward, the Executive Director will be responsible for making sure that all assessments for new admissions occur within 30 days of placement. This area will be monitored immediately following each new admission.
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