Ohio

Department of Developmental Disabilities

Office of Provider Standards & Review Plan of Correction

Provider / Facility Name: Rose-Mary Center Provider # / Facility #: 1810946 County of Review: Cuyahoga

Date of Review: 3/11 3/14, 2014 Reviewer: Kateri Hargrove POC due within 14 days of receipt of Compliance Summary

Question
1.2 Does the plan address the individual's
assessed needs in the area of behavior support?

Citation
The licensee failed to ensure that the plan addressed all of the assessed needs of the individual in the area of behavior support. A review of the behavior support data for ID # 6 from January 2013 to January 2014 show ed an increase in targeted behaviors from 649 per month for the first 6 months to 720 per month for the second 6 months. The data, w hich is used to assess the individual's needs in the area of behavior support w as not incorporated into the IP to meet the individual's behavioral needs. The licensee failed to ensure that the plan addressed the assessed needs of the individual in the area of healthcare. A review of documentation found that ID # 4 moved into the facility on 5/27/13 w ith an initial IP dated 6/19/13. The 6/19/13 IP w as developed even though many healthcare assessments w ere not conducted until after the date of the IP. For example, the initial dental assessment w as dated 7/17/13, the initial vision exam w as completed on 12/6/13, the nutritional assessment w as dated 9/18/13. For ID # 7, the IEP dated 9/23/13 included an OT assessment w ith recommendations. The licensee failed to include the recommendations of the OT assessment into

Plan of Correction/Appeals

POC Approved Y/N

1.4 Does the plan address the individual's

assessed needs in the area of health care?

Plan of Correction
DODD 008F REV. 2/1/13

Question

Citation
the IP so that the OT services could be provided in the facility.

Plan of Correction/Appeals

POC Approved Y/N

1.12 Was the IP revised based on the

changes in the individuals needs/w ants?

1.13 Does the IP address the individual's

assessed needs in the area of supervision?

2.1 If the individual(s) being served are

unable to self-medicate, is the medication stored in a secure location based on the individual and the environment they live in?

The licensee failed to ensure that the IP w as revised based on the changes in the individuals' needs/w ants. A review of the unusual incident log found many entries to state "continue to follow the IBP as w ritten", there w as no evidence that w hen a trend or pattern w as identified, that the team met to discuss the trend or pattern so that the IP could be review ed and, if necessary, revised to meet the needs of the individual. For ID # 2, the individual had at least 2 MUIs filed for choking incidents. His supervision level w as increased to 1:1, but only during mealtimes. On 2/7/14, ID # 2 had an incident of choking on Saran Wrap w hile he w as not receiving 1:1 supervision. There w as no evidence that the IP w as revised to address choking incidents at times other than mealtime. ID # 7 has a PICA diagnosis and is required to be in the line of sight of staff. Even w ith this supervision level, ID # 7 has had numerous incidents in w hich he has been able to eat inedible items including a piece of clay, hair grease, alcohol prep pad. The IP for ID # 7 has not been revised to address the fact that the current supervision level is not meeting his needs. The licensee failed to ensure that the IP addressed the individual's assessed needs in the area of supervision. ID # 7 had numerous UIs addressing his ingestion of inedible objects. ID # 7 has a diagnosis of PICA. The UIs show that there is a need for additional supervision in order to ensure the individual is not able to ingest inedible objects, these results w ere not addressed in the individual's IP. The licensee failed to ensure that medication is stored in a secure location based on the individual and the environment. A w alkthrough of the facility on 3/11/14 revealed medication for ID # 16 w as not stored securely. ID # 16 is unable to self-medicate. In addition, at

