N.,• ;` Health Human Services

TEXASv N.,• ;`

Health and Human Texas Health and Human Services Commission44 • Services Charles Smith

Executive Commissioner

February 08, 2018 roVE

Charles Harris12 2018

Spindletop MHMR CenterP.O. Box 3846 BY:

Beaumont, TX 77704

HCS Contract Number: 001007211 Component Code: 140

RE: Survey Result

Greetings,

Please find enclosed a final version of the survey report. WSC has made the followingdetermination:

No items were remaining in non-compliance at the time of the exit conference.No corrective action is required. You will be certified from January 26, 2018 to January25, 2019.

If you have any question or require additional information, please contact HHS egulatoryServices, WSC at( 713 7135- 8961.

Sincerely,

doCherylarri. ' ro m ManagerWaiver Su - ., and Certification

WSC Regula ory Services

Enclosures

HCS Survey Report (Final)

cc: HHS Regulatory Services, Waiver Survey and Certification File

Reference No.: 14936/kbj

701 W. 51st St. • P. O. Box 149303 • Austin, Texas 78714- 9030 • 512- 438- 4163 •

[email protected]. us

An Equal Opportunity Employer and Provider

1.............:- JV TEXASV Health and Human Texas Health and Human Services Commission

i` ' ServicesCharles Smith

Executive Commissioner

MEMORANDUM

DATE : February 8, 2018 flECEJVETO: Charles Harris, CEO FEB 12 2018 liSpindletop MHMR Center HCS

BY:FROM: Cheryl Harris

Program Manager/Waiver Survey& Certification

HHS Regulatory Services

SUBJECT: Certification for Spindletop MHMR Center HCS Program

0Vendor#: 001007211 Component Code: 140

The Spindletop MHMR Center HCS Program was surveyed by the Health and Human ServicesCommission ( HHS) Regulatory Services, Waiver Survey & Certification personnel on January23, 2018 to January 25, 2018. The purpose of the visit was to conduct an Annual CertificationSurvey for determining the extent to which t e program is in compliance with the HCSCertification Principles and administrative practi es as set forth in the Home and Community-Based Services Program rules.

As a result, the program is in compliance with the Principles and is certified from January 26,2018 to January 25, 2019.

cc: HHS Regulatory Services Waiver Survey& Certification File

14936/kbj

701 W. 51" St. • P. O. Box 149303 • Austin, Texas 78714- 9030 • 512- 438- 4163 •

[email protected]

An Equal Opportunity Employer and Provider

111

1.7s.

z 4

ifrloiTEXAS Waiver Survey and Certification Form 10- 1. 5

Revised NovemberDepartment of Agingand Disability Services HCS Survey Report

Provider Name Contract No./ Component Cod Type of Survey: Date( s) of Survey:

Spindletop Center 1007211 / 140 Annual 1/ 23/ 2018 - 1/ 25/ 201€

Facilitator Team Member( s):

Kevin Reed Frances Mason

LeRoy Phillips

Andrew Williams

Marcus Hill ECEIVEHarold Sanders

C c

Johnny Cox FEB 12 2018Shanesha Mitchell

Peter ZelleyBY:

Reference TAC Title 40, Part I, Chapter 9, SD

FOLLOW- UP PRINCIPLES

9. 174( a)( 50) Certification Principles: Service Delivery.a) The program provider must:

50) maintain a system of delivering HCS Program services and CFC services that iscontinuously responsive to changes in the individual' s personal goals, condition,

abilities, and needs as identified by the service planning team;

