Initial Comments:
A focused fundamental survey was conducted September 25-29, 2023, 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 20 and the original sample consisted of four individuals. Four deficiencies were identified.
Plan of Correction:
483.420(d)(3) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must have evidence that all alleged violations are thoroughly investigated.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to thoroughly investigate incidents of abuse, neglect, or mistreatment. This was noted for the two investigations into possible neglect. The findings included:
A) Review of the facility's investigations for the past year was conducted on September 25-26, 2023. This review revealed that the facility had two investigations into possible neglect that were not thoroughly investigated. The findings are as follows:
Individual #5
On June 29, 2023, Individual #5 was transferred to her wheelchair while in the tub room. Two staff were in the tub room during the incident. Individual #5 fell to the floor, face first. The investigative packet did not indicate the nature of this individual's injuries. This individual was sent to the hospital for further evaluation. The investigative packet did not include the report from the hospital which documented that this individual sustained a nasal fracture; there was no documentation in the packet that indicated a fracture was sustained. The conclusion section for this incident was the documentation from Individual #1's investigation. Further review revealed that the explanation of determination of neglect was incomplete; the documentation stopped mid-sentence. Preventative measures did not include to re-train staff to buckle Individual #4's chest strap prior to moving the back of the wheelchair to the upright position.
The facility director (FD) was interviewed on September 26, 2023, at 1:20 PM. The FD confirmed that the investigative packet did not represent a thorough investigation into Individual #5's nasal fracture.
Individual #1
On September 26, 2022, Individual #1 had a choking incident during lunch while at school. This individual was eating chicken and bread, when he began turning red in the face and was unable to clear his throat. The school nurse gave three abdominal thrusts, and Individual #1 was able to expel the piece of bread. This individual returned to baseline with normal breathing and vital signs and continued with the soft portion of his meal. Review of the investigation packet revealed that the school nurse who performed the abdominal thrusts was not interviewed as a witness to the incident. In addition, the facility's policy on choking, which states that an individual should be checked in the emergency room after a choking incident, was not evaluated or included in the investigation packet.
The FD was interviewed on September 26, 2023, at 1:30 PM. The FD confirmed that the investigative packet did not represent a thorough investigation into Individual #1's choking incident.
Plan of Correction:In order to ensure that all alleged violations are thoroughly investigated the following steps will be taken.
1. Facility Certified Investigator (CI) to revise the CI report for Individual #5 to include what specific injuries the individual sustained and a complete explanation of determination for the correct individual listed in the CI report. To be completed by 11/30/23. Director to monitor for completion.
2. Facility CI to include the hospitalization report in the CI packet for individual #5 as well as all of the corrective action information, including the re-training that occurred. To be completed by CI by 11/30/23. Director to monitor for completion on master POC tracking sheet.
3. Another re-training for all staff to occur regarding individual #5 and that along with the seat belt being secured, after this occurs and the resident is properly in the wheelchair, the chest strap will also be buckled into place. Retraining to be completed by 10/31/23 by Director. Personnel Officer to monitor for completion on master POC tracking sheet.
4. Facility to develop a new system to have CI reports reviewed by another CI or an outside CI prior to being submitted to Admin Reviewers. This will be completed by the 25th day after the investigation has been assigned. The purpose of this would be to review the CI report for thoroughness and that any necessary follow up/re-training, etc. has occurred. Monitored for completion by QIDP on master POC tracking sheet. Ongoing.
5. Should information from the CI packet be missing. CI will have 2 days to resubmit packet to reviewing CI. Reviewing CI will document on CI review sheet dates CI packet was reviewed. QIDP to monitor for completion. Director to track on master POC tracking sheet. Ongoing.
6. CI's for incidents involved with individuals #5 and #1 will be retrained by outside CI on conducting a thorough investigation. This will be monitored on the master POC tracking sheet by Personnel Office. To be completed by 11/30/2023. Monitored for completion by Personnel Officer on master POC tracking sheet.
7. Facility to develop a checklist called CI's Checklist, for CI's to use to ensure a complete CI packet is presented/ready to be reviewed prior to an incident report being submitted for final approval. QIDP to monitor for completion by 10/31/2023. Director to monitor on master POC tracking sheet.
8. The checklist is to include a thoroughly completed CI report, listings of appropriate documents to be included in the CI packet, such as photographs, all witness statements, physical evidence, hospital records, etc. Checklist to be completed by 10/31/23 by outside CI. Personnel Officer to monitor for completion on master POC tracking sheet.
9. CI's to be trained on CI checklist by 10/31/2023 by outside CI. Personnel Office to monitor for completion on master POC tracking sheet.
