Initial Comments:
A recertification survey was conducted February 4-5 and February 7, 2025, 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 six and the sample consisted of three individuals. Five deficiencies were identified as a result of this survey.
Plan of Correction:
483.420(a)(2) STANDARD
PROTECTION OF CLIENTS RIGHTS
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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 staff interview, it was determined that the facility failed to ensure written informed consent was received prior to the use of a behavior-modifying medication. This was noted for two of the three individuals in the sample (Individuals #1 and #3). The findings included:
A) Individual #1
The record of Individual #1 was reviewed on February 4-5, 2025. This review revealed current physician's orders, signed for February 2025, that prescribed Melatonin for insomnia. Further review revealed no documentation that written informed consent was received prior to the implementation of this behavior-modifying medication.
B) Individual #3
The record of Individual #3 was reviewed on February 5, 2025. This review revealed current physician's orders, signed for February 2025, that prescribed Melatonin for insomnia. Further review revealed no documentation that written informed consent was received prior to the implementation of this behavior-modifying medication.
C) The qualified intellectual disabilities professional (QIDP) and nurse were interviewed on February 5, 2025, at 11:00 AM. The QIDP and nurse confirmed that written informed consent was not obtained prior to the use of the behavior-modifying medication Melatonin for Individuals #1 and #3.
Plan of Correction: With Regards to Individuals #1 and #3, their plans for medications for sleep will be reviewed with Human Rights Committee and will adhere to the process of obtaining informed consent. The consents for these three individuals will be reviewed by the Human Rights Committee on this Tuesday, February 25th.
The QIDP will ensure that the necessary process and paperwork will be adhered to. They will assume primary responsibility for obtaining the consents. The QIDP monitors progress thru weekly visits to the site. In addition, progress is noted in monthly and quarterly progress notes.
The Administrator of Residential Services will ensure that this is done in a timely manner and will also ensure that all individuals who are receiving medication for sleep have informed consent prior to the medication being given.
The Director of Programs and Social Work will ensure that all plans are reviewed in a timely manner and that all QIDPs are informed that any medication given to aid in sleep follows the above-described process. All QIDPS were updated on this requirement on February 10, 2025. The Director of Programs will review the need for informed consent and human rights review for any individuals with medications for sleep and ensure that all plans will be reviewed by the Human Rights Committee by 3/25/25. The Director of Programs and Social Work will also maintain a calendar of consents and due dates by 3/3/2025.
The Administrator of Residential Services will assume overall responsibility for the implementation of this plan.
483.440(c)(6)(iii) STANDARD
INDIVIDUAL PROGRAM PLAN
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The individual program plan must include, for those clients who lack them, training in personal skills essential for privacy and independence (including, but not limited to, toilet training, personal hygiene, dental hygiene, self-feeding, bathing, dressing, grooming, and communication of basic needs), until it has been demonstrated that the client is developmentally incapable of acquiring them.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure training programs in the areas of medication management and financial skills were implemented. This was noted for all three individuals (Individuals #1, #2, and #3) in the sample. The findings included:
A) Goal plans for the past year were reviewed on February 4-5, 2025. This review revealed the following:
Individual #1
- A medication administration goal was not implemented during the past year. This goal was created and implemented on January 15, 2025.
- A medication administration goal was not implemented during the past year. This goal was created and implemented on January 15, 2025.
Individual #2
- A medication administration goal was not implemented during the past year. This goal was created and implemented on January 7, 2025.
- A financial goal was not implemented during the past year. This goal was created and implemented on January 7, 2025.
Individual #3
- A medication administration goal was not implemented during the past year. This goal was created and implemented on January 21, 2025.
- A financial goal was not implemented during the past year. This goal was created and implemented on January 21, 2025.
B) An interview with the Qualified Intellectual Disabilities Professional (QIDP) on February 5, 2025, at 12:30 PM, confirmed that Individuals #1, #2 and #3 did not have a training program in the areas of medication administration and financial skills during the past year. The QIDP stated these training programs were created and implemented in January of 2025 for all three individuals.
