Initial Comments:
A focused fundamental survey visit was completed on December 13 and 14, 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 20, and the sample consisted of four 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 completed with the facility administrator, and interview with administrative staff, the facility failed to exercise general policy, budget and operating direction to provide for the health and safety of Individuals in the provision of maintenance and repair of the residence. This practice is specific to all room areas on both the 200 wing and the 300 wing of this residence building.
Findings include:
Observation of both the 200 wing and 300 bedroom wing of the building was completed with the facility administrator on 12/14/2023 between approximately 9:00 AM and 09:45 AM.
These observations are as follows:
300 Wing
All bedroom areas were observed to have chipped and peeling paint on walls, scratched and gouged areas on bedroom doors and bedroom furniture to include wooden bed frames and dressers. Throughout many of the rooms, there were two aluminum heating units approximately 24 inch length by 18 inch high which were mounted approximately 2.5 feet from ceiling on the outside bedroom wall. All of these units evidenced peeling paint with some loose paint chips hanging from the unit exposing the underlying aluminum frame.
Specific room observations included the following :
-Bedroom 3
right lower area of door frame to pass through closet :
the wall has a gouged area approximatley 8 to 12 inches from bottom which is approximatley 3 inch by 5 inch in measurement. This area is dented and pushed in at that location. Beneath this area, at the bottom of the wall is a yellow patched area of the wall that also covers the door frame itself for an area of approximatley 5 x 6 inches. This area is flexible and when touched, will move inward. Interview with the administrator who was accompanying the survey staff indicated that this area was a repair for wall damage that had caused a hole in the wall area.
- Shower room area across from bedroom 4 ( no room number assigned)
there is a shower cart located next to the back left wall of this room. Upon moving this cart, there was an area of mold/mildew, approimately 1.5 foot in length and 6 to 8 inches in height on the wall where the bed of shower cart would have contact.
- Wainscoting on full length of the left and right wall in hallway is a lightweight corrugated material that is stained and nicked throughout the surface area and full length on both sides of wall.
200 Wing
All bedroom areas were observed to have chipped and peeling paint on walls, scratched and gouged areas on bedroom doors and bedroom furniture to include wooden bed frames and dressers. Wainscoting on full length of the left and right wall in hallway is a lightweight corrugated material that is stained and nicked throughout the surface area.
Interview with the Facility Director throughout the course of the observation period noted that this interviewee acknowledged the conditions observed during the observation period attributing much of the damage to the movement of wheelchairs and assistive devices throughout the residence. This interviewee also noted that the agency maintenance services department will paint selected areas, e.g. bedrooms on a routine basis, approximatley every one to three months.
When questioned if there is a process and/or procedure in place to request services beyond the routine timed services, interview with this Director on 12/14/2023 at 10:17 AM indicated that there is no process to request services on an as needed basis.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements;
On 1/3, Maintenance removed the mildew in the shower room of 300 wing and painted the area.
On 1/16, in the 200 wing, Maintenance started to fill gouges on bedroom doors, paint the doors, and place a protective barrier on them to avoid damage. Expected to be finished within 30 days.
On 1/26, a contractor is scheduled to look at wainscotting and quote to replace. Quote will be received within 30 days.
Maintenance will spackle/dry wall and paint. They will place a corner guard to help secure the wall and protect area in bedroom 3 by 2/15.
300 wing bedroom doors expected start on 2/1. Completed within 30 days.
Heating units scraped and repainted within 60 days.
New furniture will be ordered within 30 days for any that are in disrepair.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice;
Management (Director, Nursing Coordinator, QIDP, Nurse Case Manager, and Health Services Coordinator) will meet with maintenance to review all other areas for repairs of the residence by 3/1. Repairs will be made within 60 days.
3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur;
During routine visit, Maintenance assistant will complete a weekly audit of repairs needed and fix issues same day. Any issues that require more time or a quote from a contractor will be submitted to Maintenance Supervisor to be completed/scheduled within 30 days. Maintenance supervisor will complete a monthly follow up for the previous month's audit to ensure repairs have been completed and submit audit to Director. If any repairs need an extended timeline due to contractors or supplies, a new end date will be agreed upon and noted on the audit.