Question

Citation
least one other resident of the facility has a diagnosis of PICA and numerous incidents of ingesting inedibles. The medication w as found stored unsecured in the A North common bathroom and tw o additional tubes w ere found unsecured in ID # 16's hygiene kit w hich w as kept in his bedroom. The licensee failed to ensure that aversive interventions w ere review ed and approved by the Specially Constituted Committee prior to implementation. A review of the semi-annual medical report completed on 12/18/13 show ed that ID # 3's socks w ere being taped to her ankles every night. There w as no evidence that this aversive intervention w as approved by the Specially Constituted Committee as of the date of the review . ID # 7 also had an order to tape pant legs and sleeves as needed. There w as no evidence that this w as review ed and approved by the Specially Constituted Committee. A review of the physician's orders for ID # 7 for the months of January and February 2014 revealed an order to use hand mitts to prevent individual from picking skin and open areas. There w as no evidence that this behavioral intervention had been review ed and approved by the Specially Constituted Committee prior to implementation. The licensee failed to ensure that aversive interventions are only being implemented w hen the identified behaviors are destructive to the individual or others. A review of the records for ID # 3 and ID # 7 found that the licensee w as taping the individual's socks, sleeves, and pant legs. There w as no evidence that this intervention w as in response to a behavior that w as destructive to the individual and/or others. The licensee failed to ensure that w hen aversive interventions are implemented they are employed w ith sufficient safeguards and in a safe manner. ID # 1 has is to w ear a helmet. The individual is to be checked every 15 minutes w hen the helmet is in use. A review of documentation found instances in

Plan of Correction/Appeals

POC Approved Y/N

3.1 If the plan includes aversive

interventions (including rights restrictions), did the specially constituted committee (Behavior Support/Human Rights Committee) review and approve the plan prior to implementation?

3.2 If the IP includes aversive

interventions, are the interventions being implemented only w hen the identified behaviors are destructive to the individual or others?

3.3 If the IP includes aversive

interventions, are behavior support methods employed w ith sufficient safeguards and in a safe manner?

Question

Citation
w hich the use of the helmet w as not checked every 15 minutes and that documentation of the total amount of time the individual w as in the helmet w as inaccurate based on staff error in calculating the total amount of time. A supine restraint is also used w ith ID # 7 and the individual is to be checked every 10 minutes w hen in the restraint. Documentation show ed the total amount of time the individual w as in the restraint, but did not show the times that staff did the 10 minute checks. ID # 6 also has the use of the supine restraint in the plan. The restraint is to be used no more than 5 minutes after her equipment is applied. Documentation w as not clear on how long the restraint w as used as reports either did not have the accurate calculation of total time, or in one case, the times listed w ere crossed out and re-w ritten. In one case, the log noted that ID # 6 w as placed in a supine restraint, but the UI for that incident w as silent to the use of the supine restraint. ID # 3 w ears splints/mitts. The MAR said that range of motion is to be done every shift w hen restraints are used. This w as not alw ays documented to show that the range of motion had been completed. The licensee failed to ensure that there is a physician's order in place authorizing the use of an aversive. ID # 1 uses a helmet. There w as no use of the helmet in the physician's order sheets for the months of December, January and February. The licensee failed to ensure that w hen the IP includes aversive interventions, that informed consent is obtained prior to implementation. A review of the plan for ID # 4 revealed the use of psychotropic medications as a behavioral intervention. The plan, dated 6/19/13, w as implemented on 7/1/13, but the guardian did not give consent until 7/18/13. Though there w as a signed consent by the guardian for the plan, there w as no evidence of the licensee ensuring that the guardian gave informed consent as required by rule. ID # 4's

Plan of Correction/Appeals

POC Approved Y/N

3.5 If the IP includes the use of aversive

interventions, is there a physician's order in place authorizing the use of the aversive?

3.6 If the IP includes aversive interventions

(including rights restrictions), w as informed consent obtained prior to implementation?

