HEALTH & WELFARE. 1. What con ective action(s) will be accomplished for those individuals found to have been affected by the deficient practice;

Transcription

1 D A H 0 DEPARTMENT OF HEALTH & WELFARE C.L. BUTCH OTER- Governor RCHARD M. ARMSTRONG- Drector DEBRA RANSOM, R.N.,R.H..T., Chef BUREAU OF FACLTY STANDARDS 3232 Elder "street P.O. Box Bolse,D PHONE :W FAX May26, 205 Brdger Fly, Admnstrator Communcare, nc #4 Leland 40 West Frankln Road, Sute F Merdan, D RE: Communcare, nc #4 Leland, Provder #3G02 Dear Mr. Fly: Ths s to advse you of the fndngs of the Medcad/Lcensure survey of Communcare, nc #4 Leland, whch was conducted on May 5,205. Enclosed s a Statement of Defcences/Plan of Correcton Form CMS-2567, lstng Medcad defcences and a smlar form lstng State lcensure defcences. n the spaces provded on the rght sde of each sheet, please provde a Plan of Correcton. t s mportant that your Plan of Correcton address each defcency n the followng manner:. What con ectve acton(s) wll be accomplshed for those ndvduals found to have been affected by the defcent practce; 2. How you wll dentfy other ndvduals havng the potental to be affected by the same defcent practce and what correctve acton(s) wll be taken; 3. What measures wll be put n place or what systemc change you wll make to ensure that the defcent practce does not recur; 4. How the correctve acton(s) wll be montored to ensure the defcent practce wll not recur,.e., what qualty assurance program wll be put nto place; 5. The plan must nclude the ttle of the person responsble for mplementng the acceptable plan of correcton; and

2 Brdger Fly, Admnstrator May26, 205 Page 2 of2 6. nclude dates when correctve acton(s) wll be completed. 42 CFR states ordnarly a provder s expected to take the steps needed to acheve complance wthn 60 days of beng notfed of the defcences. Please keep ths n mnd when preparng your pau of correcton. For.correctve actons, whch requre constmcton, compettve bddng or other ssues beyond the control of the faclty, addtonal tme may be granted. Sgn and date the form(s) n the space provded at the bottom of the frst page. After you have completed your Plan of Conecton, returo the orgnal to ths offce by June 8, 205, and keep a copy for your records. You have one opportunty to queston cted defcences through au nfmmal dspute resoluton process. To be gven such au opportunty, you are requred to send your wrtten request aud all requred nformaton as drected n the State nformal Dspute Resoluton (!DR) Process whch cau be found on the nternet at: Scroll down untl the Program nformaton headng on the rght sde s vsjble aud there are three DR selectons to choose from. Ths request must be receved by June 8, 205. f a request for nfmmal dspute resoluton s receved after June 8, 205, the request wll not be granted. An ncomplete nformal dspute resoluton process wll not delay the effectve date of auy enforcement acton. Thank you for the courteses extended to us durng our vst. f you have questons, please call ths offce at (208) , opton 4. Sncerely, Health Faclty Surveyor Non-Long Term Care WCOL~~ Co-Supervsor Non-Long Term Care AH/pmt Enclosures

