Unacceptable & Acceptable Plans of Correction. - Example -

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1 Unacceptable & Acceptable Plans of Correction Unacceptable Plan of Correction - Example - This is an example of an unacceptable plan of correction. You can use this for comparison to the example of an acceptable plan of correction that follows on page three (3) of this document. Notice how the five plan of correction criteria requirements, described in the for Assisted Living Facilities presentation, are addressed in each example. This first example would NOT be acceptable to DADS Regulatory Services. Violation Plan of Correction Compliance Date Exit Date: 7/13/06 Criterion 1 How corrective action will be accomplished for those residents affected by the violation(s). (Regulatory Reference) P061 TAC 92.41(a)(4)(C) Employees: Continuing Education All direct care staff will find a way to get their education. Direct care staff must complete six documented hours of education annually, based on each employee's hire date. Subject matter must address the unique needs of the facility. Suggested topics include: (i) promoting resident dignity, independence, individuality, privacy, and choice; (ii) resident rights and principles of self-determination; (iii) communication techniques for working with residents with hearing, visual, or cognitive impairment; (iv) communicating with families and other persons interested in the resident; (v) common physical, psychological, social, and emotional conditions and how these conditions affect residents' care; (vi) essential facts about common physical and mental disorders, for example, arthritis, cancer, dementia, depression, heart and lung diseases, sensory problems, or stroke; (vii) cardiopulmonary resuscitation; (viii) common medications and side effects, including Criterion 2 How the facility will identify other residents affected by the same violation(s). All residents are at risk. Criterion 3 The measures that will be put into place or systemic changes made to ensure the violation(s) will not recur. This is an invalid violation. The surveyor did not take all factors into consideration. The facility does provide all necessary care and services. Criterion 4 How the facility will monitor its corrective actions to ensure that the violation(s) is being corrected and will not recur. This will be monitored by whomever I designate. Assisted Living Facilities 1 Rev. 07/07

2 (ix) (x) (xi) psychotropic medications, when appropriate; understanding mental illness; conflict resolution and de-escalation techniques; and information regarding community resources. This REQUIREMENT was not met as evidenced by: (Deficient Practice Statement) Based on record review and interview, the facility failed to comply with mandatory training requirements by failing to ensure that 2 of 3 direct care staff received at least six hours of education annually. (Relevant Findings) Record review of the facility's employee files revealed that Staff A, an attendant, was hired on 12/28/03. Review of the in-service log revealed Staff A received only 2.0 hours of in-service from 12/28/04 through 12/28/05. Further review of the employee files revealed that Staff B, an attendant (hired 10/31/91), received 2.6 hours of in-service from 10/31/04 through 10/31/05. During an interview on 7/13/06 at 1:00 p.m. the manager revealed that a new person had just been hired to coordinate the in-service training. The manager further revealed that, before hiring this new person, there was no one person assigned to oversee training. Individual supervisors were responsible for ensuring employees training was completed. During an interview on 7/13/06 at 1:15 p.m. the RN revealed that the facility had experienced problems but had a new administrator in place now. She confirmed that there was no one staff person in place prior to this new administrator, to coordinate training for the facility. Record review of employee files, revealed that the new administrator was hired on 4/15/06 and had started working on 5/1/06. Further record review of employee files for Staff A, revealed that since 12/28/05 to the date of this review (7/13/06), this employee had only completed 3.5 hours of training. There is no record that Assisted Living Facilities 2 Rev. 07/07

3 Staff A completed any training since the new administrator, who reportedly is in charge of coordinating training requirements for facility employees, assumed her duties. Further record review of employee files for Staff B, revealed that since 12/28/05 to the date of this review (7/13/06), this employee had not completed any additional training. There is no record that Staff B completed any training during this period. During an interview on 07/13/06 at 4:15p.m., Administrator A revealed that she had assumed her duties on 5/1/06 and was still in the process of learning her duties. She said that she had been developing a plan for coordinating training requirements but had not yet implemented it. Criterion 5 The date(s) when corrective action will be completed. Correction date: 9/12/06 Signature: Samuel Smith, Manager Assisted Living Facilities 3 Rev. 07/07

