Rose-Mary Center report

8/12/2019 Rose-Mary Center report

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Ohio

Plan of Correction

DODD 008F

REV. 2/1/13

1Department ofDevelopmental Disabilities

Office of Provider Standards & ReviewPlan of Correction

Provider / Facility Name: Rose-Mary Center Date of Review: 3/113/14, 2014

Provider # / Facility #: 1810946 Reviewer: Kateri Hargrove

County of Review: Cuyahoga POC due within 14 days of receipt of Compliance Summary

Question Citation Plan of Correction/AppealsPOC

ApprovedY/N

1.2 Does the plan address the individual'sassessed needs in the area ofbehavior support?

The licensee failed to ensure that the planaddressed all of the assessed needs of theindividual in the area of behavior support. A

review of the behavior support data f or ID # 6from January 2013 to January 2014 show edan increase in targeted behaviors from 649 permonth for the firs t 6 months to 720 per monthfor the second 6 months. The data, w hich isused to assess the individual's needs in thearea of behavior support w as not incorporatedinto the IP to meet the individual's behavioralneeds.

1.4 Does the plan address the individual'sassessed needs in the area ofhealth care?

The licensee failed to ensure that the planaddressed the assessed needs of theindividual in the area of healthcare. A reviewof documentation found that ID # 4 moved intothe fac ility on 5/27/13 w ith an initial IP dated6/19/13. The 6/19/13 IP w as developed eventhough many healthcare assessments werenot conducted until af ter the date of the IP.For example, the initial dental assessmentw as dated 7/17/13, the initial v ision exam w ascompleted on 12/6/13, the nutritionalassessment was dated 9/18/13. For ID # 7,the IEP dated 9/23/13 included an OTassessment with recommendations. Thelicensee failed to include therecommendations of the OT assessment into


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ApprovedY/N

the IP so that the OT services could beprovided in the facility.

1.12 Was the IP revised based on thechanges in the individuals

needs/w ants?

The licensee failed to ensure that the IP wasrevised based on the changes in the

individuals' needs/w ants. A review of theunusual incident log found many entries tostate "continue to follow the IBP as w ritten",there w as no evidence that w hen a trend orpattern w as identified, that the team met todiscuss the trend or pattern so that the IPcould be review ed and, if necessary, revisedto meet the needs of the individual. For ID #2, the individual had at least 2 MUIs filed forchoking incidents. His supervision level w asincreased to 1:1, but only during mealtimes.On 2/7/14, ID # 2 had an incident of chokingon Saran Wrap w hile he was not receiving 1:1

supervision. There w as no evidence that theIP w as revised to address choking incidentsat times other than mealtime. ID # 7 has aPICA diagnosis and is required to be in theline of sight of staf f. Even w ith thissupervision level, ID # 7 has had numerousincidents in w hich he has been able to eatinedible items including a piece of clay, hairgrease, alcohol prep pad. The IP for ID # 7has not been revised to address the fact thatthe current supervision level is not meeting hisneeds.

1.13 Does the IP address the individual'sassessed needs in the area ofsupervision?

The licensee failed to ensure that the IPaddressed the individual's assessed needs inthe area of supervis ion. ID # 7 had numerousUIs addressing his ingestion of inedibleobjects . ID # 7 has a diagnosis of PICA. TheUIs show that there is a need f or additionalsupervision in order to ensure the individual isnot able to ingest inedible objects, theseresults w ere not addressed in the individual'sIP.

2.1 If the individual(s) being served areunable to self-medicate, is themedication stored in a secure locationbased on the individual and theenvironment they live in?

The licensee f ailed to ensure that medicationis stored in a secure location based on theindividual and the environment. A w alkthroughof the fac ility on 3/11/14 revealed medicationfor ID # 16 w as not stored securely. ID # 16

is unable to self- medicate. In addition, at


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ApprovedY/N

least one other resident of the facility has adiagnosis of PICA and numerous incidents ofingesting inedibles. The medication w asfound stored unsecured in the A Northcommon bathroom and two additional tubes

w ere found unsecured in ID # 16's hygienekit w hich was kept in his bedroom.

3.1 If the plan includes aversiveinterventions (including rights restrictions),did the specially constituted committee(Behavior Support/HumanRights Committee) review and approve theplan prior toimplementation?