10. CI who completed Individual #1's report to be retrained on CI process by outside CI, which is to gather witness statements from all applicable witnesses, etc. CI to also include all necessary documentation in CI report, including facility policy on choking. To be completed by 11/30/2023 by outside CI. Personnel Officer to monitor for completion on master POC tracking sheet.
11. Retraining to occur with Admin Reviewers to ensure a complete CI packet is provided by CI prior to completing the review on Incident Management state reporting system. Retraining to be completed by Director by 11/30/2023. To be monitored for completion by QIDP on master POC tracking sheet.
483.430(a)(1) STANDARD
QIDP
Name - Component - 00
The qualified mental retardation professional has at least one year of experience working directly with persons with mental retardation or other developmental disabilities.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to ensure the qualified intellectual disabilities professional (QIDP) had at least one year of experience working with individuals with intellectual disabilities. This was noted for two employees hired within the past year for the QIDP position. The findings included:
A) A review of the credentials for new employees hired within the past year was conducted on September 25-26, 2023. This review revealed that the facility hired two employees for the QIDP position in the past year. Documentation review revealed that both employees had at least a bachelor's degree in the respected fields. There was no documentation to verify that either employee had at least one year of experience working with individuals with intellectual disabilities.
B) The facility director (FD) was interviewed on September 29, 2023, at 9:45 AM. The FD confirmed that there was no facility documentation that verified the work experience of these two employees in the intellectual disabilities field.
Plan of Correction:In order to ensure that the qualified intellectual disabilities professional (QIDP) had at least one year of experience working with individuals with intellectual disabilities, the following steps will be taken.
1. A checklist called Interview Checklist to be developed to be used during all interviews. To be developed by Human Resources designee (HR) by 11/30/2023. Monitored for completion by Director on master POC tracking sheet.
2. Checklist to include interview information as well as confirmation that previous employers were contacted to confirm that the candidate meets all requirements for job duties. To be completed by HR by 11/30/23. Monitored by Director for completion on master POC tracking sheet.
3. When contacting a previous employer, the following information will be documented, name and title of the person confirming job experience and date and time of confirmation. Also to be documented for QIDP position is at least 1 year of experience working with individuals with intellectual disabilities. This is to be included in the candidate's employee record. Completed by HR or designee. Ongoing. Monitored by director on master POC tracking sheet.
4. Director to contact former agencies listed on previous and current QIDP as listed on the resumes to confirm employee qualifications. To be completed by 10/31/23. Monitored by Personnel Officer on master POC tracking sheet.
5. Director to sign off/initial on QIDP's work until one year of experience is obtained, if applicable. Director contacted current QIDP's former employers and received confirmation between the two prior positions that QIDP has a combination of 1 year experience. Director has been signing off on QIDP's work and will continue to do so through the end of the month. Completed by 10/31/2023. Monitored by Personnel Officer on master POC tracking sheet.
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 record review and staff interview, it was determined that the facility failed to ensure staff displayed the knowledge and competence to address the physical health needs of the individuals. This was noted for all four individuals in the sample (Individuals #1, #2, #3, and #4). The findings included:
The records of Individuals #1, #2, #3, and #4 were reviewed on September 26-29, 2023. This review revealed the following:
A) Individual #1
Record review revealed Individual #1 was diagnosed with the following physical conditions (but not limited to): cerebral palsy and osteoporosis.
Further review revealed this individual had a "team procedure" for stretching, using a scooter board, unsupported sitting, ambulation, and using the EZ stander in order to maintain or increase range of motion, strength, and mobility. These exercises were to be completed one to five times per week. Review of documentation revealed stretching exercises were completed five times, use of the scooter board three times, unsupported sitting three times, ambulation zero times, and use of the EZ stander zero times in the past year.
B) Individual #2
Record review revealed Individual #2 was diagnosed with the following physical conditions (but not limited to): cerebral palsy with quadriplegia and scoliosis.
Further review revealed that this individual was admitted to the facility on January 30, 2023. "Team procedures" were implemented on February 28, 2023, for passive range of motion (PROM) exercises to be completed on upper extremities three to five times per week and lower extremities four to five times per week. Documentation review for these exercises revealed that they were performed one time since the procedure was implemented.
C) Individual #3
Record review revealed Individual #3 was diagnosed with the following physical conditions (but not limited to): cerebral palsy, osteoporosis of the spine, severe osteopenia of the right hip, neuromuscular sclerosis, and spastic quadriplegia.
Further review revealed this individual had a "team procedure" for PROM exercises to be completed five times per week on first and second shift. Review of documentation for the PROM exercises revealed they were completed 16 times for upper extremities and 15 times for lower extremities on first shift, and zero times for upper and lower extremities on second shift during the past year.
