Initial Comments:
A focused fundamental survey was conducted January 9-12, 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 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 observations, individual record review, review of facility documentation, and interviews, it was determined the governing body failed to provide oversight and operating direction in the areas of protection of client rights and evacuation drills. This applied to all individuals residing at the facility. Findings included:
1. Governing body failed to ensure that all individuals had clothing and appropriate bedding. Refer to W 137.
2. Governing body failed to ensure that documentation was accurate and to authenticate that fire drills were conducted per shift of staff per quarter. Refer to W 440.
Interview with the director of residential services on January 12, 2024, at 1:47 PM confirmed that the governing body failed to provide direction and oversight in the areas of protection of client rights and fire drills.
Plan of Correction:The governing body will ensure that it exercises general policy, budget and operating direction over the facility.
1. (W137) the facility will ensure the rights of all clients, including ensuring that all clients have the right to retain and use appropriate personal possessions and clothing.
For individuals #2 and #6, as well as all other individuals in the facility, the QIDP placed missing items that were not found during the survey into the individual's rooms. The QIDP completed an inventory of all items for the individuals to identify any needs that required to be purchased. QIDP purchased new bedding sets for each individual as back-ups to ensure access for each individual even when others are placed in the laundry room to be cleaned.
For individual #2 and #6, and all other individuals in the facility, the facility will ensure that all individuals have access to appropriate personal possessions and clothing. The DRS will re-train QIDP and all facility staff on the rights of the individual and the rights to have access to appropriate personal possessions and clothing (Target Date 2/15/2024). The QIDP will create a daily inventory sheet for all individuals in the facility to be completed by the facility staff. If there are any inventory issues, the facility staff will inform the QIDP or designee of the issue, and the issues will be addressed immediately. The QIDP will complete a weekly inventory walkthrough for all individuals in the facility for 4 weeks and forward them to the DRS for review. (Target Date: 3/4/2024).
In the future, the QIDP will complete monthly inventory walkthroughs for all individuals. The QIDP will forward these reviews to the DRS for 6 months where they will be reviewed and maintained at the regional office. The DRS will complete monthly walkthroughs to ensure the individuals have access to appropriate personal possessions and clothing for 6 months. (Target Date 8/1/2024).
The DRS will submit weekly and monthly walkthroughs to the Vice President to review for accuracy for 3 months. The VP, or her designee, will complete random walkthroughs to ensure that all clients have the right to retain and use appropriate personal possessions and clothing.
2. (W440) The facility will ensure that evacuation drills are run at least quarterly for each shift of personnel.
The DRS will retrain the QIDP, DSSL, and all staff on standard evacuation drills (Target Date: 2/15/2024). The QIDP, or designee, will complete all fire drills in accordance with the fire drill schedule put together by the DRS. To ensure accuracy and completion, the QIDP or designee will complete the following steps when completing a fire drill:
1. Notify the system to be placed on test, in order to set the fire system off.
2. Complete the fire drill and each staff member will sign or initial completion of the drill.
3. The QIDP or designee will complete the fire drill form, sign and submit it for review to the DRS.
4. The QIDP will attach documentation from the fire system company showing when the system was turned off.
5. The DRS will review all fire drills for accuracy and sign off on documentation. A copy of the documentation will be kept in the regional office and the original will be kept on site.
The QIDP will provide this documentation for 6 months. (Target Date: 8/1/2024) The DRS will observe completion of the fire drills bi-monthly for 6 months to ensure accuracy. (Target Date: 8/1/2024) The VP, or her designee, will review fire drill documentation for 6-months to ensure accuracy, including reviewing observations made by DRS during reviews.
483.420(a)(12) STANDARD
PROTECTION OF CLIENTS RIGHTS
Name - Component - 00
The facility must ensure the rights of all clients. Therefore, the facility must ensure that clients have the right to retain and use appropriate personal possessions and clothing.
Observations:
Based on observations and interview, it was determined that the facility failed to ensure that all individuals had clothing and pillowcases. This applied to two (#2 and #6) of seven individuals living at the residence. Findings included:
Observations were conducted at the residence on January 9, 2024, from 3:30 PM to 6:25 PM.
1. At 3:58 PM, Individual #6's bedroom closet was observed to have one jacket, and multiple pairs of shoes and socks in the closet. There was no other clothing observed in the bedroom.