3 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PLAN OF CORRECTON (X) PROVDERSUPPLER/CLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A BULDNG PRNTED: 05/26/205 OMB NO X3) SURVEY NAME OF PROVDER OR SUPPLER COMMUNCARE, NC #4 LELAND 3G02 8. WNG 05/5/205 STREET ADDRESS, CTY. STATE. ZP CODE 450 LELAND WAY BOSE, D (X4)D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) D PREFX PROVDERS PLAN OF CORRECTON leach CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) (;<S) COMPLETON W 000: NTAL COMMENTS WOOO The followng defcences were cted durng the, annual recertfcaton survey conducted from 5//5 to 5/5/5., The survey was conducted by: Ashley Hensched, QDP, Team Lead! Karen Marshall, MS, RD, LD Common abbrevatons used n ths report are: AQDP- Assstant Qualfed ntellectual Dsabltes Professonal DT- nterdscplnary Team PP- ndvdualzed Program Plan LPN - Lcensed Practcal Nurse, MAR - Medcaton Admnstraton Record QDP- Qualfed ntellectual Dsabltes Professonal W (b)(2) ADMSSONS, TRANSFERS, DSCHARGE Admsson decsons must be based on a prelmnary evaluaton of the clent that s conducted or updated by the faclty or by outsde sources. Ths STANDARD s not met as evdenced by: Based on record revew and staff ntervew, t was determned the faclty faled to ensure admsson decsons were based on a prelmnary, evaluaton of an ndvdual that was conducted or updated by the faclty for of ndvduals (ndvdual #2) admtted wthn the past year. Ths falure resulted n the potental for an ndvdual to, be admtted wthout ndcatons the faclty could, W99 Correctve Actons: Ths was an oversght. As stated n the survey results "prelmnary nformaton was mssed as ndvdual #2 came from a sster faclty and was consdered a transferred ndvdual." Ths ndvdual stated that he wanted to move, hs mother/guardan vsted ths locaton and wanted hm to move, we were n a transtonal perod between QDPs and the QDP Supervsor dd make ths judgement. We do have a system for pre-admsson staffngs but as stated, consdered ths a transfer rather than a new admsson. Our thnkng about ths ssue has now 07/5/5 TTLE (X6) )-L... v r-.j r;/jc;jp;. ~ t /l.ny defcrency statement endmg wth an astensk (*}denotes a defcmncy whrch the mstltutron may be excused from correctmg provrdrng t S determrned that other SSJfeguardS provde suffcent protecton to the patents. (See nstructons.} Except for nursng homes, the fndngs stated above are dsdosable 90 days fo!lowlg.the date of survey whether or not a plan of correcton s provded. For nursng homes, the above fndngs and plans of correcton are dsclosable 4 days-followng the d<te these documents are made avalable to the faclty. f defcences are cted, an approved plan of correcton s requste to contnued program partcpaton. FORM CMS-256"(02-99) Prevous Versons Obsolete E tent D:F03/ Foctty!D: 3G02 f contnuaton sheet P<l!)e of S

4 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PLAN OF CORRECTON (X) PROVDERSUPPLERCLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A BULDNG PRNTED: 05/26/205 OMB NO tx3) SURVEY 3G02 B. NNG 05/5/205 NAME OF PROVDER OR SUPPLER COMMUNCARE, NC #4 LELAND STREET ADDRESS, CTY, STATE, ZP CODE 450 LELAND WAY BOSE, D (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES!EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) D PREFX PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) (X5l COMPLETON W 99 Contnued From page meet hs needs. The fndngs nclude:. ndvdual #2s PP, dated 2/2/5, documented a 22 year old male whose dagnoses ncluded unspecfed mental retardaton and pervasve developmental dsorder. He had been resdng n a sster faclty wthn the company untl he was admtted to the faclty on /6/4. w 99 been clarfed. A pre-admsson overvew wll be constructed and labeled as a "late entry". Please note that a post-admsson staffng was conducted. dentfyng Others Potentally Affected:! No one else at ths locaton s potentally affected., The hstory secton of ndvdual #2s PP stated hs parents had wanted hm to lve n a faclty whch was closer to ther home. The PP stated a, vacancy became avalable and after dscusson [ wth ndvdual #2 and hs guardan, the move was facltated. However, ndvdual #2s record dd not nclude documentaton that prelmnary evaluaton, nformaton had been garnered and revewed by the DT to ensure ndvdual #2s needs could be met by the admttng faclty. Durng an ntervew on 5/5/5 from 2:00 to : 2:30 p.m., the QDP Supervsor stated the prelmnary evaluaton nformaton was mssed as. ndvdual #2 came from a sster faclty and was : consdered a transferred ndvdual. System Changes: We feel ths was an mplementaton not a systems error. See "Correctve Actons" Montorng: Our update to Operatonal Polces and procedures wll clearly state that any move from one physcal locaton to another must be consdered as a new admsson and the Admnstrator wll be responsble for questonng QDPs about the processng of pre-admsson nformaton should such a transfer agan occur. W32 : The faclty faled to ensure a prelmnary, evaluaton was conducted pror to ndvdual #2s admsson to the faclty (e)(2) DRUG USAGE Drugs used for control of napproprate behavor must be used only as an ntegral part of the clents ndvdual program plan that s drected! specfcally towards the reducton of and eventual elmnaton of the behavors for whch the drugs FORM CMS-2567(02-99) Prevous Versons Obsolete Event D: F037 w 32 We have clarfed ths process n our current QDP Oversght Manual and have ncluded the page of nstructons as Attachment A. The QDP at ths 07/5/5 Faclty D: 3G02 f contnuaton sheet Page 2 of 5