Question

Citation
plan w as revised on 12/4/13, the guardian did not consent until 12/22/13. For ID # 7, there w as no evidence of consent from the guardian for the use of the hurdler restraint, w hich w as approved by the HRC on 2/13/14, or the use of tape to pant legs, socks, and sleeves. The medical orders for ID # 3 also included taping the individual's socks. There w as no evidence of consent for that intervention. The licensee failed to ensure that documentation w as available to show the required information related to the use of physical restraint. ID # 1 is to w ear a helmet. The individual is to be checked every 15 minutes w hen the helmet is in use. A review of documentation found instances in w hich the use of the helmet w as not checked every 15 minutes and that documentation of the total amount of time the individual w as in the helmet w as inaccurate based on staff error in calculating the total amount of time. A supine restraint is also used w ith ID # 7 and the individual is to be checked every 10 minutes w hen in the restraint. Documentation show ed the total amount of time the individual w as in the restraint, but did not show the times that staff did the 10 minute checks. ID # 6 also has the use of the supine restraint in the plan. The restraint is to be used no more than 5 minutes after her equipment is applied. Documentation w as not clear on how long the restraint w as used and reports either did not have the accurate calculation of total time, or in one case, the times listed w ere crossed out and re-w ritten. In one case, the log noted that ID # 6 w as placed in a supine restraint, but the UI for that incident w as silent to the use of the supine restraint and there w as no documentation to show the total time used or the required checks. ID # 3 has a plan that includes the use of a helmet and arm splints. The equipment w as utilized on 2/24/14, but the documentation w as not clear so it could not be determined if the required minimum checks w ere conducted. The first sheet

Plan of Correction/Appeals

POC Approved Y/N

3.7 If the IP includes physical restraints is

there documentation available to show that: -The restraints w ere not in effect longer than 12 hours. -The individual w as checked every 30 minutes w hile restrained -The individual w as given an opportunity for motion and exercise for at least 10 minutes during each tw o hours of restraint?

Question

Citation
indicated the equipment w as applied at 4:30 and checked at 5:30 (60 minutes) and removed at 5:40, w hile the other sheet indicated equipment applied at 4: The licensee failed to ensure that the IP addressed the use of rights restrictions or aversives. A review of the Human Rights committee minutes from 2/13/14 for ID # 7 revealed the approval of the continued use of the hurdler restraint. This w as not in the current plan for the individual. Throughout the facility televisions w ere covered so that the controls could not be accessed and TV remotes w ere not accessible to individuals. Throughout the facility, it w as observed that toys, games, personal belongings and other items w ere stored in a manner that limited the ability of the individuals to access the items. The licensee failed to ensure that accounts w ere reconciled at least every 60 days by someone w ho does not handle the individual funds. Though the records show ed that the account of ID # 5 w as reconciled at the frequency required by someone w ho does not handle the individual funds, the reconciliation w as not accurate. ID # 5 w as charged $185.74 for clothing tw o times for the same transaction. This amount w as deducted from his funds on 8/15/13 and again on 8/30/13. The error w as identified during the review and funds w ere restored on 3/13/14. The licensee failed to ensure that treatments, and dietary orders are being follow ed. During the review it w as observed that ID # 6 w as not w earing her bilateral AFOs per physician's order. A review of UIs found that on September 23, 2013 ID # 13 received the w rong medication on tw o occasions by tw o different LPNs. During observation on 3/12/14, LPN G. Weiss w as observed passing medications on B West w ithout using the MAR. The nutritional assessment for ID # 4 dated 9/18/13 recommended 30 minutes of exercise daily, there is no evidence that recommendation has been implemented. The

Plan of Correction/Appeals

POC Approved Y/N

3.10 Were there rights restrictions or

aversives in place w hich w ere not addressed in the IP?

4.2 Does the ICF/ID ensure that cash

accounts, savings accounts, and checking accounts are reconciled at least every 60 days by someone w ho does NOT handle the individual funds?

No further POC required as POC w as implemented and verified during the course of the review .

5.1 Are medication, treatments and dietary

orders being follow ed?