2 A. At 4:05 PM, Individual #2's bedroom closet was observed to have no clothing or clothing hangers. The dresser with drawers within the bedroom was observed to not have any clothing stored in the dresser drawers. There was no other clothing observed in the bedroom. When questioned, the staff replied that Indvidual #6 and #2 borrow clothing when necessary from another resident.
B. Further observations of Individual #2's bedroom revealed that their bedding was removed from the bed, leaving only a mattress cover. Two pillows were observed without coverings. The surveyor questioned the staff as to the whereabouts of Individual #2's bedding, to which they responded, "its in the washing machine." The surveyor then asked if the pillowcases were in the washing machine also, to which the staff answered "[Individual #2] does not have pillowcases." At 5:15 PM, the qualified intellectual disabilities professional (QIDP) confirmed that Individual #2 did not possess pillowcases for their bed pillows.
An interview was conducted with the QIDP on January 9, 2024, at 6:19 PM. The QIDP confirmed that Individual #6 had no clothing and Individual #2 also did not have clothing or pillowcases. When questioned as to what clothing Individual #6 and Individual #2 wear, the QIDP produced a box of new clothing for Individual #2 and showed an invoice for clothing that was ordered for Individual #6 on December 7, 2023.
Plan of Correction:The facility will ensure the rights of all clients, including ensuring that all clients have the right to retain and use appropriate personal possessions and clothing.
For individuals #2 and #6, as well as all other individuals in the facility, the QIDP placed missing items that were not found during the survey into the individual's rooms. The QIDP completed an inventory of all items for the individuals to identify any needs that required to be purchased. QIDP purchased new bedding sets for each individual as back-ups to ensure access for each individual even when others are placed in the laundry room to be cleaned.
For individual #2 and #6, and all other individuals in the facility, the facility will ensure that all individuals have access to appropriate personal possessions and clothing. The DRS will re-train QIDP and all facility staff on the rights of the individual and the rights to have access to appropriate personal possessions and clothing (Target Date 2/15/2024). The QIDP will create a daily inventory sheet for all individuals in the facility to be completed by the facility staff. If there are any inventory issues, the facility staff will inform the QIDP or designee of the issue, and the issues will be addressed immediately. The QIDP will complete a weekly inventory walkthrough for all individuals in the facility for 4 weeks and forward them to the DRS for review. (Target Date: 3/4/2024).
In the future, the QIDP will complete monthly inventory walkthroughs for all individuals. The QIDP will forward these reviews to the DRS for 6 months where they will be reviewed and maintained at the regional office. The DRS will complete monthly walkthroughs to ensure the individuals have access to appropriate personal possessions and clothing for 6 months. (Target Date 8/1/2024).
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 provided medication error documentation and interviews, it was determined that the facility failed to ensure training in the area of health needs of the individuals. This applied to two of three medication errors reviewed. Findings included:
A review of facility provided documentation of medication errors on November 8, 2023, and December 22, 2023, was completed on January 11, 2024. This review revealed that staff A was responsible for a medication error for Individual #4 on November 8, 2023, when staff A failed to administer an ordered medication. This review further revealed that staff A was responsible for a medication error for Individual #1 on December 22, 2023, when staff A again failed to administer an ordered medication. This review failed to reveal that staff A was retrained following these errors to prevent reoccurrence.
Interview with the director of residential services (DRS) on January 12, 2024, at 10:30 AM, confirmed that staff A was not trained in the health care needs of the individuals related to medication administration following the medication errors on November 8, 2023, and December 22, 2023.
Plan of Correction:The facility will ensure that all employees who work with clients, training must focus on skills and competencies directed toward clients health needs.
The staff member identified in the survey as not receiving training in the area of health needs of the individual was removed from medication passes until training is completed. (Completed: 1/12/2024)
The QIDP will schedule immediate retraining for staff member identified in the survey as not receiving the training in the area of health needs of the individual. This training will be completed by the facility RN, documented on a training in-service sheet, and forwarded to the DRS for review. (Target Date: 2/15/2024) The staff member will complete an online module, on Relias, relating to medication administration. (Target Date: 2/15/2024).
The DRS will ensure that policies clearly outline the procedures for retraining staff following medication errors to prevent reoccurrence. The DRS will retrain the QIDP and facility nurse on this procedure and maintain that documentation at the regional office. (Completed: 1/31/2024). In the event that an error occurs, the QIDP along with the facility nurse, will ensure that training is completed prior to providing care directed towards client health needs. The training will be completed on an agency in-service sheet, signed by the trainer and trainee. The re-training will be forwarded to the DRS for review.