The licensee failed to ensure that aversiveinterventions w ere review ed and approved bythe Specially Constituted Committee prior toimplementation. A review of the semi-annualmedical report completed on 12/18/13 show edthat ID # 3's socks w ere being taped to herankles every night. There was no evidencethat this aversive intervention w as approved bythe Specially Constituted Committee as of thedate of the review . ID # 7 also had an order totape pant legs and sleeves as needed. There

w as no evidence that this w as review ed andapproved by the Specially ConstitutedCommittee. A review of the physician's ordersfor ID # 7 for the months of January andFebruary 2014 revealed an order to use handmitts to prevent individual f rom picking skinand open areas. There w as no evidence thatthis behavioral intervention had been reviewedand approved by the Specially ConstitutedCommittee prior to implementation.

3.2 If the IP includes aversiveinterventions, are the interventions beingimplemented only w hen the identified

behaviors are destructive to theindividual or others?

The licensee failed to ensure that aversiveinterventions are only being implementedw hen the identified behaviors are destructiveto the individual or others. A rev iew of therecords f or ID # 3 and ID # 7 found that thelicensee w as taping the individual's socks,sleeves, and pant legs. There w as noevidence that this intervention w as in responseto a behavior that w as destructive to theindividual and/or others.

3.3 If the IP includes aversiveinterventions, are behavior support methodsemployed w ith suf ficient safeguards and in asafe manner?

The licensee failed to ensure that w henaversive interventions are implemented theyare employed w ith suf ficient safeguards and ina safe manner. ID # 1 has is to w ear ahelmet. The individual is to be checked every15 minutes w hen the helmet is in use. Areview of documentation found instances in


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ApprovedY/N

w hich the use of the helmet w as not checkedevery 15 minutes and that documentation ofthe total amount of time the individual w as inthe helmet w as inaccurate based on stafferror in calculating the total amount of time.

A supine res traint is also used w ith ID # 7 andthe individual is to be checked every 10minutes w hen in the restraint. Documentationshow ed the total amount of time the individualw as in the restraint, but did not show thetimes that staf f did the 10 minute checks. ID# 6 also has the use of the supine restraint inthe plan. The restraint is to be used no morethan 5 minutes after her equipment is applied.Documentation w as not clear on how long therestraint w as used as reports either did nothave the accurate calculation of total time, orin one case, the times listed w ere crossed

out and re-w ritten. In one case, the log notedthat ID # 6 w as placed in a supine res traint,but the UI for that incident w as silent to theuse of the supine restraint. ID # 3 w earssplints/mitts. The MAR said that range ofmotion is to be done every shift w henrestraints are used. This w as not alwaysdocumented to show that the range of motionhad been completed.

3.5 If the IP includes the use of aversiveinterventions, is there aphysician's order in place authorizing theuse of the aversive?

The licensee failed to ensure that there is aphysician's order in place authorizing the useof an aversive. ID # 1 uses a helmet. Therew as no use of the helmet in the physician'sorder sheets for the months of December,January and February.

3.6 If the IP includes aversive interventions(including rights restrictions),w as informed consent obtained prior toimplementation?

The licensee f ailed to ensure that w hen the IPincludes aversive interventions, that informedconsent is obtained prior to implementation.

A review of the plan for ID # 4 revealed theuse of psychotropic medications as abehavioral intervention. The plan, dated6/19/13, w as implemented on 7/1/13, but theguardian did not give consent until 7/18/13.Though there w as a signed consent by theguardian f or the plan, there w as no evidenceof the licensee ensuring that the guardian gaveinformed consent as required by rule. ID # 4's


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ApprovedY/N

plan w as revised on 12/4/13, the guardian didnot consent until 12/22/13. For ID # 7, therew as no evidence of consent f rom the guardianfor the use of the hurdler restraint, w hich w asapproved by the HRC on 2/13/14, or the use of

tape to pant legs, socks, and sleeves. Themedical orders for ID # 3 also included tapingthe individual's socks. There w as no evidenceof consent for that intervention.

3.7 If the IP includes phys ical restraints isthere documentation availableto show that:-The restraints w ere not in eff ect longer than12 hours.-The individual w as checked every 30minutes w hile restrained-The individual w as given an opportunity f ormotion and exercise for at

least 10 minutes during each tw o hours ofrestraint?