Question

Citation
plan for ID # 4 dated 6/19/13 recommended the completion of an OT and Speech assessment. There w as no evidence that these assessments have been completed. ID # 4 had an initial dental evaluation on 7/17/13 w hich w as not follow ed up on until 1/6/14 at w hich time ID # 4 has refused dental care and no other appointments have been rescheduled. The licensee failed to ensure that the plan w as being implemented as w ritten. Observations conducted throughout the course of the review found that many pieces of equipment necessary to implement the services identified in individual plans w ere in disrepair or broken and could not be used to deliver services. In addition, items that could be used to provide active treatment such as toys and games w ere found to be stored out of reach of the individuals. The sw imming pool in the facility w as not w orking during the course of the review and had been out of services since August of 2013. There w as no evidence that for those w hose plans indicated a need or w ant to use the pool that other sw imming options has been investigated and made available. Observations also evidenced staff w ho w ere not providing individuals w ith the appropriate supervision levels. One individual, w ho w as supposed to have 15 minute checks w as found alone, in a common area, lying betw een tw o bean bags. Staff w ere observed to direct w ith individuals w hile sitting on couches, at tables, etc. There w as limited interaction betw een staff and individuals. ID # 7 w ho has a diagnosis of PICA w as, on numerous occasions able to ingest inedibles. ID # 2 has a history of choking. On tw o occasions, staff reported after a choking incident that they w ere not aw are that he w as to have 1:1 staffing during meals and it w as found that staff w ere not providing that level of supervision at the time of the incidents. ID # 1 has a purchasing program

Plan of Correction/Appeals

POC Approved Y/N

5.2 Is the plan being implemented as

w ritten?

Question

Citation
that w as to be completed 20 - 25 times per month, but w as only completed 12 times from December 2013 - February 2014. ID # 6's behavioral data is to be documented daily. Several days w ere not documented in January of 2014. ID # 5's data sheets w ere not completed correctly as staff w ere not consistently filling out the number of prompts. ID # 3's program states that she meets her objective if she has zero episodes of maladaptive behaviors for a certain period of time. Staff w ere not consistently indicating if she had a maladaptive behavior so it could not be determined if she w as meeting the objective. ID # 4 has a daily medication program. The program w as not documented 9 times in November 2013 and 3 times in January 2014. On 12/16/13, ID # 9 had a seizure at 4:45pm and at 6:00pm. He is to w ear a helmet after having a seizure, the helmet w as not applied until after the second seizure. ID # 7 has a diagnosis of PICA. A w alkthrough of the facility, including ID # 7's living area revealed numerous inedible items w ithin his immediate reach including hand soap on the counter in the bathroom, latex gloves, deodorant and dish w ashing liquid. The licensee failed to ensure that investigations included causes and contributing factors. A review of UIs found that the investigative reports did not identify the cause and contributing factors. On 1/18/14 ID # 13 w as involved in a peer to peer altercation w hile staff w as sitting on couch. Outcome of investigation did not identify cause and contributing factors and outcome w as "continue to monitor". On 7/20/13 ID # 6 had an incident in w hich she had bruising and edema of right eye. Report indicates the helmet w as on too tight. There w as no follow up other than "continue to monitor" and "report any injuries to nursing". There w as no assessment completed to check the fit of the helmet. On 12/4/13, ID # 6 w as involved in an incident in w hich her face shield helmet and

Plan of Correction/Appeals

POC Approved Y/N

6.6 Is there evidence that a prevention plan

w as identified, that the prevention plan addressed the causes and contributing factors identified in the investigation and that the individual' s IP w as revised if necessary?

Question

Citation
splints w ere applied and she w as placed in a 4 point supine restraint. The report w as silent to the cause and contributing factors. The licensee failed to ensure that appropriate actions w ere taken to ensure the health and safety of at-risk individuals. A review of incidents found that investigations w ere not thorough, reports lacked good descriptions, there w as discrepancies betw een staff's report of the incident, the nursing assessment, and the final conclusion of the QMRP. On 10/12/13 ID # 10 w as involved in an incident of head banging after w hich the individual w ent back to his room and subsequently injured himself w ith continual head banging behavior. On 10/10/13, ID # 12 had blisters on legs, the investigation w as inconclusive and did not identify actions to be taken immediately. On 12/4/13, ID # 15 had red bruise on back, again, the report w as not thorough in that there w ere inconsistencies throughout the investigation w ith different definitions and descriptions of the injury. The UI defined the injury as a "red bruise on her back on the left side above her buttocks" w hile the log described the injury as "a flaky area to the left buttock". Without thorough investigation and accurate descriptions, appropriate actions cannot be determined. While the provider did conduct a monthly review of unusual incidents, the review did not consistently identify trends and patterns. In January of 2014 there w ere 24 incidents w ith "Description Unknow n" that w ere not identified as a trend or patter, ID # 6 had 4 peer to peer incidents that w ere not identified and ID # 9 had 6 seizures that resulted in injuries. The licensee failed to ensure that there w ere no unreported incidents. On 7/17/13, ID # 2 w as found w ith 3 broken teeth. No UI or MUI w as reported. On 7/30/13, ID # 8 w as found to have marks on her legs, an internal investigation determined it w as from hitting herself on the legs w ith a belt. No MUI w as reported. On 12/4/13 a UI w as w ritten for an