In the future, all training relating to medication errors will be completed and signed by the trainer and trainee to ensure that the clients health needs are met. That training documentation will be maintained in the individuals charts in which the error occurred, along with any documentation relating to the error. For all medication errors, the DRS will review and sign off on the error report and completed re-training for all staff involved.
483.430(e)(3) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
Staff must be able to demonstrate the skills and techniques necessary to administer interventions to manage the inappropriate behavior of clients.
Observations:
Based on observations, a focused review of behavior support plans, staff training records, and interview, it was determined the facility failed to ensure that staff demonstrated the skills and techniques necessary to manage inappropriate behaviors for two (#5 and #6) of seven individuals at the residence. Findings included:
Observations were completed at the residence on January 9, 2024, from 3:30 PM to 6:25 PM.
1. At 3:34 PM, upon entry into the kitchen with staff, the deadbolt lock on the cabinet located under the sink was observed to be unlocked with a deadbolt placed over the latch in an open position. The surveyor observed the cabinet to contain knives and cleaning products. When questioned regarding the unlocked cabinet, staff responded, "the door should be locked when staff are not in front of the sink." The staff then refastened the lock on the kitchen sink cabinet door.
A review of Individual #6's behavior support plan (BSP) was completed on January 12, 2024. This review revealed that Individual #6's BSP, dated February 14, 2023, to February 13, 2024, identified "restrictive components" which required "locked sharp knives and scissors due to self-injurious behaviors." Further review of staff training records for Individual #6's BSP was completed on January 12, 2024. This review revealed that the staff present during the time of the evening observations were trained on Individual #6's BSP on February 13, 2023.
2. Upon entry to the residence, a three-quarter full water bottle was observed placed on an end table in the front left room of the residence. The water bottle remained in the room until the qualified intellectual disabilities professional (QIDP) was questioned at 5:50 PM. At this time, the QIDP stated that this water bottle should not have been left unattended due to Individual #5's behavior.
A review of Individual #'5's BSP was completed on January 12, 2024. This review revealed that Individual #5's BSP, dated February 14, 2023, to February 13, 2024, identified a target behavior of fluid seeking which is defined as "scanning the room for drinks, grabbing drinks that belong to others and consuming them." Further review of Individual #5's BSP identified "Proactive Strategies" for this target behavior include: staff should monitor drinks that they bring into the home and cleaning products are locked to ensure Individual #5 does not ingest any hazardous materials. Review of staff training records for Individual #5's BSP was completed on January 12, 2024. This review revealed that the staff present during the time of the evening observations were trained on Individual #5's BSP on February 13, 2023.
An interview was conducted with the director of residential services (DRS) on January 12, 2024, at 1:38 PM. The DRS confirmed that the staff failed to implement the necessary interventions from the BSP's for Individual #5 and #6 according to their training.
Plan of Correction:The facility will ensure that staff must be able to demonstrate the skills and techniques necessary to administer interventions to manage the inappropriate behavior of clients.
For individuals #6, #5 and all other individuals in the facility, the QDIP will re-train all staff on the individual's behavior support plans to ensure that staff are able to demonstrate the skills and techniques necessary to administer interventions to manage inappropriate behavior of clients. (Target Date: 2/15/2024). The QIDP will complete monthly walkthroughs to ensure that all staff are demonstrating the skills and techniques necessary to administer interventions to manage the inappropriate behavior of clients. The QIDP will document these walkthroughs and forward them to the DRS for review for 6 months (Target Date: 8/1/2024)
The QIDP will provide monthly trainings to be completed by all staff within the facility on the individuals behavior support plan to ensure they have the skills necessary to administer interventions in regards to managing inappropriate client behavior. This training will be completed on an agency in-service sheet and will be sent to the DRS for review (Target Date: 8/1/2024).
In the future, all staff will be trained at least quarterly (or more frequently if necessary) on the behavior support plans of the individuals.
483.440(c)(5)(iv) STANDARD
INDIVIDUAL PROGRAM PLAN
Name - Component - 00
Each written training program designed to implement the objectives in the individual program plan must specify the type of data and frequency of data collection necessary to be able to assess progress toward the desired objectives.