Nursing Assistants, Nurses, and any other staff will use repair request form and submit to maintenance for any issues not noted during monthly audits. Forms will submitted to into bin on Maintenance office door. These items will be fixed within the next week or if longer is needed, the Director will be notified by email.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur;
All forms and audits will be kept in a binder and reviewed by management team monthly to ensure compliance. Any uncompleted items will be addressed in an email to Maintenance for explanation and completed within 30 days.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
Director will receive all forms and audits upon completion by Maintenance Department. If an issue is still uncompleted, a meeting will be held with Maintenance Department within 10 days.
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 observations, record review and interview with the Qualified Intellectual Disabilities Professional (QIDP), the facility failed to ensure that Individuals were informed of the use, attendant risks of treatment, and of the right to refuse treatment regarding the use of alarm units on all exits of the residence building. This practice is applicable to 19 of 20 sample Individuals.
Findings include:
1. Observations completed on 12/13/2023 from 3:30 PM to 6:00 PM revealed that once in the facility there is an alarm sound when passing by or near each exit door. When questioned reguarding the use of alarms/alerts on the doors to this building, interview with the Qualified Intellectual Disabilities Professional (QIDP) on 12/14/2023 at approximately
10:30 AM indicated that the door alarms/alerts were placed on all exits of the building as an alert for staff, that sound whenever anyone is in within approximately 2 feet passing by the door. This system was installed in response to multiple elopement events from the building by Individual #1.
2. Observations in the day room area of the residence was completed on 12/13/2023 from 3:30 PM to 4:25 PM. Individual #1 was observed independently moving about the day room in his wheelchair. He was near a staff member who would verbally engage Individual #1 when he would attempt to leave the day room area.
Interview on 12/13/2023 at approximately 3:45 PM with the above-mentioned staff revealed that this staff was assigned specifically to Individual #1 as a line of sight supervision protocol due to history of repasted elopements from the facility including one incident where Individual #1 was found outside on the grounds of the facility.
3. A review of Individual #1's record was completed on 12/14/2023 between 8:30 AM and 10:30AM,and revealed a Behavioral Support Plan dated 09/21/2023. Within this plan is a section titled Consent:. Under this section, the following is listed ;
"This plan documents the use of Psychotropic Medication and Behavior modification and Protective Devices to ensure safety, Proper Body Alignment, and to Prevent Contractures, and it requires review by the Human Rights Committee." In further review, there was no indication that review or consent had been secured from either Individual #1 or his designated guardian for the use of door alarms/alerts installed on all exit doors of the facility, or the protocol of line of sight enhanced supervision
Interview with the Qualified Intellectual Disabilities Professional (QIDP) on 12/14/2023 at approximately 10:30 AM confirmed that informed consent was not secured as outlined above. In further interview, when questioned if review and consent for the use of the restrictive practice of door alarm/ alerts throughout the building had been obtained for the remaining 19 Individuals who reside at this residence, this interviewee stated that consent had not been secured from the reminding Individuals in this residence.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements;
QIDP contacted family member of individual #1 on 1/15. Family did not answer. QIDP will attempt to contact the family again within 10 days.
On 1/18, QIDP discussed plan with individual #1 to review restrictive plan, including door alarms and line of sight. Individual gave consent to plan. HRT approved the plan on 1/18.
Staff will be retrained by QIDP on the updated plan within 2 weeks of approval.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice;
QIDP reviewed restrictive plan for door alarms with other 19 individuals and requested consent by them or designated guardian on 1/15. After consent received, plans were submitted to HRT and approved on 1/18. Staff will be retrained by QIDP on any updated plans within 2 weeks of approval.
3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur;
If an individual has an increase in restrictive measures, the Management team will meet and review the need to see if it will restrict other individuals. The meeting will be held within 2 weeks of the identified need for restriction. If a restriction will need to be applied to all individuals, then the QIDP will contact each team for consent within 30 days. QIDP will update plans by the next monthly routine HRT meeting. Staff will be trained by QIDP within 2 weeks of plan approval.