Plan of Correction/Appeals

POC Approved Y/N

6.7 Upon identification of an unusual

incident, is there evidences that the provider took the follow ing immediate actions as appropriate: -Report w as made to the designated person -Report w as made w ithin 24 hours of the incident -Appropriate actions w ere taken to protect the health and safety of the at-risk individual

6.8 Did the ICF/ID conduct a monthly review

of unusual incidents?

6.11 During the review , w as there evidence

of any unreported incidents that should have been reported as either an Unusual Incident or a Major Unusual Incident?

Question

Citation
unapproved behavior support involving ID # 6 but no MUI w as reported. On 1/13/14 and 4/2/13, ID # 2 had incidents of choking. The incidents w ere filed as Heimlich/Medical Emergency MUIs but w ere not filed as neglect MUIs since the staff did not follow the individual's supervision level. On 12/6/13 ID # 6 aw oke w ith her right eye sw ollen shut. The log notes say that this w as due to SIB on 12/3/13. There w as no UI or MUI filed. On 12/16/13 a UI w as w ritten regarding ID # 9 and an inappropriate message w ritten on a w hite board about him. The back of the UI report notes that the individual had numerous red areas and scratches on his back. There w as no UI or MUI w ritten in regards to the injuries noted by the nurse. The licensee failed to ensure that staff had training on the individuals' IPs and BSPs prior to implementation. During the review of personnel files it w as noted that initial training done during orientation for staff DeAndra Funches, Tia Singer, and Jerrica Jones w ere either incomplete or not done at all. Jerrica Jones' training for A-North individuals w as not done at all, training for Tia Singer on A-North w as incomplete. DeAndra Funches w as trained on 6 individual IPs but received no training on 4 individual IPs for individuals living on B-West. A review of the BSP dated 6/19/13 for ID # 4 revealed no evidence of staff training on the plan until 9/17/13. According to the QMRP, the plan w as implemented on 7/1/13. Throughout the course of the review , it w as observed that staff did not have the training necessary to implement service plans. As a follow up, staff w ere interview ed w ith some staff reporting that though they did receive training, they felt that it w as not adequate in preparing them to provide services to individuals per their plans. Some stated that trainings w ere either very short (10 minute training on MUI/Abuse/Neglect procedures) or that a process of "read and sign" w as utilized and

Plan of Correction/Appeals

POC Approved Y/N

7.15 For all direct service staff, did the staff

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

10

Question

Citation
asking questions for clarification w as not encouraged. Many related that BSPs change and staff often do not receive training on the plan revisions. ID # 2 had tw o incidents of choking in w hich staff stated in the course of the investigation that they w ere not aw are that the individual had a 1:1 supervision level during mealtimes. An im m ediate citation w as issued on site. The licensee failed to include the full name of staff person Rudolph Jackson Jr. w hen completing the sex offender and child-victim offender database check w hen he w as hired in June of 2013. The licensee completed the check during the course of the review . An im m ediate citation w as issued on site. The licensee failed to include the full name of staff person Rudolph Jackson Jr. w hen completing the U.S. General Services Administration system for aw arded management database check w hen he w as hired in June of 2013. The licensee completed the check during the course of the review . An im m ediate citation w as issued on site. The licensee failed to include the full name of staff person Rudolph Jackson Jr. w hen completing the check of the database of incarcerated and supervised offenders w hen he w as hired in June of 2013. The licensee completed the check during the course of the review . A w alkthrough of the facility on 3/11/14 found ID # 10's bedroom had dirty w alls, floors, ceiling and doorknobs. There w ere holes in the ceiling no mirror in the bathroom, no show er head (only a plastic tube). The grout in and around the bathtub w as dirty. The restrooms of B-Wing East smelled of mildew and urine and the show er room had small black gnat-like insects flying around. The restroom on B-Wing West had a black ring around the base of the show er. The toilet in the play room on B-Wing had a black ring around the inside of the bow l and no soap in