D) Individual #4
Record review revealed Individual #4 was diagnosed with the following physical conditions (but not limited to): cerebral palsy, spastic quadriplegia, osteoporosis, and cerebral ataxia.
Further review revealed this individual had "team procedures" for active assisted range of motion (AAROM), PROM, weight bearing, postural exercise, using a scooter board, ambulation, strengthening, and using the Trike in order to maintain or increase range of motion, strength, and mobility. These exercises were to be completed one to five times per week. Review of documentation revealed AAROM was completed 21 times in past year; PROM was completed 18 times in past year; weight bearing was completed twice in past year; postural exercises completed four times in past year; use of the scooter board 16 times in past year; ambulation 13 times in past year; strengthening (converted to formal goal half way through year) completed 14 times in six months; and use of the Trike was completed one time in the past year.
E) The facility director (FD) was interviewed on September 29, 2023, at 9:30 AM. The FD confirmed that the team procedures to maintain or increase range of motion, strength, and mobility for Individuals #1, #2, #3, and #4 were not completed as scheduled during the past year.
Plan of Correction:In order to ensure facility staff display the knowledge and competence to address the physical health needs of all individuals, the following steps will be taken.
1. Weekly Interdisciplinary team (IDT) meetings, attended by DSS, TL, QIDP, PC and Director to occur to review each resident and their daily living needs, which will include team procedures. Residents 1, 2, 3 & 4 to be completed in order and then all other residents to follow. This will take a few months to thoroughly review and update/revise each resident's program. Weekly meetings to be documented on the IDT meeting agenda. Personnel Officer to monitor on master POC tracking sheet. Ongoing.
2. Direct Services Supervisor (DSS) and Team Leader (TL) to hold weekly meetings with direct care and program assistant staff to review resident information that was reviewed at IDT meeting for that week. QIDP to monitor for meeting completion. Director to monitor on master POC tracking sheet. Ongoing.
3. Direct care and program assistant staff will be retrained by TL or DSS regarding each resident's team procedures and sign off on the resident communication memo that they reviewed/received the necessary information for each resident. To be completed at each staff meeting, monitored by QIDP and Personnel Officer on master POC tracking sheet. To be completed by 12/31/2023.
4. Occupational Therapy and Physical Therapy to complete assessments and make recommendations and document this information in each individual's records. QIDP or designee will make any necessary revisions/changes to each resident's team procedure. Ongoing.
5. TL or DSS or designee to observe team procedures and document confirmation of completion at the end of each shift on the individual's team procedures data sheets. QIDP will monitor for completion weekly. QIDP documentation tracking will also be included on the individual's team procedure data sheets. Ongoing.
6. Documentation by TL, DSS or designee to occur on the "team procedure tracking sheet". To be tracked by QIDP on a weekly basis by QIDP on team procedure tracking sheet. Ongoing.
7. OT/PT to meet with TL and/or DSS on a weekly basis, minimum of biweekly, to review resident team procedures. Documentation to occur on OT/PT notes. Meetings to occur weekly for 1 quarter and then change to monthly for 1 year. There are usually IDT meetings weekly and can be more often if needed. QIDP to document for completion. Director to monitor on master POC tracking sheet. Ongoing.
8. PT/OT to complete a facility training to discuss the importance of completing team procedures for all residents. Training to be held by 11/30/23. QIDP to monitor for completion. Director to track on master POC tracking sheet.
9. PT/OT will be asked to define stretches and importance of order based on resident's diagnosis, abilities, etc. This information is to be documented in individual's PT/OT notes. Ongoing. To be documented by QIDP and monitored by director on master POC tracking sheet.
10. Facility HR will address lack of job duties being completed per facility staff disciplinary action. Should there be repeat occurrences by the same staff, of not completing team procedures facility disciplinary action to be followed. TL and DSS to also provide retraining for staff members found not to be completing team procedures as assigned. Ongoing. Director to track on master POC tracking sheet.