Nurse Case Manager and QIDP will ensure all new admissions are made aware of any current restrictions that apply to all individuals and gain consent prior to admission. QIDP will then create a restrictive plan and submit to HRT within 30 days of admission. Staff would be trained by QIDP within 2 weeks of approval.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur;
HRT will flag any plans that they deem restrictive for more than just the individual listed on the plan. They will notify the QIDP at the time of the HRT meeting. The QIDP will update plans and gain consent for other individuals the HRT deems to be needed by the next monthly meeting. Once additional plans are approved by HRT, the staff would be trained by the QIDP within 1 week.
Life Path Program Specialist will conduct quarterly audits of restrictive plans completed within past 3 months to ensure any new or enhanced restrictions put in place were applied to all individuals if necessary. If an issue is found for correction, the QIDP will contact each team for consent within 30 days. QIDP will update plans by the next monthly routine HRT meeting. Staff will be trained by QIDP within 2 weeks of plan approval.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
Director will receive all audits upon completion. If an issue is still uncompleted by the next HRT meeting, a meeting will be held with QIDP within 10 days to discuss and correct.
483.430(a) STANDARD
QIDP
Name - Component - 00
Each client's active treatment program must be integrated, coordinated and monitored by a qualified intellectual disability professional who-
Observations:
Based on observation, a review of facility records and documentation and interview with the facility Qualified Intellectual Disabilities Professional (QIDP ), the QIDP failed to integrate, coordinate and monitor each clients' active treatment program.
Findings include:
- The facility failed to ensure that Individuals were informed of the use, attendant risks of treatment, and of the right to refuse treatment regarding the use of alarm units on all exits of the residence building. This practice is applicable to 19 of 20 sample Individuals.
Refer to W 124.
- The facility failed to assure that objectives of the individual program are expressed in behavioral terms that provide measurable indices of performance for four of five sample individuals. This practice is specific to Individual #1, #2, #3 and #4. Refer to W 231.
- The facility failed to ensure that each written training program designed to implement the objectives in the individual program plan must specify the schedule for use of the method. This practice is specific to Individual #1, #2, #3 and #4. Refer to W 235.
- The facility failed to incorporate the use of systematic interventions to manage inappropriate behaviors into the Individual program plan for one of one sample Individual who displays elopement behavior for one of one sample Individual. This practice is specific to
Individual #1. Refer to W 289.
Plan of Correction:Refer to W 124 for corrective action on restrictive plans.
Refer to W 231 for corrective action on measurable indices.
Refer to W 235 for corrective action on program schedules.
Refer to W 289 for corrective action on BSP interventions in IPP.
483.440(c)(4)(iii) STANDARD
INDIVIDUAL PROGRAM PLAN
Name - Component - 00
The objectives of the individual program plan must be expressed in behavioral terms that provide measurable indices of performance.
Observations:
Based on record review and interview with the Qualified Intellectual Disabilities Professional (QIDP), the facility failed to assure that objectives of the individual program are expressed in behavioral terms that provide measurable indices of performance for four of five sample individuals. This practice is specific to Individual #1, #2, #3 and #4.
Findings include:
A review of records for Individuals#1, #2, #3 and #4 was conducted on 12/14/2023 from approximately 9:00 AM to 12:00PM. This review noted that training program objectives developed for these Individuals were not expressed in behavioral terms to provide measurable indices of performance. Individual #1 is exemplary of this practice.
Individual #1
A review of current training plans in place for Individual #1 noted that training objectives for three of four training programs in place were not written in behavioral terms that provide measurable indices of performance as follows:
1, Training Program: Reaching out to make a choice
Step #2: [Individual #1] will make a choice with verbal prompts or better 15% of the time on average during the three month period. Beyond the training plan statement indicating that the Individual will make a choice, there is no further delineation of what choice should be demonstrated in order to measure successful completion of this training plan objective.
2. Training program: Mobility
Step #2: [Individual #1] will walk to desired location with 2 stops/redirections or better of the time on average during the tree month period. Beyond the training plan statement indicating that the Individual will walk to a location, there is no further information to provide measurable parameters by which progress can be measured to asses achievement of this objective.
3. Drinking from Cup
Step #2: [Individual #1] will drink from his cup appropriately with verbal prompts or better 25% of the time on average during the three month period.