Plan of Correction: With regards to Individuals #1, #2 and #3, their medication administration and financial goals will be revised to provide specific target dates and be specific with regards to measurable goals and objectives. In addition, the QIDP will develop financial and medication administration goals for all individuals in the Hughestown Home. This will be completed by 3/25/25.
With regards to all individuals who receive ICF/ID services, each Individual's QIDP will ensure that each person has a financial and medication administration goal. The exception will be for those individuals who are viewed to be "developmentally incapable" or there is medical or historical evidence of past training that was unsuccessful. This will be reviewed during the annual meeting with the interdisciplinary team.
Each QIDP will be responsible for the individuals on their caseload to ensure that they are following thru on these goals, monitoring progress and sharing the outcomes with each individual's team. All goals will be developed and implemented by 6/1/2025.
The Director of Programs and Social Work will ensure that the QIDPs are meeting their individual responsibility and that all required documentation is provided. The Director will also support the QIDP team to develop goals which are appropriate and meaningful for each individual.
The Administrator of Residential Services will assume overall responsibility for the implementation of this plan as outlined.
483.440(f)(3)(i) STANDARD
PROGRAM MONITORING & CHANGE
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The committee should review, approve, and monitor individual programs designed to manage inappropriate behavior and other programs that, in the opinion of the committee, involve risks to client protection and rights.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure human rights committee (HRC) approval was received prior to the use of a behavior-modifying medication. This was noted for two of the three individuals in the sample (Individuals #1 and #3). The findings included:
A) Individual #1
The record of Individual #1 was reviewed on February 4-5, 2025. This review revealed current physician's orders, signed for February 2025, that prescribed Melatonin for insomnia. Further review revealed no documentation that HRC approval was received prior to the implementation of this behavior-modifying medication.
B) Individual #3
The record of Individual #3 was reviewed on February 5, 2025. This review revealed current physician's orders, signed for February 2025, that prescribed Melatonin for insomnia. Further review revealed no documentation that HRC approval was received prior to the implementation of this behavior-modifying medication.
C) The qualified intellectual disabilities professional (QIDP) and nurse were interviewed on February 5, 2025, at 11:00 AM. The QIDP and nurse confirmed that HRC approval was not obtained prior to the use of the behavior-modifying medication Melatonin for Individuals #1 and #3.
Plan of Correction: The Human rights committee will review and approve all plans which include behavior-modifying medication. This will now include medications for treatment of insomnia. This has not been the practice of the Human Rights Committee previously, but it will be modified accordingly.
Individual #1 and #3 will have informed consent and their plan will be reviewed by the Human Rights Committee. This will be completed by 2/25/25.
The QIDP for all ICF residents will assume responsibility for ensuring that informed consent is received prior to Human Rights Committe review. All residents' plans will be reviewed by the Human Rights Committe by 3/25/25.
The Director of Programs will ensure that the plans and approval are scheduled for the Human Rights Committee in a timely manner and that they include any medications for the treatment of insomnia as well as any medications which are used for behavior-modifying purposes.
The Chairperson of the Human Rights Committee will update the Committee on this process change. This will be done on 2/25/25.
The Administrator of Residential Services will ensure that this plan is implemented as outlined above.
483.450(e)(4)(i) STANDARD
DRUG USAGE
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Drugs used for control of inappropriate behavior must be monitored closely for desired responses and adverse consequences by facility staff.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure a medication used to control inappropriate behavior was monitored closely for desired responses. This was noted for two of the three Individuals in the sample (Individual #1 and Individual #2). The findings included:
A) The record of Individual #1 was reviewed on February 4-5, 2025. The review revealed that this individual was scheduled for telehealth psychiatry appointments on May 16, 2024, June 20, 2024, July 18, 2024, November 21, 2024, and December 19, 2024. Provider initiated a new medication, Trazadone 25 milligrams, for insomnia on June 20, 2024; however, this individual was not seen in person or via telehealth prior to prescribing this new medication. Individual #1 was only seen on video by the provider on July 18, 2024.
B) The record of Individual #2 was reviewed on February 4-5, 2025. The review revealed that this Individual was scheduled for telehealth psychiatry appointments on January 18, 2024, May 16, 2024, August 20, 2024, and November 21, 2024. Individual #2 was not seen on video by the provider for any of these appointments.
