Initial Comments:
A monitoring survey was conducted on May 1-2, 2025, to determine compliance with the requirements of 42 CFR Part 483, Subpart I Reqirements for Intermediate Care Facilities. The census during the survey was 18. One deficiency was identified.
Plan of Correction:
483.420(d)(2) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to ensure all allegations of abuse, neglect or mistreatment were immediately reported to administration. This was noted for the only allegation of sexual abuse (Individual #1). The findings included:
Facility incident reports and investigations from September 14, 2024 through present were reviewed on May 1-2, 2025. This review revealed the following:
A) According to an investigation report, on March 27, 2025 a staff allegedly witnessed Individual #2 with his hand on Individual #1's genital area (over clothing), gripping his sweatpants. Individual #1 was removed from the situation and the incident was reported to facility nursing. The facility director and qualified intellectual disabilities professional (QIDP) were not informed of this incident until April 1, 2025.
Additionally, according to witness statements within the investigation packet, other similar incidents were observed in the past between the same two individuals; however, these alleged incidents were not reported to administration.
B) The QIDP and facility director were interviewed on May 2, 2025, at 11:00 AM. The QIDP and director confirmed that the above-referenced incident and past alleged incidents were not reported immediately to facility administration.
Plan of Correction:1. Qualified Intellectual Disability Professional (QIDP) revised training information provided to facility staff. Training information revised to include the importance of reporting abuse, neglect, or mistreatment immediately to supervisor, Director, QIDP, Program Coordinator (PC) or Licensed Practical Nurses (LPN's). Director to ensure QIDP completed revised incident management protocol. Completed by 5/16/25. Director to monitor for completion on master POC tracking sheet.
2. QIDP trained facility staff, (including staff involved in cited incidents), on the revised incident management protocol. This training was documented on the Incident Management Revision Signature Sheet. Director ensured QIDP trained facility staff on the revised incident management protocol. Completed 5/16/25. Director to monitor for completion on master POC tracking sheet.
3. QIDP revised facility's hot line contact form phone numbers to include Director's, QIDP's, and PC's phone numbers should there be an incident that needs to be reported when these staff are not present in the building. Completed by 5/16/25. Director ensured QIDP revised facility's hot line contact form. Director to monitor for completion on master POC tracking sheet.
4. QIDP trained facility staff, (including staff involved in cited incidents), on the revised hot line contact form. QIDP also hung this hotline form at the nurse's station and at the back door bus ramp, at the time clock bulletin board, the main bulletin board at the fiscal office, and on the communication memo clipboard. Completed by 5/16/25. Director ensured QIDP trained facility staff on the revised hot line contact form and that the revised form was hung at the Nurse's Station and at the back door bus ramp. Director to monitor for completion on master POC tracking sheet.
5. Director to implement corrective actions to all applicable incident reports/investigations. Ongoing. Administrative Review team will ensure Director included necessary corrective action(s) to applicable incident reports/investigation. Director to monitor for completion on master POC tracking sheet. Ongoing.
6. Director to review investigations to ensure incidents are reported immediately and corrective actions are included when applicable by utilizing the administrative review forms. The completed administrative review forms will be in each investigative file. QIDP to ensure completed administrative review forms are included in each investigative file. Director to monitor for completion on master POC tracking sheet. Ongoing
7. QIDP to review incident scenarios with facility staff regarding staff expectations in identifying an incident and actions taken following an observed incident. To be completed a minimum of quarterly during staff meetings. This will be documented on staff meeting signature sheets. Ongoing. Director to ensure QIDP reviews incident scenarios with facility staff on a quarterly basis during staff meetings. Director to monitor for completion on master POC tracking sheet. Ongoing.
8. QIDP to complete a minimum of quarterly incident management training for facility staff. Quarterly training to include immediately reporting an incident, who to contact, and staff expectations upon observing/reporting incidents. Ongoing. This will be documented on an Incident Management Review Communication Memo form which will be kept in QIDP's office. Director will ensure QIDP completes quarterly incident management training with facility staff. Director to monitor for completion on master POC tracking sheet. Ongoing.
9. QIDP to ensure alleged resident target to receive individual training regarding inappropriate/appropriate touch, completed by the South Central HCQU. In progress. Director to monitor for completion on master POC tracking sheet. To be completed by 6/30/25.
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