483.440(d)(1) STANDARD
PROGRAM IMPLEMENTATION
Name - Component - 00
As soon as the interdisciplinary team has formulated a client's individual program plan, each client must receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure a continuous active treatment program was implemented. This was noted for all four individuals in the sample (Individuals #1, #2, #3, and #4). The findings included:
Goal plan data for Individuals #1, #2, #3, and #4 in the areas of self care, financial, communication and medication administration from the past year were reviewed on September 28-29, 2023. This review revealed the following issues:
A) Individual #1
1. Self care, to be completed five times per week on second shift:
December 2022 - no data
February 2023 - no data
March 2023 - one trial completed
April 2023 - no data
August 2023 - no data
2. Financial, to be completed five times per week on second shift:
December 2022 - no data
January 2023 - one trial completed
February 2023 - no data
March 2023 - one trial completed
April 2023 - one trial completed
July 2023 - one trial completed
August 2023 - two trials completed
3. Communication, to be completed five times per week on second shift:
December 2022 - one trial completed
January 2023 - one trial completed
February 2023 - no data
March 2023 - one trial completed
April 2023 - one trial completed
May 2023 - one trial completed
July 2023 - two trials completed
August 2023 - one trial completed
B) Individual #2 (admitted to facility January 30, 2023)
1. Self care, to be completed five times per week:
March 2023 - one trial completed
April 2023 - no data
May 2023 - no data
June 2023 - no data
July 2023 - four trails completed
August 2023 - two trails completed
2. Financial, to be completed five times per week:
March 2023 - one trial completed
April 2023 - one trial completed
May 2023 - no data
June 2023 - no data
July 2023 - five trials completed
August 2023 - four trials completed
3. Communication, to be completed five times per week:
March 2023 - one trial completed
April 2023 - one trial completed
May 2023 - no data
June 2023 - no data
July 2023 - two trials completed
August 2023 - three trial completed
C) Individual #3
1. Self care, to be completed five times per week:
March 2023 - one trial completed
April 2023 - no data
May 2023 - no data
June 2023 - no data
July 2023 - four trails completed
August 2023 - two trails completed
2. Financial, to be completed five times per week:
March 2023 - one trial completed
April 2023 - one trial completed
May 2023 - no data
June 2023 - no data
July 2023 - five trials completed
August 2023 - four trials completed
3. Communication, to be completed five times per week:
March 2023 - one trial completed
April 2023 - one trial completed
May 2023 - no data
June 2023 - no data
July 2023 - two trials completed
August 2023 - three trial completed
D) Individual #4
1. Self care, to be completed five times per week:
October 2022 - four trials
November 2022 - no data
December 2022 - three trials completed
January 2023 - no data
February 2023 - one trial completed
March 2023 - two trials completed
April 2023 - 13 trials completed
May 2023 - three trials completed
June 2023 - seven trials completed
July 2023 - five trials completed
August 2023 - four trials completed
2. Financial, to be completed five times per week:
December 2022 - two trials completed
January 2023 - one trial completed
March 2023 - seven trials completed
April 2023 - 18 trials completed
May 2023 - six trials completed
June 2023 - eight trials completed
July 2023 - seven trials completed
August 2023 - six trials completed
3. Communication, to be completed five times per week on first and second shifts: (Goal started 6/2023)
July 2023 - six trials completed
August 2023 - five trials completed
E) The facility director (FD) was interviewed on September 29, 2023, at 9:40 AM. The FD confirmed that, during the past year, all four individuals in the sample did not receive consistent, continuous training in accordance with their needs and individual program plan.
Plan of Correction:In order to ensure facility provides a continuous active treatment program, the following steps will be taken.
1. Weekly Interdisciplinary team (IDT) meetings, attended by DSS, TL, QIDP, PC and Director to occur to review each resident and their daily living needs, which will include active treatment. Residents 1, 2, 3 & 4 to be completed in order and then all other residents to follow. This will take a few weeks to thoroughly review each resident's program. Weekly meetings to be documented on the IDT meeting agenda. QIDP to monitor for meeting completion. Director to monitor on master POC tracking sheet. Ongoing.
2. Direct Services Supervisor (DSS) and Team Leader (TL) to hold weekly meetings with direct care and program assistant staff to review resident information that was reviewed at IDT meeting for that week. This will be documented on the Direct Care weekly meeting agenda. QIDP to monitor for meeting completion. Director to monitor on master POC tracking sheet. Ongoing.
3. All staff will be trained in the necessity of daily goal completion and documentation. All outcomes must be implemented and documented as written for each outcome. Any outcome changes will be based on outcome documented data. Training to occur by DSS or designee by 11/13/2023. DSS or designee to be trained by therapy staff by 11/3/2023. QIDP to monitor for completion. Director to track on master POC tracking sheet.
4. Staff will be retrained by PC, therapists or designee regarding each resident's active treatment program and sign off on the resident communication memo that they reviewed/received the necessary information for each resident. To be completed by Director and monitored by Personnel Officer. Ongoing.
5. TL and DSS to document completion of the daily documentation and treatment sheets on the active treatment sign off sheet at the end of each of their shifts. QIDP or designee to monitor for completion. ongoing. Director to track on master POC tracking sheet.
6. TL and DSS to ensure assignment is made each day for staff to complete active treatment. Should the assigned staff not complete active treatment, facility disciplinary action to occur by HR personnel. QIDP to monitor daily for completion and to track on Master POC tracking sheet. ongoing.
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