C) An interview with the Program Administrator on February 4, 2025 at 1:00 PM confirmed that Individual #1 and Individual #2 were not seen on video by the provider for scheduled telehealth psychiatry appointments.
Plan of Correction: St. Joseph's Center is in the process of transitioning their psychiatric services to Station MD. As part of this transition, individuals with more intense behavioral needs will be reviewed monthly. Other individuals will be scheduled on a consultative basis and at least annually. The initial session is scheduled for March 5th, 2025.
Individual #1 and Individual #2 will be a part of this transitional plan and will be scheduled to be seen accordingly. If there needs change or if there are issues regarding their psychotropic medications, they will be seen sooner. All visits are telehealth visits.
The QIDP will ensure that the schedules for psychiatric review meet the needs of each individual receiving psychotropic medications in the Hughestown Community ICF/ID Program.
The QIDPs in general, will ensure that each person on their caseload who are receiving psychotropic medications are being reviewed on an appropriate basis which will include telehealth appointments so that the individual can be seen by the prescribing physician.
Prior to each psych review, the team meets to review the documentation and discuss how each individual is doing. At the actual review, the team summarizes the results and then discusses what is currently going on with the individual, concerns, nursing or medical issues and any other pertinent information. The team includes the Director of Programs, the QUIDP, the Behavior Analyst and their team.
At the end of the review, the team determines when the individual will be reviewed next.
The Director of Programs/Social Work will assume responsibility for ensuring that the scheduling of the individuals with Station MD are both appropriate and timely. This is part of our current process and will continue with Station MD.
The Administrator of Residential Services will ensure that this plan of correction is implemented as described above.
483.460(k)(1) STANDARD
DRUG ADMINISTRATION
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The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.
Observations:
Based on documentation review, record review and staff interview, it was determined that the facility failed to ensure medications were administered in accordance to physician's orders. This was noted for one individual in the sample (Individual #3). The findings included:
A) The record of Individual #3 was reviewed on February 5, 2025. This review revealed a verbal telephone order, dated September 16, 2024, to increase the medication Melatonin from six milligrams (mgs) to ten mgs for insomnia. Review of Individual #3's current signed physician's orders, dated for February 2025 prescribed Melatonin three mgs - take two tablets (six mgs) at 8:00 PM. Upon further review of past physician's orders and medication administration records (MARs), it was discovered that the MARs were changed appropriately when the medication was increased; however the physician's orders were not. The signed physician's orders for October 2024 listed Melatonin six mgs, November 2024 listed ten mgs, and December 2024 through February 2025 listed six mgs.
B) The facility nurse was interviewed on February 5, 2025, at 12:30 PM. The nurse confirmed that Individual #3 has been receiving ten mgs of Melatonin since September 16, 2024, therefore not being administered in accordance to current physician's orders.
Plan of Correction: With regards to Individual #3, the Physician's orders were corrected so that they matched to reflect the accurate dose of the prescribed medication. The MARs were accurate and did not need to be changed. This change was done on 2/6/25 by the day shift charge nurse.
Each month prior to the doctor's review of the monthly orders, the nurse on 2nd shift will review the orders with the MARS to be sure that they are accurate and that they match. At this time, or any time an error is noted, the nurse who finds the error is responsible to make the correction immediately.
In addition, prior to putting the orders in the charts, the nurse who is placing the orders in the chart will also do a second check for accuracy and that the orders match. The House Supervisor will do a monthly check also as another way to ensure that the medication orders and MAR are consistent. Again, the House Supervisor, if he or she finds an error, they are responsible for correcting the error immediately.
On a quarterly basis, the RN coordinator will review the orders and the MARs to ensure that they match. The RN coordinator will make any corrections immediately. They will also communicate to the responsible nurse what the errors were and then determine if there is need for training or other remediation.
All ICF/ID clients will have both a monthly and quarterly review process that ensures that there is consistency between the MARs and the Physician's orders by doing routine audits.
The Administrator of Residential Services will ensure that this plan will be implemented as outlined above.
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