Observations:
Based on record reviews and interview, it was determined that the facility failed to collect data with enough frequency to adequately measure the individuals' progress toward residential program goals. This applied to three of three individuals in the core sample. Findings included:
1. A record review was completed for Individual #1 on January 10, 2024. At that time, a review of the residential program goals and data collection for the months of October, November, and December of 2023, was completed. Data was expected to be collected weekly for Individual #1's laundry and community goals. This review revealed that data collected for Individual #1's laundry and community residential program goals were as follows:
- Laundry: Receive a folded pile of clothes from staff and place them in the dresser, on Fridays. Documentation revealed that this goal was implemented zero out of four days for October 2023, three out of four days for November 2023, and zero out of five days for December 2023.
- Community: Will participate in a minimum of one activity weekly, on Mondays. Will select activity and complete the activity each week. Documentation revealed that this goal was implemented two out of five days for October 2023, zero out of four days for November 2023, and zero out of four days for December 2023.
2. A record review was completed for Individual #2 on January 10, 2024. At that time, a review of the residential program goals and data collection for the months of October, November, and December of 2023, was completed. Data was expected to be collected weekly for Individual #2's laundry and community goals. This review revealed that data collected for Individual #2's laundry and community residential program goals were as follows:
- Laundry: After shower, will place dirty clothes in laundry basket, on Sundays. Documentation revealed that this goal was implemented zero out of five days for October 2023, one out of four days for November 2023, and zero out of five days for December 2023.
- Community: Will participate in a minimum of one activity weekly, on Saturdays. Will select activity and complete the activity each week. Documentation revealed that this goal was implemented one out of four days for October 2023, two out of four days for November 2023, and zero out of five days for December 2023.
3. A record review was completed for Individual #3 on January 10, 2024. At that time, a review of the residential program goals and data collection for the months of October, November, and December of 2023, was completed. Data was expected to be collected weekly for Individual #3's laundry and community goals. This review revealed that data collected for Individual #1's laundry and community residential program goals were as follows:
- Laundry: Will gather laundry folding board and use it to fold shirts, on Fridays. Documentation revealed that this goal was implemented four out of four days for October 2023, two out of four days for November 2023, and zero out of five days for December 2023.
- Community: Will participate in a minimum of one activity weekly, on Sundays. Will select activity and complete the activity each week. Documentation revealed that this goal was implemented one out of five days for October 2023, zero out of four days for November 2023, and zero out of five days for December 2023.
An interview was conducted with the director of residential services (DRS) and the qualified intellectual disabilities professional (QIDP) on January 12, 2024, at 1:45 PM. The DRS and QIDP both confirmed that goals were not being implemented with enough frequency to measure progress towards objectives for Individual's #1, #2, and #3.
Plan of Correction:The facility will ensure that each written training program designed to implement the objectives in the individual program plan must specify the type of data and frequency of data collection necessary to be able to assess progress toward the desired objectives.
The QIDP will review and revise the residential program goals for individuals #1, #2, #3 and all other individuals in the facility to ensure they are specific, measurable, and show the ability to assess progress. The QIDP will re-train all staff in the individual's program plan and documentation requirements in order to assess progress (Target Date: 2/15/2024). The QIDP will complete bi-weekly observations relating to goal implementation for 6 months (Target Date: 8/1/2024). Those observations will be completed on an observation sheet and will be forwarded to the DRS for review. The QIDP will complete weekly documentation reviews to ensure that the data collection process is being thoroughly completed and will be forwarded monthly to the DRS for review for 6 months (Target Date: 8/1/2024).
In the future, all staff will be trained quarterly on the individual program plan that documents the data collection necessary to be able to assess progress toward the desired objectives.
483.450(b)(2) STANDARD
MGMT OF INAPPROPRIATE CLIENT BEHAVIOR
Name - Component - 00
Interventions to manage inappropriate client behavior must be employed with sufficient safeguards and supervision to ensure that the safety, welfare and civil and human rights of clients are adequately protected.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that interventions to manage inappropriate client behaviors were employed with sufficient safeguards and supervision. This applied to one (#2) of three individuals in the survey sample. Findings included:
A record review for Individual #2 was completed on January 11, 2024. A review of Individual #2's physician's orders, dated December 15, 2023, revealed the following behavior modifying medication: aripiprazole 15 milligram (mg) tab; take 1 tablet by mouth once daily for mood.