The licensee failed to ensure thatdocumentation w as available to show therequired information related to the use ofphysical res traint. ID # 1 is to w ear ahelmet. The individual is to be checked every15 minutes w hen the helmet is in use. Areview of documentation found instances inw hich the use of the helmet w as not checkedevery 15 minutes and that documentation of

the total amount of time the individual w as inthe helmet w as inaccurate based on stafferror in calculating the total amount of time.

A supine res traint is also used w ith ID # 7 andthe individual is to be checked every 10minutes w hen in the restraint. Documentationshow ed the total amount of time the individualw as in the restraint, but did not show thetimes that s taf f did the 10 minute checks. ID# 6 also has the use of the supine restraint inthe plan. The restraint is to be used no morethan 5 minutes after her equipment is applied.Documentation w as not clear on how long therestraint w as used and reports either did nothave the accurate calculation of total time, orin one case, the times listed were crossedout and re-w ritten. In one case, the log notedthat ID # 6 w as placed in a supine res traint,but the UI for that incident w as silent to theuse of the supine restraint and there w as nodocumentation to show the total time used orthe required checks. ID # 3 has a plan thatincludes the use of a helmet and arm splints.The equipment w as utilized on 2/24/14, butthe documentation w as not clear so it couldnot be determined if the required minimumchecks w ere conducted. The first sheet


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ApprovedY/N

indicated the equipment w as applied at 4:30and checked at 5:30 (60 minutes) andremoved at 5:40, w hile the other sheetindicated equipment applied at 4:

3.10 Were there rights restrictions oraversives in place w hich w ere notaddressed in the IP?

The licensee failed to ensure that the IP

addressed the use of rights restrictions oraversives. A review of the Human Rightscommittee minutes fr om 2/13/14 f or ID # 7revealed the approval of the continued use ofthe hurdler restraint. This w as not in thecurrent plan f or the individual. Throughout thefac ility televisions w ere covered so that thecontrols could not be accessed and TVremotes w ere not accessible to individuals.Throughout the facility, it w as observed thattoys, games, personal belongings and otheritems w ere stored in a manner that limited theability of the individuals to access the items.

4.2 Does the ICF/ID ensure that cashaccounts, savings accounts, andchecking accounts are reconciled at leastevery 60 days by someonew ho does NOT handle the individual f unds?

The licensee failed to ensure that accountsw ere reconciled at least every 60 days bysomeone w ho does not handle the individualfunds. Though the records show ed that theaccount of ID # 5 w as reconciled at thefrequency required by someone w ho does nothandle the individual funds, the reconciliationw as not accurate. ID # 5 w as charged$185.74 f or clothing tw o times for the sametransaction. This amount w as deducted fromhis f unds on 8/15/13 and again on 8/30/13.The error was identified during the review andfunds w ere restored on 3/13/14.

No further POC required as POC w as implemented and verif iedduring the course of the review .

5.1Are medication, treatments and dietaryorders being followed?The licensee f ailed to ensure that treatments,and dietary orders are beingfollow ed. During the review it w as observedthat ID # 6 w as not w earing her bilateral AFOsper physician's order. A review of UIs f oundthat on September 23, 2013 ID # 13 receivedthe w rong medication on tw o occas ions bytw o different LPNs. During observation on3/12/14, LPN G. Weiss w as observed passingmedications on B West w ithout using theMAR. The nutritional assessment for ID # 4dated 9/18/13 recommended 30 minutes ofexercise daily, there is no evidence thatrecommendation has been implemented. The


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ApprovedY/N

plan for ID # 4 dated 6/19/13 recommendedthe completion of an OT and Speechassessment. There w as no evidence thatthese assessments have been completed. ID# 4 had an initial dental evaluation on 7/17/13

w hich w as not followed up on until 1/6/14 atw hich time ID # 4 has ref used dental care andno other appointments have beenrescheduled.