Beyond the training plan statement indicating that the Individual will walk to a location, there is no further information to provide measurable parameters by which progress can be measured to asses achievement of this objective.
Interview with the QIDP on 12/14/2023 at approximately 11:00 AM, confirmed that the above training program objectives did not provide measurable indices of performance.
Plan of Correction:Plan of Correction:
1. How corrective actions will be accomplished for those individuals identified in deficiency statements;
QIDP will hold IDT meetings for individuals 1, 2, 3, 4 to review individual program plans (IPPs) and assure objectives are expressed in measurable indices (i.e. specific locations/times/choices). Meetings will be held by 3/1. Staff will be retrained by QIDP on updated plans within 2 weeks.
QIDP was retrained on IPPs by Compliance department on 12/28/23 and 1/9/24.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice;
Within 90 days, QIDP will review and modify programs for all individuals to show more narrow/specific measurement of parameters for progress. Updated plans will then be sent to IDT members for review. If an IDT member requests a meeting to review, QIDP will schedule IDT meeting within 2 weeks. Staff will be retrained by QIDP on any updated plans within 2 weeks.
3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur;
Compliance department will complete audit of programs for a sample of 10 individuals within 3 months to ensure objectives are expressed in measurable indices.
A LifePath Program Specialist will complete an audit quarterly starting 4/1. The audit will be for a sample of 5 individuals to ensure objectives are expressed in measurable indices. Each quarter a new set oft 5 individuals will be audited.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur;
Audits will be submitted to QIDP within a week of completion. If items need correction, IDT meeting will be held for review on plans out of compliance within 30 days. Staff will be retrained by QIDP on any updated plans within 2 weeks.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
Director will receive all audits upon completion. If an issue is still uncompleted, a meeting will be held with QIDP within 10 days to discuss and correct.
.
483.440(c)(5)(ii) STANDARD
INDIVIDUAL PROGRAM PLAN
Name - Component - 00
Each written training program designed to implement the objectives in the individual program plan must specify the schedule for use of the method.
Observations:
Based on record review and interview with the Qualified Intellectual Disabilities Professional (QIDP), the facility failed to ensure that each written training program designed to implement the objectives in the individual program plan must specify the schedule for use of the method. This practice is specific to Individual #1, #2, #3 and #4.
Findings include:
A review of records for Individuals #1, #2, #3 and #4 was conducted on 12/14/2023 from approximately 9:00 AM to 12:00PM. This review noted that the training programs in place do not provide clear direction to staff persons implementing these plans about when the strategies should be implemented. Individual #1 is exemplary of this practice.
Individual #1
A review of the current training plans in place for Individual #1 noted that training plans for four of four training programs in place did not provide clear direction to staff implementing the plans when these training plans should be implemented, Training plans include the following:
1) Training Program: Reaching out to make a choice, Training step #2. This plan indicates that it should be implemented: 10 times a month with shift Responsible: 7a-3p (first shift ) and 3p-11p (second shift ).
- Training Program: Drink from a cup, Training step #2.
Implemented: 10 times a month.
Shift Responsible: 7a-3p, 3p-11p.
-Training Program: Mobility, Training step #2.
Implemented: 10 times a month.
Shift Responsible: 7a-3p, 3p-11p.
-Training Program: Putting on Shirt, Training step #2.
Implemented: 10 times a month.
Shift Responsible: 7a-3p, 3p-11p.
Beyond the listing of shift responsible and total sessions per month, there is no specific and clear direction to staff regarding times of implementation.
Interview with the QIDP on 12/14/2023 at approximately 11:00 AM, confirmed the above findings.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements;
QIDP will hold IDT meeting for individual #1 by 3/1 to discuss training programs and define clear direction to staff for when the training plan will be implemented. Staff will be retrained by QIDP in updated plan within 2 weeks.
QIDP was retrained on IPPs by Compliance department on 12/28/23 and 1/9/24.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice;
Within 90 days, QIDP will review and modify programs for all individuals to define clear direction to staff for time of implementation. Updated plans will then be sent to IDT members for review. If an IDT member requests a meeting to review, QIDP will schedule IDT meeting within 2 weeks. Staff will be retrained by QIDP on any updated plans within 2 weeks.
