ARTICLE
Presentation (PDF) Open in new window Indiana State Department of Health 2013 ICF-DD Update Steve Corya, ICF-IID Surveyor Supervisor Components of an Acceptable Plan of Correction -Describe what the facility did to correct the deficient practice for each individual cited in the deficiency. -Describe how the facility reviewed all clients in the facility that could be affected by the same deficient practice, and state what actions the facility took to correct the deficient practice for any client the facility identified as being affected. For example: -If the deficient practice is related to falls, you would need to review the fall risk for all clients. For example: -If the deficient practice is related to Individual Program Plan implementation, you would need to ensure program plans are being implemented for everyone in facility. For example: - If the deficient practice is related to the Comprehensive Functional Assessments (CFA’s), you would need to review all CFA’s to determine all affected by the practice. Describe the steps or systemic changes the facility has made or will make to ensure that the deficient practice does not recur, including any in-services, but this also should include any system changes you made. -For example: -Reviewed P&Ps -Instituted new P&Ps -Inservice -Instituted a new form Describe how the corrective actions(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. Monitoring should include: -Who is responsible. -The system by which the responsible person(s) will monitor. -Frequency of monitoring. If “random” monitoring is indicated, a specific time frame needs to be included, i.e., weekly, monthly, etc. -For each tag, include the date by which the systemic changes will be competed. Said date must be after the exit date of the survey. -If including supporting documentation, please be sure NO confidential information on client is listed, i.e., names, DOB, SS#, Medicaid#, Room #, etc. These can be blotted out and replaced with the client number, if needed. -Administrator or designee must sign and date the 1st page of the Plan of Correction (CMS- 2567L). Top Ten Cited Deficiencies W149 Facility Must Develop and Implement Policy and Procedures to Prevent and Detect Abuse, Neglect and Mistreatment. W104- The Governing Body of the Facility Must Exercise General Policy, Budget and Operations Direction. W249 –Identified Interventions and Services Must Be Implemented In Sufficient Number And Frequency To Support Individual Program Plan Objectives. W331-Nursing Services Provided in Accordance with Individual Needs W154-All Allegations of Abuse/Neglect/ Mistreatment and Injuries of Unknown Origin are Thoroughly Investigated. W153-All Allegations of Abuse/Neglect/ Mistreatment and Injuries of Unknown Origin Immediately Reported to Administrator and other State Officials. W436-Furnish, Maintain in Good Repair and Teach Appropriate Use of Specialized Equipment/Adaptive Devices. W227-Individual Program Plan States Objectives Necessary to Meet Individual’s Needs. W157-Investigations-Appropriate Corrective Action Must Be Taken for Investigated Incidents. W159 Each Individual's Active Treatment Program Must Be Integrated, Coordinated, and Monitored by a Qualified Intellectual Disabilities Professional. Contact Information Steve Corya - ICF-IID Surveyor Supervisor Ph. 317-233-7651 / e-mail scorya@ISDH.in.gov
Contact Information Steve Corya - ICF-IID Surveyor Supervisor Ph. 317-233-7651 / e-mail scorya@ISDH.in.gov