5 DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES ;\NO PLAN OF CORRECTON (X) PRDVOERSUPPLERCLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A BULDNG PRNTED: 05/26/205 OMB NO (X3) SURVEY NAME OF PROVDER OR SUPPLER COMMUNCARE, NC #4 LELAND (X4) D! PREFX 3G02 SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) B. WNG D PREFX STREET ADDRESS. CTY. STATE. ZP CODE 450 LELAND WAY BOSE, PROVDERS PLAN OF CORRECTON leach CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) 05/5/205 XS) COMPLETON W 32 Contnued From page 2 are employed. Ths STANDARD s not met as evdenced by: Based on record revew and staff ntervew, t was determned the faclty faled to ensure a behavor modfyng drug was used only as a comprehensve part of an ndvduals PP that was drected specfcally towards the reducton and eventual elmnaton of the behavors for whch the drug was employed for of 4 ndvduals (ndvdual #3) whose behavor modfyng drugs were revewed. Ths resulted n an ndvdual recevng a behavor modfyng drug wthout a plan that dentfed how the drug may change n relaton to progress or regresson. The fndngs nclude:. ndvdual #3s 2/9/5PP stated he was a 52 year old male whose dagnoses ncluded major depresson, Prader Wll syndrome, and mld mental retardaton. ndvdual #3s record was revewed and contaned the followng: W32 locaton was hred /4 and stll s learnng the very complex job of a QDP. The QDP Supervsor generally prepares the medcaton reducton plan. The QDP Supervsor dd not suffcently tran the she QDP as to ths ssue. ) The QDP Supervsor wll revew the attached document wth the QDP. 2) The QDP Supervsor and QDP wll update ths ndvduals medcaton reducton plan. dentfyng Others Potentally Affected: No others at ths locaton were affected. System Changes: Please refer to correctve actons. Montorng: The QDP and QDP Supervsor wll montor each others work related to the preparaton of consents and consstency wth other documents mentoned above. - A 4/22/5 order for Effexor (an antdepressant drug) 37.5 mg every day for two weeks then dscontnue. _ An undated physcans order for Clonazepam (an antconvulsant drug) 0.5 mg one-half tablet every 2 hours twce daly., -A May 205 MAR documented begnnng 5/7/5 he receved Clonazepam as ordered and the Effexor was dscontnued on 5/4/5. -n addton, an Aprl 205 Nursng Summary. FORM CMS-2567(02-99) Prevous Versons Obsolete Event 0: F037 Factlt-jO: 3G02 f contnuaton sheet Page 3 of 5

6 replaced DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PlAN OF CORRECTON (X) PROVDERSUPPLER/CLA DENTFCATON NUMBER: (X2} MULTPlE CONSTRUCTON A BULDNG PRNTED: 05/26205 OMB NO X3) SURVEY NAME OF PROVDER OR SUPPLER COMMUNCARE, NC #4 LELAND!X4) D PREFX 3G02 SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) B. WNG D PREFX STREET ADDRESS, CTY, STATE, ZP CODE 450 LELAND WAY BOSE, D PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) 05/5/205.XS! Cm,,PLET!ON W 32 Contnued From page 3 documented the Clonazepam was ordered on 5/6/5 for "mood." w 32 ndvdual #3s 3/30/5 Psychoactve Medcaton Reducton Plan dd not nclude any nformaton. related to the use of Clonazepam. Durng an ntervew on 5/5/5 from 2:00 to 2:30 p.m., the QDP Supervsor sad she was not aware ndvdual #3s physcan had prescrbed Clonazepam for hs mood. The QDPs notes documented on 5/6/5 the faclty LPN nformed the QDP that ndvdual #3s physcan decded to temporarly prescrbe Clonazepam to allow for daly stablty untl the Effexor was dscontnued.. : The faclty faled to ensure ndvdual #3s Clonazepam medcaton was used only n conjuncton wth a program that was drected at reducng the behavor for whch the medcaton was prescrbed. W (f)(3) FLOORS The faclty must have exposed floor surfaces and floor coverngs that promote mantenance of santary condtons. ~ Ths STANDARD s not met as evdenced by: Based on observaton and staff ntervew, t was determned the faclty faled to ensure the faclty floor was kept n good repar for 7 of 7 ndvduals, (ndvduals # - #7) resdng at the faclty. Ths resulted n the envronment beng kept n ll-repar! and the creaton of unsantary condtons. The fndngs nclude: W 434 and W434 Correctve Actons: We were aware of the need to replace the floorng and have been workng on several other necessary upgrades to ths locaton such as wndows. The vnyl was n the not too dstant future the chars beng used seem to be part of the reason we are seeng so : many marks on the floor. We expect to buy new chars for ths locaton n hopng to prevent further damage to newly nstalled floors. We wll begn the process of obtanng bds to replace ths floorng. The floors wll be replaced based on contractors schedules and avalablty.! 07/5/5 FORM Cr..tS-2567{02-99) Prevous Versons Obsolete Event 0: F037 Faclty D: 3G02 f contnuaton sheet Page 4 of 5