3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur;
Compliance department will complete audit of programs for a sample of 10 individuals within 3 months to ensure training programs define clear direction to staff for when the training plan will be implemented.
A LifePath Program Specialist will complete an audit quarterly starting 4/1. The audit will be for a sample of 5 individuals to ensure training programs define clear direction to staff for when the training plan will be implemented. Each quarter a new set oft 5 individuals will be audited.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur;
Audits will be submitted to QIDP if items need correction. IDT meeting will be held for review on plans out of compliance within 30 days. Staff will be retrained by QIDP on any updated plans within 2 weeks.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
Director will receive all audits upon completion. If an issue is still uncompleted, a meeting will be held with QIDP within 10 days to discuss and correct.
483.450(b)(4) STANDARD
MGMT OF INAPPROPRIATE CLIENT BEHAVIOR
Name - Component - 00
The use of systematic interventions to manage inappropriate client behavior must be incorporated into the client's individual program plan, in accordance with §483.440(c)(4) and (5) of this subpart.
Observations:
Based on observations, record review and interview with facility and administrative staff,
the facility failed to incorporate the use of systematic interventions to manage inappropriate behaviors into the Individual program plan for one of one sample Individual who displays elopement behavior for one of one sample Individual. This practice is specific to
Individual #1.
Findings include:
Observation in the day room area completed on 12/13/2023 from 3:30 PM to 4:25 PM noted Individual #1 who is known to this surveyor as being an elopement risk. Individual #1 was moving about the day room in his wheelchair who was moving his wheelchair in the area independently near a staff member who would verbally engage Individual #1 when he would attempt to leave the area.
Interview on 12/13/2023 at approximately 3:45 PM with the above-mentioned staff revealed that Individual #1 was a to be kept in his line of sight due to history of elopements where Individual #1 was found outside on the grounds of the facility.
interview with the Qualified Intellectual Disabilities Professional on 12/14/2023 between 10:00 and 10:30 AM confirmed that Individual #1 is on line of sight level of supervision at this time. This interviewee noted that the institution of this protocol was completed in response to the results of an investigation relating to an incident of elopement by Individual #1 when he was found outdoors on the grounds of the facility. The need for an enhanced level of supervison, defined as line of sight, was a conclusion of that investigation.
2. A review of Individual #1's record was completed on 12/14/2023 from approximately 9:00 AM to 11:30 AM. In a review of a behavior support plan, dated 09/21/2023 and updated on 02/01/2023, the plan identifies the following target behaviors; :
-Agitation Behaviors- defined as yelling pacing, restlessness.
-Elopement Attempts-leaving the building without supervision
Under the section title Respond to behaviors , the following is noted:
-Currently [Individual #1] has psychotropic medication prescribed for the treatment of Bipolar D/O as evidenced by ongoing restlessness behaviors, agitation, inability to relax, and duration of insomnia.
- The team will discuss the reductions and current medication if [Individual#1] attains the projected reductions in target behaviors as indicated in his Medication Reduction plan.
- Staff should be alert to [Individual #1 ' s] physical needs before he experiences discomfort to help alleviate and prevent stressors.
Beyond discussion of strategies that would trigger review of reduction of medication, there were no further information incorporated into this plan to provide staff with direction on how to implement interventions to address the identified target behaviors when they are displayed by individual #1.
Additionally, there was no indication that the supervision level of line of sight, as observed by the survey staff on 12/13/2023, had been identifed by the Interdisciplinary team as a behavior support intervention and incorporated into this behavior support plan.
Interview with qualified intellectual disabilities professional/ behavior support specialist on 12/14/2023 at approximately 11:00 AM confirmed the above findings.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements;
QIDP will hold IDT meeting for individual #1 by 3/1 to discuss incorporation of the use of systematic interventions to manage inappropriate behaviors into the IPP. IDT will discuss enhanced supervision as a behavior support intervention. Plan will be updated and approved at following monthly HRT meeting. Staff will be retrained by QIDP in updated plan within 2 weeks of HRT approval.
