Initial Comments:
A recertification survey was conducted February 21, 22, and 23, 2024, to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I, Requirements for Intermediate Care Facilities. The census during the survey was five and the sample consisted of three individuals. Two deficiencies were identified as a result of this survey.
Plan of Correction:
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 facility incident report review, documentation review, and staff interview, it was determined the staff failed to ensure that staff demonstrated the necessary skills and competencies directed towards the health and safety needs for one individual in the sample (Individual #1 ).
Findings included:
A. Individual #1
1. Review of facility incident report revealed that on August 7, 2023 at approximately 9:30 AM, staff were taking residents from the house to the bus for transport when Individual #1 wheeled himself through door and down the ramp. Staff was at the bus assisting another individual and heard Individual #1's wheelchair on the ramp and stopped him as he was brushing up against a bush. Individual #1 did not obtain any injuries at that time.
2. Interview with staff on February 22, 2024 revealed that Individual #1 is capable of propelling himself around in his wheelchair and staff are to keep him within line of sight.
B. Interview with the Administrator of Residential Services (ARS) on February 23, 2024, at 10:00 AM confirmed the above-mentioned findings.
Plan of Correction: Following this incident, the team reviewed this situation and looked at the ways in which the safety of Individual #1 could be better protected. The team suggested that a safety reference for Individual #1 be developed around when staff is transporting residents. This reference would specify that during transportation time, staff should have eyes on Individual #1 throughout the whole process. This safety reference and any other safety references will be highlighted in the IHP.
The QIDP will develop the reference as well as train the staff on the reference. The QIDP will also ensure that Individual #1 has the ability to request to go out by using a switch. This QIDP will also be sure that any other safety references for the individuals who live in the Hughestown Community ICF home are to be highlighted as part of each person's IHP and that all staff are trained on these references.
The Director of Programs and Social Work will direct the QIDPs across all ICF/ID Programs to highlight safety goals as part of the IHP process. In addition, the Director will ensure that safety goals are developed as needed.
The Administrator for Residential Services will ensure that the plan of correction is implemented as outlined above.
483.440(e)(1) STANDARD
PROGRAM DOCUMENTATION
Name - Component - 00
Data relative to accomplishment of the criteria specified in client individual program plan objectives must be documented in measurable terms.
Observations:
Based on record review and interview with administrative staff, the facility failed to ensure that data relative to the accomplishment of the criteria specified within the Individual program plan objectives is documented in measurable terms relative to the frequency as outlined in the training plan for three of three sample Individuals. (Individual #1, #2, and #3)
Findings included:
A. A review of records of Individual #1, #2, and #3 was completed on February 22, 2024. This review revealed that daily program plan data from February 1, 2023 to January 31, 2024 was not available for review. Interview with the Qualified Intellectual Disability Professional (QIDP) on February 22, 2024 at 12:15 PM revealed that daily program data is "shredded every month " for all training plans for all individuals. The facility was unable to present the survey team with the program plan data relative to three individuals current plans regarding the above-mentioned time frame.
B. A review of Individual #1, #2, and #3's current goals revealed that there were also gaps in documentation for the month of February 2024. Daily program data was missing on all three individual's current goals for the month of February 2024. These goals are as follows:
1. Individual #1 - Social Objective #2; Cognitive Objective #1; Communication Objective #1; and ADL Objective #2.
2. Individual #2 -Program Data Sheets were missing data for most of the month of February. Goals included (AM) Assisting with brushing teeth; Passive range of motion of upper and lower extremities; Attend to music on iPod or story read by staff; Utilize EZ stander for 20 minutes when not at day program; and participate in activity with staff or peers for 10 minutes. The goals are to be repeated in the PM. Goals were only documented from February 18, 2024 through February 20, 2024, on the AM shift only.
3. Individual #3 - Choosing outfit to wear; Placing dirty bib in hamper; Passive ROM; and Sensory activity.
C. Interview with the QIDP on February 22, 2024, at 12:15 PM revealed that the Program documentation was not available for the surveyors' review as it was shredded.
D. Interview with the Administrator of Residential Services (ARS) on February 23, 2024, at 10:00 AM confirmed the above-mentioned findings that revealed that the Program documentation was not available for the surveyors' review as it is shredded after one month.
Plan of Correction: Data collected for Individual #1, #2 and #3 are currently available as of the time of the survey. The process for maintaining a year's worth of data was implemented 2/24/2024. The data sheets will be maintained at the home and will be available upon request. This practice will be followed for all individuals in the Hughestown ICF/ID home. The QIDP will monitor this process in the Hughestown ICF/ID home and will keep the Administrator of Residential Services up to date and if there are any problems or concerns. This process is also being implemented for all individuals in all ICF/ID homes.
In addition, the QIDP will do a bi-weekly review of the data being collected in the Hughestown home. If there are any concerns, both the QIDP and the Administrator of Residential Services will meet with the staff involved to assess the situation. Additional training or corrective action will be determined at that time and implemented as soon as possible.
The Director of Programs and Social Work will also implement this process across all ICF/ID programs. The QIDP for each individual is responsible to do the bi-weekly reviews for each person on their caseload. Any concerns or issues will be reported to the Director of Programs and Social Work, who will update the Administrator of Residential Services. Training and or corrective actions will be determined and implemented as soon as possible.
The Administrator of Residential Services will assume overall responsibility for the implementation of this Plan of Correction as outlined above.
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