7 sze DEPARTMENT OF HEALTH AND HUMAN SERVCES CENTERS FOR MEDCARE & MEDCAD SERVCES STATEMENT OF DEFCENCES AND PLAN OF CORRECTON (Xt) PROVDERSUPPLER/CLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A BULDNG PRNTED: 05/26/205 OMS NO (X3) SURVEY COMPlETED NAME OF PROVDER OR SUPPLER COMMUNCARE, NC #4 LELAND 3G02 8 WNG 05/5/205 STREET ADDRESS, CTY, STATE, ZP CODE 450 LELAND WAY BOSE, D (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) 0 PREFX PROVDERS PLAN OF CORRECTON leach CORRECTVE ACTON SHOULD m: CROSS-REFERENCED TO THE APPROPRAl E DEFCENCY) X5) COMPLETON W 434 Contnued From page 4. The AQDP accompaned the surveyor durng an envronmental revew on 5/3/5 from :00-2:5p.m. Durng that tme, the followng concerns were noted: W434[ dentfyng Others Potentally Affected: All ndvduals lvng at ths locaton are affected. System Changes: Please refer to correctve actons. a. n the lvng room t appeared the carpet had unraveled exposng a nne foot long by one-half, nch wde area. b. n the ktchen and dnng room area, there were n excess of 00 gouges n the vnyl floorng. The of the gouges ranged from one and one-half nches long by one-fourth nches wde to seven, nches long by one-fourth nch wde. The AQDP acknowledged the carpet had unraveled n the lvng room and the ktchen and, dnng room vnyl floorng was gouged. Montorng: The AQDP completes a monthly Preventatve Mantenance Checklst where ssues wth floorng and other mantenance ssues n the house are noted and processed., The faclty faled to ensure the carpetng and f vnyl floorng was mantaned n a clean and santary manner. form CMS-2567(02-99) Prevous Versons Obsolete Event 0: F037 Faclty 0: 3G02 f contnuaton sheet Page 5 of 5

8 Bureau of F acltv Standards STATEMENT OF DEFCENCES AND PlAN OF CORRECTON (Xl) PROVlDERSUPPLERCLA DENTFCATON NUMBER (X2) MULTPLE CONSTRUCTON A BULDNG: PRNTED: 05/26/205 lx3) SURVEY 3G02 B. WNG 05/5/205 NAME OF PROVDER OR SUPPLER COMMUNCARE, NC #4 LELAND (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) M ooo ntal Comments The followng defcences were cted durng the annual lcensure survey conducted from 5//5 to 5/5/5. STREET ADDRESS, CTY, STATE, ZP CODE 450 LELAND WAY BOSE, D 83709! D PREFX M 000 PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) :<5) CCMPLETE. The surveyors conductng your survey were: Ashley Hensched, QDP, Team Lead! Karen Marshall, MS, RD, LD MM (d) Resdental Faclty MM2 MM2 07/5/5! The resdental faclty s to admt only resdents who have had a comprehensve evaluaton, coverng physcal, emotonal, socal, and cogntve factors, conducted by an approprately : consttuted nterdscplnary team., Ths Rule s not met as evdenced by: f Refer to W99. MM (d) Wrtten Plans s descrbed n wrtten plans that are kept on fle n the faclty; and Ths Rule s not met as evdenced by: Refer to W32. MM97 MM298 Please refer to W99 MM97 Please refer to W /5/5 MM298: (e) Storage Areas, Attcs, Basements MM298 Please refer to W434 07/5/5 Storage areas, attcs, basements, and grounds must be kept free from refuse, ltter, weeds, or other tems detrmental to the health, safety, or welfare of the resdents., Ths Rule s not met as evdenced by: Refer to W434. Bureau of Faclty Standards LJ\BORATORY DRE~;9~~~~0_YDER~~~RREPRESE~TATVES SGNATURE j " "" STATE FORM / " /..:-?/~ Z: ~ - F037 A. TTLE ;t-,[..,.~ _;, z.jr {:<6) (JJ\ E

9 Bureau of Faclty Standards STATEMENT OF DEFCENCES AND PLAN OF CORRECTON (X) PROVDERSUPPUERJCUA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A. BULONG: PRNTED: 05/26/205!X3) SURVEY CQr,PLETEO 3G02 B. WNG 05/5/205 NAME OF PROVDER OR SUPPLER COMMUNCARE, NC #4 LELAND X4)D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTFYNG NFORMATON) STREET ADDRESS. CTY. STATE. ZP CODE 450 LELAND WAY BOSE, D D PREFX PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY)!XS CO.PtETE : ; :! :!, Oureau of Faclty Standards SlATE FORM t.6~s F037 f contnuaton sheet 2 of 2