QIDP was retrained on IPPs by Compliance department on 12/28/23 and 1/9/24.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice;
Within 30 days, QIDP will review and modify programs for individuals with interventions for inappropriate behaviors to ensure systematic interventions are in IPP. Updated plans will then be sent to IDT members for review. If an IDT member requests a meeting to review, QIDP will schedule IDT meeting within 2 weeks. Staff will be retrained by QIDP on any updated plans within 2 weeks of HRT approval.
3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur;
Compliance department will complete audit of programs for a sample of individuals within 3 months to review individuals with inappropriate behaviors and the IPP includes interventions.
A LifePath Program Specialist will complete an audit quarterly starting 4/1. The audit will be for a sample of individuals with inappropriate behaviors and review that the IPP includes interventions. Each quarter a new set oft 5 individuals will be audited.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur;
Audits will be submitted to QIDP if items need correction. IDT meeting will be held for review on plans out of compliance within 30 days. Staff will be retrained by QIDP on any updated plans within 2 weeks.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
Director will receive all audits upon completion. If an issue is still uncompleted, a meeting will be held with QIDP within 10 days to discuss and correct.
483.460(f)(1) STANDARD
COMPREHENSIVE DENTAL DIAGNOSTIC SERVICE
Name - Component - 00
Comprehensive dental diagnostic services include a complete extraoral and intraoral examination, using all diagnostic aids necessary to properly evaluate the client's condition not later than one month after admission to the facility (unless the examination was completed within twelve months before admission).
Observations:
Based on record review and interview with facility staff, the facility failed to provide comprehensive dental diagnostic services including complete extraoral and intraoral examination using all diagnostic aids necessary to properly evaluate the client's condition not later then one month after admission to the facility unless an examination was completed within twelve months before admission. This practice is applicable to one of one sample Individual who is a new admission to this facility, specifically Individual # _____.
Findings include:
A review of the records of Individual # 3 was completed on 12/14/2023 between
10:30 AM and 11:15 AM. This review noted that this Individual was admitted to this facility on 09/21/2023. In a review of pre-admission information completed by nursing services dated 09/11/2023, it was noted that "[Individual # 3] last seen Penn dental 2 years ago".
Interview with facility nursing staff conducted on 12/14/2023 at approximately
12:20 PM confirmed that upon admission, Individual #3's mother, who is her legal guardian, confirmed that her daughter had not received dental services in the 2 years prior to admission. Further review of the record revealed that post admission to this facility on 09/21/2023, Individual #3 was not examined by a dentist until 11/17/2023.
Subsequent interview with the facility Qualified Intellectual Disabilities Professional (QIDP)
on 12/14/2023 at approximately 11:00 AM confirmed that the dental appointment was not completed until that date.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements;
Individual had dental exam on 11/17/23. Dental exam was scheduled within 30 days and cancelled by the dentist. A medical report form was filled out for the cancellation.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice;
Nurse Case Manager will review all new admissions within past 12 months to review all pre-admission medical assessments were completed. If non-compliance issues noted, individuals will be scheduled for appointment within 30 days.
3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur;
Nursing Coordinator will complete review of any new admissions within 1 week of admission to determine compliance of pre-admission medical assessments. If any appointments are needed, Health Services Coordinator will schedule within first 30 days.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur;
Management team will review all new admissions within 30 days to ensure all pre-admission medical evaluations were completed. Any items found non-compliant will be corrected within 30 days.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
Director will review all audits and medical evaluations upon their completion. If an issue is still uncompleted, a meeting will be held with IDT within 10 days to discuss and correct.
483.480(c)(1)(i) STANDARD
MENUS
Name - Component - 00
Menus must be prepared in advance.
Observations:
Based on observation, record review, and interview with facility staff, the facility failed to have menus that are prepared in advance. This practice is specific to the breakfast menu for this facility.
Findings include:
1. Observations completed on 12/13/2023 between 8:15 and 8: 30 AM revealed that Individual # 5 was observed sitting at a table in the dining room area of the facility. On the table in front of this Individual was a green cafeteria tray where an unidentified amount of commercially prepared chex mix snack food was placed. A staff person who was seated next to Individual #1 had a plastic cup with an attached straw which contained milk. Individual #1 was observed to pick up the chex mix with her fingers and place it in her mouth. After consuming a few mouthfuls of food, the staff person would then provide Individual # 5 with a sip of milk before she continued to feed herself the snack mix.