5.2 Is the plan being implemented asw ritten?

The licensee failed to ensure that the plan w asbeing implemented as w ritten.Observations conducted throughout thecourse of the review found that many piecesof equipment necessary to implement theservices identified in individual plans w ere indisrepair or broken and could not be used todeliver services . In addition, items that couldbe used to provide active treatment such as

toys and games w ere found to be stored outof reach of the individuals. The sw imming poolin the fac ility w as not working during thecourse of the review and had been out ofservices since August of 2013. There w as noevidence that for those w hose plans indicateda need or w ant to use the pool that othersw imming options has been investigated andmade available. Observations also evidencedstaff w ho w ere not providing individuals w iththe appropriate supervision levels. Oneindividual, w ho w as supposed to have 15minute checks w as found alone, in a commonarea, lying between two bean bags. Staffw ere observed to direct w ith individuals w hilesitting on couches, at tables, etc. There w aslimited interaction betw een staf f andindividuals.ID # 7 who has a diagnosis of PICA w as, onnumerous occasions able to ingestinedibles. ID # 2 has a history of choking.On tw o occasions, staff reported after achoking incident that they w ere not aware thathe w as to have 1:1 s taff ing during meals andit w as found that staff w ere not providing thatlevel of supervision at the time of theincidents. ID # 1 has a purchasing program


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ApprovedY/N

that w as to be completed 20 - 25 times permonth, but was only completed 12 times fromDecember 2013 - February 2014. ID # 6'sbehavioral data is to be documented daily.Several days w ere not documented in January

of 2014. ID # 5's data sheets were notcompleted correctly as staff w ere notconsistently filling out the number of prompts.ID # 3's program states that she meets herobjective if she has zero episodes ofmaladaptive behaviors for a certain period oftime. Staff were not consistently indicating ifshe had a maladaptive behavior so it could notbe determined if she w as meeting theobjective. ID # 4 has a daily medicationprogram. The program w as not documented 9times in November 2013 and 3 times inJanuary 2014. On 12/16/13, ID # 9 had a

seizure at 4:45pm and at 6:00pm. He is tow ear a helmet after having a seizure, thehelmet w as not applied until af ter the secondseizure. ID # 7 has a diagnosis of PICA. Aw alkthrough of the fac ility, including ID # 7'sliving area revealed numerous inedible itemsw ithin his immediate reach including handsoap on the counter in the bathroom, latexgloves, deodorant and dish w ashing liquid.

6.6 Is there evidence that a prevention planw as identified, that the prevention planaddressed the causes and contributingfactors identified in the investigation and thatthe individual' s IP was revised ifnecessary?

The licensee failed to ensure thatinvestigations included causes andcontributing fac tors. A review of UIs f oundthat the investigative reports did not identifythe cause and contributing factors. On1/18/14 ID # 13 w as involved in a peer to peeraltercation w hile staff w as sitting on couch.Outcome of investigation did not identifycause and contributing f actors and outcomew as "continue to monitor". On 7/20/13 ID # 6had an incident in w hich she had bruising andedema of right eye. Report indicates thehelmet w as on too tight. There w as no followup other than "continue to monitor" and"report any injuries to nursing". There w as noassessment completed to check the fit of thehelmet. On 12/4/13, ID # 6 was involved in anincident in w hich her face shield helmet and


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ApprovedY/N

splints w ere applied and s he was placed in a4 point supine restraint. The report w as silentto the cause and contributing factors.

6.7 Upon identification of an unusualincident, is there evidences that the

provider took the follow ing immediateactions as appropriate:-Report w as made to the designated person-Report w as made w ithin 24 hours of theincident-Appropriate actions w ere taken to protectthe health and saf ety of theat-risk individual

The licensee failed to ensure that appropriateactions w ere taken to ensure the health and

safety of at-risk individuals. A review ofincidents f ound that investigations w ere notthorough, reports lacked good descriptions,there w as discrepancies betw een staff's reportof the incident, the nursing assessment, andthe final conc lusion of the QMRP. On10/12/13 ID # 10 was involved in an incident ofhead banging af ter which the individual w entback to his room and subsequentlyinjured himself w ith continual head bangingbehavior. On 10/10/13, ID # 12 had blisterson legs, the investigation w as inconclusiveand did not identify actions to be taken

immediately. On 12/4/13, ID # 15 had redbruise on back, again, the report w as notthorough in that there w ere inconsistenciesthroughout the investigation w ith differentdefinitions and descriptions of the injury. TheUI defined the injury as a "red bruise on herback on the left side above her buttocks"w hile the log described the injury as "a flakyarea to the left buttock". Without thoroughinvestigation and accurate descriptions,appropriate ac tions cannot be determined.