Record review of Individual #2's behavior support plan (BSP), dated February 14, 2023 - February 13, 2024, failed to reveal that the medication aripiprazole (abilify) was incorporated into Individual #2's BSP for addressing inappropriate behaviors. Further review revealed signed consents by Individual #2's medical power of attorney (MPOA) on August 16, 2023, to "start Abilify 2mg daily for behaviors related to autism." This review failed to reveal signed consents by Individual #2's MPOA for the current dosage of aripiprazole 15mg once daily. This review failed to reveal that the aripiprazole medication had been reviewed and approved by the facilities human rights committee (HRC).
An interview was conducted with the qualified intellectual disabilities professional (QIDP) on January 11, 2024, at 1:00 PM. The QIDP confirmed that the aripiprazole medication has not been incorporated into Individual #2's BSP and confirmed that consents had not been obtained. The QIDP further confirmed that this intervention was implemented without sufficient safeguards.
Plan of Correction:The facility will employ interventions to manage inappropriate client behavior with sufficient safeguards and supervision to ensure that the safety, welfare, and civil and human rights of clients are adequately protected for individual #2 and all others residing in the facility.
On 1/17/2024, the IDT met and obtained new consent for individual #2 behavior modification medication. (Completed)
The QIDP in conjunction with the HRC Chairperson will obtain consents for interventions and complete a meeting with the IDT in order to ensure that the safety, welfare, and civil and human rights of the individual are adequately protected. For individual #2, the behavior modifying medications will be incorporated into the individuals program plan for addressing inappropriate behaviors. (Target Date: 2/15/2024)
For individual #2 and all others, the QIDP will schedule IDT meetings for any change to the individual's needs and will provide those recommendations to the Human Rights Committee as needed. At the conclusion of Quarterly/IDT Meetings, the QIDP will meet with the HRC Chairperson to review all current restrictive procedures and plans. This meeting will be documented on an HRC sign-in sheet. If an intervention to manage inappropriate client behavior with sufficient safeguards and supervision is no longer needed or, a new intervention is needed, 3 Human Rights Committee members must be notified, and an appropriate consent will be obtained. The HRC Notification and Approval Form must be completed and maintained with the HRC Chairperson.
The DRS will review and train QIDP, DSSL, and Facility Nurse on Human Rights Processes and Procedures (Target Date: 2/15/2024).
In the future, prior to any interventions to manage inappropriate client behavior, the DRS, QIDP and HRC-Chairperson will review any medication changes that are used to manage inappropriate client behavior and/or restrictive procedures. The appropriate consents and behavior interventions will be provided to the team to ensure the facility employs interventions to manage inappropriate client behavior with sufficient safeguards and supervision. The DRS, QIDP, Behavior Specialist, and IDT will meet to ensure the appropriate consents were received and the appropriate interventions are being used to manage inappropriate client behavior with sufficient safeguards. The Behavior Specialist and QIDP will ensure that any use of interventions to manage inappropriate client behavior will be incorporated into the client's IPP. The QIDP and Behavior Specialist will provide the appropriate training to all staff to ensure that the proper safeguards are being met. (On-going)
The DRS, in conjunction with the HRC Chair, will train all members of the IDT regarding the process of ensuring that the proper safeguards are in place prior to admission for all individuals that require interventions to manage inappropriate client behavior. (On-going)
483.460(c) STANDARD
NURSING SERVICES
Name - Component - 00
The facility must provide clients with nursing services in accordance with their needs.
Observations:
Based on observation, record review and interview, it was determined that the facility failed to ensure that nursing services were provided to the individuals in accordance with their healthcare needs. This applied to one (#1) of three individuals in the core sample. Findings included:
Observation of the breakfast meal was completed on January 10, 2024, from 6:25 AM to 7:45 AM. At 7:15 AM, Individual #1 came downstairs and sat at the dining room table for breakfast. Staff brought breakfast to the table and then went back into the kitchen in the next room. Staff intermittently returned to the dining room to provide care for multiple individuals. Individual #1 ate and drank independently and finished his breakfast at 7:23 AM.
Record review for Individual #1 was completed on January 11, 2024. This review revealed that Individual #1 was hospitalized from January 6, 2024, to January 9, 2024. Further review of the transfer summary report from the hospital revealed that Individual #1 had received a clinical swallow evaluation on January 8, 2024. This evaluation stated "Recommend 1:1 supervision to cue for small bites/sips." Review of the facility provided health care plan for Individual #1 that was created by the facility nurse on January, 9, 2024, failed to reveal any identified health care needs related to the clinical swallow evaluation recommendations.