When asked about the use of the chex snack mix as a breakfast food for Individual # 5, interview with this staff person between 8:20 and 8:30 AM noted that this Individual is very picky in her food preferences. She does not show interest in usual breakfast foods that have been provided, e.g. pancakes, eggs , but will eat the snack mix.
Interview with the Qualified Intellectual Disabilities Professional on 12/14/2023 approximately 12:15 PM revealed that when asked to review the facility menus for all meals, this interviewee provided a document for the month of December, 2023.
This menu consisted of a monthly grid for each day of the month. In each dated block of the grid, there were entries for lunch and dinner on that date. These entries consisted of food items which would be served for each designated meal on that date, e.g. Lunch = tacos, rice refried beans, Dinner = Asian beef stew. There was no information outlining the breakfast menu for this month nor substitution menu items available for the two meals which are listed for the month of December, 2023.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements;
There is a binder with seasonal menus from dietician kept at the program. The menus are kept in the dining room with the individuals' diet plans.
QIDP, Nursing Coordinator, and kitchen staff will meet with dietician within 60 days to review menus for individual #5 and ensure all meals are noted in advance. Staff will be retrained by QIDP on any updated menus within 2 weeks.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice;
QIDP, Nursing Coordinator, and kitchen staff will meet with dietician within 60 days to review menus for individuals that eat by mouth and ensure all meals are noted in advance. Staff will be retrained by QIDP on any updated menus within 2 weeks.
3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur;
QIDP will review the menus for the next month 2 weeks prior to ensure all meals are present in advance. If corrections are needed, QIDP will notify dietician and kitchen staff within 2 weeks to fix issues.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur;
Management team will review menus quarterly to ensure that they include meals were present in advance. If issues are noted, the team will meet with dietician and kitchen staff within 30 days to discuss the issues and correct for future menus.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
Director will receive all menus monthly and be made aware of any issues noted by the QIDP. If issues are present, Director will be notified of correction within 2 weeks by kitchen staff.
483.480(c)(1)(ii) STANDARD
MENUS
Name - Component - 00
Menus must provide a variety of foods at each meal.
Observations:
Based on observation, a review of facility records and documentation, and interview with facility staff, the facility failed to provide a variety of foods to inlcuded substitutions within the same food group for one of one sample Individual who eats by mouth observed during the breakfast meal. This practice is specific to Individual #4.
Findings include:
Observations completed on 12/13/2023 between 8:15 and 8: 30 AM revealed that Individual # 5 was observed sitting at a table in the dining room area of the facility. On the table in front of this Individual was a green cafeteria tray where an unidentified amount of commercially prepared chex mix snack food was placed. A staff person who was seated next to Individual #1 had a plastic cup with an attached straw which contained milk. Individual #1 was observed to pick up the chex mix with her fingers and place it in her mouth. After consuming a few mouthfuls of food, the staff person would then provide Individual # 5 with a sip of milk before she continued to feed herself the snack mix.
When asked about the use of the chex snack mix as a breakfast food for Individual # 5, interview with this staff person between 8:20 and 8:30 AM noted that this Individual is very picky in her food preferences. She does not show interest in usual breakfast foods that have been provided, e.g. pancakes, eggs , but will eat the snack mix.
2. A review of the record of Individual # 5 was completed on 12/14/2023 between
11:00 AM and 11:30 AM. In a review of a document outlining prescribed diet and any eating protocols/ consistency necessary, dated 02/09/2023, this document indicates that this Individual is currently prescribed a 2000 calorie diet with no change in food texture required. There is no further information delineated regarding food likes, dislikes and or substitutions in the event that this Individual will not consume a food item which is offered.
Interview with the Qualified Intellectual Disabilities Professional on 12/14/2023 approximately 12:15 PM revealed that when asked to review the facility menus for all meals, this interviewee provided a document for the month of December, 2023.