6.8 Did the ICF/ID conduct a monthly reviewof unusual incidents?

While the provider did conduct a monthlyreview of unusual incidents, the rev iew did notconsistently identify trends and patterns. InJanuary of 2014 there w ere 24 incidents w ith"Description Unknow n" that w ere not identifiedas a trend or patter, ID # 6 had 4 peer to peerincidents that w ere not identified and ID # 9had 6 seizures that resulted in injuries.

6.11 During the review , w as there evidenceof any unreported incidents thatshould have been reported as either anUnusual Incident or a MajorUnusual Incident?

The licensee failed to ensure that there w ereno unreported incidents. On 7/17/13, ID # 2w as found w ith 3 broken teeth. No UI or MUIw as reported. On 7/30/13, ID # 8 w as foundto have marks on her legs, an internalinvestigation determined it w as from hittingherself on the legs w ith a belt. No MUI w asreported. On 12/4/13 a UI w as written for an


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ApprovedY/N

unapproved behavior support involving ID # 6but no MUI w as reported. On 1/13/14 and4/2/13, ID # 2 had incidents of choking. Theincidents w ere filed as Heimlich/Medica lEmergency MUIs but w ere not filed as neglect

MUIs since the s taff did not follow theindividual's supervision level. On 12/6/13 ID #6 awoke with her r ight eye sw ollen shut. Thelog notes say that this w as due to SIB on12/3/13. There w as no UI or MUI f iled. On12/16/13 a UI w as written regarding ID # 9 andan inappropriate message w ritten on a whiteboard about him. The back of the UI reportnotes that the individual had numerous redareas and scratches on his back. There w asno UI or MUI w ritten in regards to the injuriesnoted by the nurse.

7.15 For all direct service staff, did the staff

person, prior to implementation,receive training on the individual's IP/BSP?

The licensee failed to ensure that staff had

training on the individuals' IPs and BSPs pr iorto implementation. During the rev iew ofpersonnel f iles it w as noted that initial trainingdone during orientation for staffDeAndra Funches, Tia Singer, and JerricaJones w ere either incomplete or notdone at all. Jerrica Jones' training for A-Northindividuals w as not done at all, training f or TiaSinger on A-North was incomplete. DeAndraFunches w as trained on 6 individual IPs butreceived no training on 4 individual IPs forindividuals living on B-West. A review of theBSP dated 6/19/13 for ID # 4 revealed noevidence of staff training on the plan until

9/17/13. A ccording to the QMRP, the planw as implemented on 7/1/13. Throughout thecourse of the review, it w as observed that staffdid not have the training necessary toimplement service plans. As a follow up, staffw ere interview ed w ith some staff reporting thatthough they did receive training, they felt thatit w as not adequate in preparing them toprovide serv ices to individuals per their plans.Some stated that trainings w ere either veryshort (10 minute training onMUI/Abuse/Neglect procedures) or that aprocess of "read and sign" w as utilized and


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ApprovedY/N

asking questions for clarification w as notencouraged. Many related that BSPs changeand staf f often do not receive training on theplan revisions. ID # 2 had tw o incidents ofchoking in w hich staff stated in the course of

the investigation that they w ere not aware thatthe individual had a 1:1 supervision levelduring mealtimes.

7.25 Was the provider staff 's name checkedagainst the sex offender andchild-victim of fender database?

An imm ediate citationw as issued on site.The licensee failed to include the f ull name ofstaf f person Rudolph Jackson Jr. w hencompleting the sex off ender and child-victimoffender database check w hen he w as hired inJune of 2013. The licensee completed thecheck during the course of the review .

No Plan of Correction is required as this w as corrected duringthe course of the review .

7.26 Was the provider staff 's name checkedagainst the U.S. generalservices administration sys tem for award

management database?

An imm ediate citationw as issued on site.The licensee failed to include the f ull name ofstaf f person Rudolph Jackson Jr. w hen

completing the U.S. General ServicesAdministration sys tem for awardedmanagement database check when he w ashired in June of 2013. The licenseecompleted the check during the course of thereview.


7.27 Was the provider staff 's name checkedagainst the database ofincarcerated and supervised offenders?

An imm ediate citationw as issued on site.The licensee failed to include the f ull name ofstaf f person Rudolph Jackson Jr. w hencompleting the check of the database ofincarcerated and supervised off enders w henhe w as hired in June of 2013. The licenseecompleted the check during the course of thereview.