Interview with the director of residential services (DRS) was completed on January 12, 2024, at 11:20 AM. During this interview, the DRS stated that nursing is responsible for ensuring that all recommendations made by physicians are incorporated into the individuals' health care plans and that staff are trained on the plans. The DRS confirmed that the above health care recommendations were not incorporated into Individual #1's plan and that Individual #1 did not receive nursing services in accordance with their needs.
Plan of Correction:For individual #1 and all others residing in the facility, the facility will provide nursing services in accordance with their current needs.
For individual #1, the facility nurse will complete a comprehensive review of the discharge instructions and the current health care plans. Upon discharge, individual #1 was scheduled a follow-up appointment and the facility nurse reviewed discharge instructions and received new orders. (Completed 1/17/2024). The facility nurse created a new health care plan and re-trained all staff on the individuals current needs. (Completed: 1/17/2024).
The DRS will modify the discharge procedure that identifies any recommendations made by physicians are incorporated to the individuals health care plans. (Target Date: 2/15/2024). The DRS will train QIDP and Facility Nurse on discharge procedure and checklist to ensure all recommendations are incorporated. (Target Date: 2/15/2024)
During any discharge over the next 6 months, the procedure will be followed by the facility nurse and any changes will be reviewed by the DRS. The DRS will review on the completed checklist and any health care plan changes for 6 months (Target Date: 8/1/24).
In the future, the facility RN in conjunction with the QIDP will review all discharge instructions to ensure that any changes made to the individuals current needs are addressed. If there are any changes, the facility RN will complete an updated health care plan and the QIDP and/or facility RN will complete training for all staff to ensure the individuals current needs are addressed.
483.460(k)(2) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.
Observations:
Based on observations, review of physician's orders, and interview, it was determined that the facility failed to ensure that all medications were administered without error. This applied to one of two medication passes observed. Findings included:
Observations of the afternoon medication pass were completed on January 9, 2024, from 4:45 PM to 5:22 PM. The staff was observed to administer Individual #3's afternoon medication at 4:53 PM, which consisted of krill oil.
A review of physician's orders dated December 15, 2023, to reconcile the medication pass was completed on January 10, 2024. This review revealed that Individual #3 had an order to receive "ICAPS MV TAB Take 1 tablet by mouth twice daily for macular degeneration supplementation." The physician's orders indicated the medication was to be given at 7:00 AM and 5:00 PM. This medication was not observed to be given during the observed pass on January 9, 2024.
An interview was conducted with the director of residential services (DRS) on January 11, 2024, at 10:35 AM. The DRS stated that the physician ordered preservision on December 22, 2023, to replace the "ICAPS MV TAB." The DRS confirmed that there was no documentation that the physician discontinued the "ICAPS MV TAB" as intended.
Plan of Correction:The facility will ensure the system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.
To immediately address the deficiency identified for individual #3, the facility nurse received a written order to discontinue the previous medication. (Completed: 1/17/2024).
For individual #3 and all other individuals in the facility, the facility nurse will ensure that all medication orders are correct. (Completed: 1/17/2024) The facility nurse will review the physician's orders and compare those against the MARS bi-weekly to ensure accuracy for 3 months (Target Date: 5/1/24) and then monthly for 3 months (Target Date: 8/1/2024). The QIDP will review MARS and Physician's Orders bi-weekly to ensure accuracy for 3 months (Target Date: 5/1/24) and then monthly for 3 months (Target Date: 8/1/2024).
The DRS will review all MARS and Physician's Orders monthly for 3 Months (Target Date 5/1/2024).
In the future, the facility will create a procedure to ensure all orders, verbal or physical, are received and documented with accuracy. The DRS will provide training to the QIDP and Facility Nurse on new procedure to ensure accurate orders in the future (Target Date: 2/15/2024). The facility nurse, when reviewing a medication change, will ensure that all previous orders are accurate. If any medication is discontinued, the facility nurse will follow the procedure to ensure all orders are documented with accuracy.
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
at least quarterly for each shift of personnel.
Observations:
Based on observations, review of facility provided documentation, and interviews, it was determined that the facility failed to ensure that fire drills were practiced at least quarterly for all shifts of staff. This applied to four out of four quarters of fire drill documentation reviewed. Findings included:
Observations were conducted at the residence in the evening on January 9, 2024, from 3:30 PM until 6:25 PM. During this time, staff revealed to the surveyors that their names were documented on fire drill forms as having participated in drills; however, they stated that they did not participate in those drills. Observations were also conducted in the morning on January 10, 2024, from 5:58 AM until 7:46 AM. During this time, the surveyors interviewed staff who confirmed that they had never participated in a fire drill.