This menu consisted of a monthly grid for each day of the month. In each dated block of the grid, there were entries for lunch and dinner on that date. These entries consisted of food items which would be served for each designated meal on that date, e.g. Lunch = tacos, rice refried beans, Dinner = Asian beef stew. There was no information outlining the breakfast menu for this month nor substitution menu items available for the two meals which are listed for the month of December, 2023.
This interviewee confirmed that this document is the only menu available at the facility for the two meals listed.. There are no breakfast menus available outlining either the food items for that meal. or appropriate substitutions.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements;
There is a binder with seasonal menus from dietician kept at the program. The menus are kept in the dining room with the individuals' diet plans.
QIDP, Nursing Coordinator, and kitchen staff will meet with dietician within 60 days to review menus to ensure a variety of foods including substitutions within the same food group for individual #4. Staff will be retrained by QIDP on any updated menus within 2 weeks.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice;
QIDP, Nursing Coordinator, and kitchen staff will meet with dietician within 60 days to review menus for individuals that eat by mouth and ensure a variety of foods including substitutions within the same food group for all meals. Staff will be retrained by QIDP on any updated menus within 2 weeks.
3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur;
QIDP will review the menus for the next month 2 weeks prior to ensure all meals have a variety of foods including substitutions within the same food group. If corrections are needed, QIDP will notify dietician and kitchen staff within 2 weeks to fix issues.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur;
Management team will review menus quarterly to ensure all meals have a variety of foods including substitutions within the same food group. If issues are noted, the team will meet with dietician and kitchen staff within 30 days to discuss the issues and correct for future menus.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
Director will receive all menus monthly and be made aware of any issues noted by the QIDP. If issues are present, Director will be notified of correction within 2 weeks by kitchen staff.
483.480(c)(1)(iv) STANDARD
MENUS
Name - Component - 00
Menus must include the average portion sizes for menu items.
Observations:
Based on a review of facility records and doucmentation, and interview with facility staff, the facility failed to have menus which include the average portion size for menu items. This practice is specific to the menu document at this facility.
Findings include:
A review of a document titled December 2023 which was provided to the survey team as the facility menu document was completed on 12/14/2023 between 11:45 AM and 12:15 PM. This review noted that this menu consisted of a monthly grid for each day of the month. In each dated block of the grid, there were entries for lunch and dinner on that date. These entries consisted of food items which would be served for each designated meal on that date, e.g. Lunch = tacos, rice refried beans, Dinner = Asian beef stew. There was no information outlining the breakfast menu for this month nor substitution menu items available for the two meals which are listed for the month of December, 2023. There was no other information on this document outlining the average portion size of each menu item based on the prescribed calorie diet for each Individual.
Subsequent interview with the Qualified Intellectual Disabilities Professional on 12/14/2023 approximately 12:15 PM confirmed that this menu document did not contain portion sizes for each item based on the caloric diet for each Individual.
Plan of Correction:Plan of Correction:
1. How corrective actions will be accomplished for those individuals identified in deficiency statements;
There is a binder with seasonal menus from dietician kept at the program. The menus are kept in the dining room with the individuals' diet plans.
QIDP, Nursing Coordinator, and kitchen staff will meet with dietician within 60 days to review menus to ensure all menus include average portion size for every meal. Staff will be retrained by QIDP on any updated menus within 2 weeks.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice;
QIDP, Nursing Coordinator, and kitchen staff will meet with dietician within 60 days to review menus to ensure all menus include average portion size for every meal. Staff will be retrained by QIDP on any updated menus within 2 weeks.
3. What corrective measures or systematic changes will be put into place to insure that the deficient practice will not recur;
QIDP will review the menus for the next month 2 weeks prior to ensure all meals include average portion size. If corrections are needed, QIDP will notify dietician and kitchen staff within 2 weeks to fix issues.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur;
Management team will review menus quarterly to ensure all menus include average portion size. If issues are noted, the team will meet with dietician and kitchen staff within 30 days to discuss the issues and correct for future menus.
5. Identify, by position, who will be responsible for monitoring the corrective actions.
Director will receive all menus monthly and be made aware of any issues noted by the QIDP. If issues are present, Director will be notified of correction within 2 weeks.
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