9.7 Are the interior, exterior and grounds ofthe building maintained in good repair and ina clean and sanitary manner?

A w alkthrough of the f acility on 3/11/14 foundID # 10's bedroom had dirty w alls, floors,ceiling and doorknobs. There w ere holes inthe ceiling no mirror in the bathroom, noshow er head (only a plastic tube). The groutin and around the bathtub w as dirty. Therestrooms of B-Wing East smelled of mildewand urine and the show er room had smallblack gnat-like insects flying around. Therestroom on B-Wing West had a black ringaround the base of the show er. The toilet inthe play room on B-Wing had a black ringaround the inside of the bow l and no soap in


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ApprovedY/N

the bathroom. Throughout the fac ility therew ere numerous door frames that w ere rustedand missing pieces. The stove in the mainkitchen w as dirty and had several spill marksdow n the front of the oven door. There is a

large pile of discarded items (paint cans,mattresses, tables, chairs, boxes, etc.)located outside near the staircase. Accordingto the maintenance man, this pile has beenaccumulating over several months and adumpster is to be ordered for spring cleaning.The sw imming pool has been out of operationsince August of 2013. The floors w ere heavilymarked w ith black marks. Dust and dirt w erefound accumulated along the trim.

9.8 Are there appropriate and comfortableequipment, furniture and appliances in goodcondition except for normal w ear and tear

adequate to meet the needs andpreferences of the individual?

The licensee failed to ensure that equipment,furniture, and appliances w ere in goodcondition. Throughout the fac ility, numerous

toys and habilitation supplies w ere found tobe broken and unable to be used. A large"banana sw ing" w as broken and had no sling.Though bed sheets and linens appeared to benew , they did not fit the mattresses.Furniture throughout the fac ility w as in need ofthorough cleaning or replacement.

9.9 Are the entrances, hallways, corridorsand ramps clear and unobstructed?

An imm ediate citationwas issued during thereview. A w alkthrough of the facility on3/11/14 revealed each hallw ay leading to thebedrooms to have 3 trash cans used tocollect dirty clothes and linens in the hallway.

10.1 Was the individual actively participatingin activities throughout thereview?

Many individuals w ere observed to not beactively participating in activities throughoutthe review . Toys, habilitation supplies,games, equipment w ere observed to bebroken or out of reach of individuals. Staf fw ere observed on occasion during the reviewto be interacting w ith individuals verbally w hilesitting on couches or at tables rather thanactively participating w ith the individuals.

10.2 Did staff interact appropriately w ith theindividual(s)?

During the course of the review, staff w ereobserved to verbally interact w ith individualsw hile sitting on the couch or at tables, but didnot actively interact w ith individuals. A reviewof an incident w ith ID # 6 that occurred on9/16/13 reported that a staf f person involved


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admitted to say ing to another staf f member"beat her ass" in response to a behavioralincident. Staff w ere observed to not ensureprivacy w hen interacting w ith individuals. Oneindividual's bra was not on her correctly and

the staff person put her hand up theindividual's shirt to adjust the bra w ithoutexplaining to the individual w hat the staff wasprepar ing to do and did this in a common areaw ithout moving to a private location.

10.4 Was the individual able toindependently get around his/her home?

Observations during the course of the reviewfound that individuals could not independentlyget around the facility as each living area issecured by flip locks that are out of reach ofmost individuals living in the home.

10.8 Are supplies and materials available asneeded (ie; hygiene supplies,habilitation materials, ac tivities, etc.)?

On 3/11/14, ID # 6, ID # 17 and ID # 18 didnot have toothbrushes. During the course ofthe review, there were times in w hich

bathrooms did not have a supply of toiletpaper or soap.10.9 Does it appear that the individual(s)supervision needs w ere being metby the available staff?

On 3/13/14 DODD review ers discovered ID #12 unsupervised in a playroom lying betw eentw o bean bags.

10.13 Are the individual(s) able to usehousehold items (TV, phone,appliances, etc.) unless otherw ise indicatedin their IP?

TVs were secured behind Plexiglas andcould not be easily w atched due to thePlexiglas being severely scratched anddiscolored. Many household items w erestored out of reach of the individuals.

Rose-Mary Center report

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