Interview with Individual #7 was conducted on January 10, 2024, at 7:28 AM. During this interview, Individual #7 was able to verbally confirm participation in fire drills during the day, and was also able to state verbally where the meeting point was outside where they would gather when evacuating. When Individual #7 was questioned if they had participated in fire drills at night, they emphatically stated, "No", while shaking their head.
A review of fire drills documentation was completed January 10-11, 2024, for the months of January 2023, through December 2023. This review revealed documentation of fire drills as follows:
- Day shift on January 6, 2023, April 3, 2023, July 6, 2023, and October 4, 2023.
- Afternoon/Evening shift on February 6, 2023, May 2, 2023, August 4, 2023, and November 7, 2023.
- Overnight shift on March 4, 2023, June 10, 2023, September 10, 2023, and December 2, 2023.
An interview was conducted with the qualified intellectual disabilities professional (QIDP) on January 12, 2024, at 9:30 AM, to discuss the process for conducting fire drills. The QIDP explained that whoever is running the drill will notify the alarm company 15-30 minutes prior to the drill in order to take the alarm system off line.
Subsequent interviews with several staff were conducted on January 12, 2024, between 11:30 AM and 12:00 PM. Three staff revealed that they have never participated in a fire drill.
A review of the system event report from the alarm company for the months of February 2023, through December 2023, was completed on January 12, 2024. This review revealed that there were no calls to the alarm company to take the system offline in order to run a fire drill on the following dates: February 6, 2023, April 3, 2023, May 2, 2023, June 10, 2023, July 6, 2023, August 4, 2023, Sept 10, 2023, October 4, 2023, November 7, 2023, and December 2, 2023. When comparing the system event report documentation and the facility provided fire drill documentation, the dates failed to correlate to show the drills actually occurred.
An interview was conducted with the QIDP and the director of residential services on January 12, 2024, at 1:40 PM. When the QIDP was presented with the information on the fire drill forms, interviews with staff and an individual, and the system event report from the alarm company, the surveyor questioned that it appeared the fire drill forms were completed without the drills actually occurring. The QIDP responded by shaking her head yes. The surveyor then asked her to verbally confirm that she was responding yes. She then stated, "Yes."
Plan of Correction:The facility will ensure that evacuation drills are run at least quarterly for each shift of personnel.
The DRS will retrain the QIDP, DSSL, and all staff on standard evacuation drills (Target Date: 2/15/2024). The QIDP, or designee, will complete all fire drills in accordance with the fire drill schedule put together by the DRS. To ensure accuracy and completion, the QIDP or designee will complete the following steps when completing a fire drill:
1. Notify the system to be placed on test, in order to set the fire system off.
2. Complete the fire drill and each staff member will sign or initial completion of the drill.
3. The QIDP or designee will complete the fire drill form, sign and submit it for review to the DRS.
4. The QIDP will attach documentation from the fire system company showing when the system was turned off.
5. The DRS will review all fire drills for accuracy and sign off on documentation. A copy of the documentation will be kept in the regional office and the original will be kept on site.
The QIDP will provide this documentation for 6 months. (Target Date: 8/1/2024) The DRS will observe completion of the fire drills bi-monthly for 6 months to ensure accuracy. (Target Date: 8/1/2024)
483.480(b)(2)(iii) STANDARD
MEAL SERVICES
Name - Component - 00
Food must be served in a form consistent with the developmental level of the client.
Observations:
Based on observations, review of facility provided documentation, and interview, it was determined that the facility failed to ensure that food texture was served in accordance with the individual's needs. This applied to one (#4) of seven individuals living at the facility. Findings included:
Observations of the dinner meal were conducted at the residence on January 9, 2024, from 5:28 PM until 5:50 PM. The dinner meal consisted of pork chops, cauliflower and buttered noodles. Individual #4 was observed to be served the cauliflower and buttered noodles that appeared to be a smooth texture. The texture of the pork chop was observed to be prepared to a stringy consistency. At 5:30 PM, the surveyor questioned the qualified intellectual disabilities professional (QIDP) on the consistency of the pork chop served to Individual #4. The QIDP stated that Individual #4 is to have a pureed texture that is smooth and further stated that the "pork chop was not pureed." The QIDP then intervened with the meal and prepared the pork chop for Individual #4 to the required pureed consistency.