Plan of Correction/Appeals

POC Approved Y/N

7.25 Was the provider staff's name checked against the sex offender and child-victim offender database?

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

7.26 Was the provider staff's name checked against the U.S. general services administration system for aw ard management database?

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

7.27 Was the provider staff's name checked against the database of incarcerated and supervised offenders?

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

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

11

Question

Citation
the bathroom. Throughout the facility there w ere numerous door frames that w ere rusted and missing pieces. The stove in the main kitchen w as dirty and had several spill marks dow 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. According to the maintenance man, this pile has been accumulating over several months and a dumpster is to be ordered for spring cleaning. The sw imming pool has been out of operation since August of 2013. The floors w ere heavily marked w ith black marks. Dust and dirt w ere found accumulated along the trim. The licensee failed to ensure that equipment, furniture, and appliances w ere in good condition. Throughout the facility, numerous toys and habilitation supplies w ere found to be 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 be new , they did not fit the mattresses. Furniture throughout the facility w as in need of thorough cleaning or replacement. An im m ediate citation w as issued during the review . A w alkthrough of the facility on 3/11/14 revealed each hallw ay leading to the bedrooms to have 3 trash cans used to collect dirty clothes and linens in the hallw ay. Many individuals w ere observed to not be actively participating in activities throughout the review . Toys, habilitation supplies, games, equipment w ere observed to be broken or out of reach of individuals. Staff w ere observed on occasion during the review to be interacting w ith individuals verbally w hile sitting on couches or at tables rather than actively participating w ith the individuals. During the course of the review , staff w ere observed to verbally interact w ith individuals w hile sitting on the couch or at tables, but did not actively interact w ith individuals. A review of an incident w ith ID # 6 that occurred on 9/16/13 reported that a staff person involved

Plan of Correction/Appeals

POC Approved Y/N

9.8 Are there appropriate and comfortable equipment, furniture and appliances in good condition except for normal w ear and tear adequate to meet the needs and preferences of the individual?

9.9 Are the entrances, hallw ays, corridors and ramps clear and unobstructed?

10.1 Was the individual actively participating in activities throughout the review ?

10.2 Did staff interact appropriately w ith the individual(s)?

12

Question

Citation
admitted to saying to another staff member "beat her ass" in response to a behavioral incident. Staff w ere observed to not ensure privacy w hen interacting w ith individuals. One individual's bra w as not on her correctly and the staff person put her hand up the individual's shirt to adjust the bra w ithout explaining to the individual w hat the staff w as preparing to do and did this in a common area w ithout moving to a private location. Observations during the course of the review found that individuals could not independently get around the facility as each living area is secured by flip locks that are out of reach of most individuals living in the home. On 3/11/14, ID # 6, ID # 17 and ID # 18 did not have toothbrushes. During the course of the review , there w ere times in w hich bathrooms did not have a supply of toilet paper or soap. On 3/13/14 DODD review ers discovered ID # 12 unsupervised in a playroom lying betw een tw o bean bags. TVs w ere secured behind Plexiglas and could not be easily w atched due to the Plexiglas being severely scratched and discolored. Many household items w ere stored out of reach of the individuals.

Plan of Correction/Appeals

POC Approved Y/N

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

10.8 Are supplies and materials available as needed (ie; hygiene supplies, habilitation materials, activities, etc.)?

10.9 Does it appear that the individual(s) supervision needs w ere being met by the available staff? 10.13 Are the individual(s) able to use household items (TV, phone, appliances, etc.) unless otherw ise indicated in their IP?

13