4 Acceptable Plan of Correction - Example - This is an example of an acceptable plan of correction. It is only an example to illustrate how the five plan of correction criteria requirements, described in the for Assisted Living Facilities presentation, can be addressed in a manner acceptable to DADS Regulatory Services. Compare this to the previous example of an unacceptable plan of correction. Violation Plan of Correction Compliance Date Exit date: 7/22/06 Criterion 1 How corrective action will be accomplished for those residents affected by the violation(s). (Regulatory Reference) P060 TAC 92.41(c)(2) Resident Assessment: Service Plan The service plan must be approved and signed by the resident or a person responsible for the resident's health care decisions. The facility must provide care according to the service plan. The service plan must be updated annually and upon a significant change in condition, based upon an assessment of the resident. Residents 1 and 13 s service plans will be read, amended as necessary, approved and signed by the residents or responsible parties no later than 10/05/06. Criterion 2 How the facility will identify other residents affected by the same violation(s). This REQUIREMENT was not met as evidenced by: (Deficient Practice Statement) Based on record review and interview, the facility failed to ensure that residents' service plans were approved and signed by the resident or the responsible parties for 9 of 13 residents (# s 1, 2, 3, 5, 7, 8, 10, 12, and 13) and that service plans had not been updated annually for 5 of 8 residents (Residents #s 3, 5, 8, 12, and 13). (Relevant Findings) Record review on 7/22/06 for the following residents revealed that the appropriate responsible party had not signed the plan: Resident #1 s service plan, dated 2/14/06. Resident #2 s service plan, dated 1/08/06. Resident #3 s service plan, dated 3/15/05. Resident #5 s service plan, dated 3/07/05. Resident #7 s service plan, dated 5/23/06. Resident #8 s service plan, dated 6/30/05. Resident #10 s service plan, dated 5/01/06. Resident #12 s service plan, dated 12/14/04. Resident #13 s service plan, dated 10/12/04. All residents had the potential to be affected by this violation. Criterion 3 The measures that will be put into place or systemic changes made to ensure the violation(s) will not recur. All resident service plans will be reviewed with family members within 14 days of the resident s admission and upon each annual review. The responsible party will sign the individual service plan following each review. Criterion 4 How the facility will monitor its corrective actions to ensure that the violation(s) is being corrected and will not recur. The manager or designee will monitor for proper assessment of residents and update service plans at least monthly. Assisted Living Facilities 4 Rev. 07/07

5 Record review on 7/22/06 for the following residents revealed that the service plan had not been updated annually: Resident #3 s service plan, dated 3/15/05. Resident #5 s service plan, dated 3/07/05. Resident #8 s service plan, dated 6/30/05. Resident #12 s service plan, dated 12/14/04. Resident #13 s service plan, dated 10/12/04. During an interview on 7/22/06 at 2:00 p.m. Staff B revealed that care plans (service plans) were not completed for any of the residents on the unit because care plans were not required for self-pay residents. During an interview on 7/22/06 at 2:35 p.m., RN A revealed that there are care plans for each resident and that Staff B is mistaken that care plans are not completed for self pay residents. RN A further revealed that care plans remain in resident s records as long as they are applicable, sometimes more than a year if there are no significant changes. During and interview on 7/22/06, the manager revealed that the RN is responsible for ensuring care plans are updated. Furthermore, the manager revealed that there is no formal process for monitoring care plan revision. He stated that typically the care plan is developed and filed in the residents records and signatures are obtained later. Criterion 5 The date(s) when corrective action will be completed. Completion Date: 8/22/06 Signature: Jean Simpson, Manager Assisted Living Facilities 5 Rev. 07/07