A review of physician's dietary orders, dated December 15, 2023, was completed on January 10, 2024. These dietary orders revealed that Individual #4 was to have "puree diet encourage small bites/sips at a slower rate."
An interview was conducted with the QIDP on January 10, 2024, at 11:05 AM. The QIDP confirmed that Individual #4 did not receive the meal prepared in accordance with their identified needs.
Plan of Correction:The facility will ensure for individual #4, and all other individuals in the facility that food will be served in a form consistent with the developmental level of the client.
The QIDP and Facility Nurse will review all Physician's Orders and Individuals Program Plan to ensure all meals are prepared in the consistency that is required to meet the individual's developmental needs. The QIDP will re-train all staff on the individual's dietary needs to meet their development level as described in the physician's orders and the individual's program plan (Target Date: 2/15/2024). The training will be documented on an agency in-service form and kept at the regional office. The QIDP or their designee will provide hands-on training, monthly for 3 months, to all program staff during monthly staff meetings to ensure the food will be served in a form consistent with the developmental level of the client. (Target Date: 5/1/24) For all new staff, the QIDP will provide training to ensure all foods are consistent with the developmental level of the client.
For individual #4, and all other individuals in the facility, the QIDP provided coaching to all staff on the correct preparation of food consistent with the developmental level of the client. (Completed: 1/10/2024). The QIDP completed a dinner observation on 1/11/24 to ensure all individuals in the facility had meals prepared consistent with their developmental level of the client.
The QIDP, or designee, will complete weekly dinner observations at the facility to ensure that food will be served in a form consistent with the developmental level of the client. The QIDP, or designee, will also complete weekly observations at the ATF/ASC to ensure that food will be served in a form consistent with the developmental level of the client.
The QIDP will submit the weekly observations to the DRS for review monthly for 6 months. The DRS, or his designee will complete monthly observations for 3 months at the ATF/ASC or at the facility to ensure that food will be served in a form consistent with the developmental level of the client.
483.480(b)(2)(iv) STANDARD
MEAL SERVICES
Name - Component - 00
Food must be served with appropriate utensils.
Observations:
Based on observations and interview, it was determined that the facility failed to provide the appropriate utensils for food served at the residence. This applied to five (#2, #3, #5, #6, and #7) of seven individuals at the residence. Findings included:
Observations were completed at the residence on January 9, 2024, from 3:30 PM to 6:25 PM. Upon entry into the residence, the dining room was observed to have placemats, napkins, and spoons set up at the table in preparation for the dinner meal. Beginning at 5:26 PM, Individuals #2, #3, #4, #5, #6, and #7 entered the dining room for the dinner meal. The meal served to the individuals at the residence was pork chops, cauliflower, and buttered noodles. At approximately 5:28 PM, Individuals #2, #3, #5, #6, and #7 were observed to pick up their whole, uncut pork chop, approximately four inches long by three inches wide, and consume their entree with their hands. At 5:32 PM, Individual #6 was also observed using their hands to eat their buttered noodles, to which staff redirected them to their spoon. The only utensil observed to be offered by the staff for the entire meal were spoons.
An interview was conducted with the qualified intellectual disabilities professional (QIDP) on January 9, 2024, at 6:05 PM. The QIDP acknowledged that the individuals listed above should have had appropriate utensils for their dinner meal or assistance from staff to consume their dinner meal. The QIDP confirmed that the individuals did not receive the appropriate utensils with their dinner meal.
Plan of Correction:The facility will ensure all individuals will be served food with the appropriate utensils.
For individuals #2, #3, #4, #5, #6, #7 and all other individuals in the facility, the QIDP will ensure all staff are re-trained on the appropriate utensils for all meals and provide options for all individuals in the facility the option to choose which utensil they prefer. (Target Date: 2/15/2024)
The QIDP, or designee, will complete weekly dinner observations at the facility for to ensure that appropriate utensils are offered and provided to the individuals within the facility for 6-months. (Target Date: 8/1/24)
The QIDP will submit the weekly observations to the DRS for review monthly for 6 months. (Target Date: 8/1/24) The DRS, or designee will complete monthly observations for 3 months at the ATF/ASC or at the facility to ensure that appropriate utensils are provided. (Target Date: 5/1/24)
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