RLID 14936 Page 1 of 22


Spindletop Center 1007211 / 140 Annual 1/ 23/ 2018 - 1/ 25/ 201E

PRIOR REVIEW COMMENT

This item was cited for Individual # 11

During a record review for Individual # 11 on 11/ 9/ 16 at the program provider's office locatedat 655 S. 8th Street in Beaumont, Texas, there was no evidence revealed that the programprovider followed up on recommendations made by the Registered Dietitian ( RD), Tara R. A

nutritional assessment completed on 1/ 15/ 16 indicated recommendations that included:

following a diet of 1800-2000 calorie weight reduction, low-fat/ low cholesterol and GERDtherapy, encouraging increased hydration, encouraging increased intake of fruits andvegetables, taking a multi- vitamin with iron daily, avoiding grapefruit products, completingphysical activity five times weekly for a period of 30 minutes, providing in service training andeducation on the recommended nutritional therapy, and adding 4 hours of dietary units to theindividual's subsequent Individualized Plan of Care ( IPC). During an interview on 11/ 8/ 16 withthe direct care staff, Randolph O. at approximately 5: 00 p.m. at location code 3GH, heindicated that the individual did not have a specific diet, but was " generally encouraged toavoid junk food." No evidence was revealed in the home of how Individual # 11 was

encouraged to follow any of the noted recommendations from the dietitian; including therecommended 1800- 2000 weight reduction diet. A review of the medications for Individual

11 did not reveal that the multi-vitamin medication is being administered. In addition, based

on the record review, there was no evidence that the individual started the multi-vitaminmedication. A debriefing was held with the program provider on 11/ 9/ 16 at 4: 55 p. m.Registered Nurse, Diana T. did not provide a response on how the recommendations werefollowed up on.

On 11/ 10/ 16 at approximately 9: 20 a. m., Licensed Vocational Nurse, Jamesetta R. presented afax transmittal dated 11/ 10/ 16 that Individual # 11' s physician Dr. Aziz was solicited for followup on the recommendations made by the Registered Dietitian. A response from the physicianwas not provided. Inseh'ice training dated 11/ 9/ 16 was presented on the " 1800 Calorie

Weight Loss Meal Plan" that reviewed general healthy nutrition, drinking water andencouraging physical activity. Registered Nurse, Diana T. presented a training signature sheetdated 11/ 10/ 16 with the 1/ 15/ 16 dietary assessment attached for day habilitation staff. Inaddition to there not being any specific parameters of how to implement the recommendationsfor Individual # 11, no evidence was presented that any training or follow up was done prior tothe survey.

The program provider failed to ensure a system of delivering services for Individual # 11 was

implemented based on the recommendations made by the Registered Dietitian, Tara R. Theindividual was put at risk of exasperation of his health conditions of obesity, hypothyroidism,GERD, anemia, 8- 12 deficiency and gout due to the lack of follow up by the program provider.No additional evidence was presented prior to the end of the survey.

Previous Sample Findings:

This principle was cited for Individual # FLWUP01.

01/ 24/ 18 @ 11: 30 AM, Record Review, Spindletop MHMR Center, 655 8th St., Beaumont, TX,

by Kevin Reed, Surveyor

The record review revealed Implementation Plans for Individual # FLWUP01 that were




completed and signed by the individual and guardian for the IPC year of 6/ 27/ 16- 6/ 26/ 17 thatincluded the following services: Behavior Support, Day Habilitation, Dental, HostHome/ Companion Care, Dietitian Services and Nursing RN Services. A review of the record

revealed no issues with the provider being responsive to the individual's needs for IndividualFLWUP01. The program provider presented evidence that the recommendations made by the

Registered Dietitian, Tara R. are being followed up on as evidenced by nursing notes dated12/ 15/ 16 by Diane Thornton, RN which discussed the following concerns: risk of exasperationof his health conditions of obesity, hypothyroidism, GERD, anemia, B- 12 deficiency and gout.Individual # FLWUP01 is currently being seen by Dr. Aziz for follow up and the Individual

FLWUP01 attended his last appointment of 06/ 15/ 17 and next appointment is set for2/ 15/ 18. In-service training dated 11/ 9/ 16 was presented on the " 1800 Calorie Weight Loss

Meal Plan" that reviewed general healthy nutrition, drinking water and encouraging physicalactivity. Registered Nurse, Diana T. presented a training signature sheet dated 11/ 10/ 16 withthe 1/ 15/ 16 dietary assessment attached for day habilitation staff.

New Sample Findings:

01/ 24/ 2018 @ 1: 30 PM, Record Review, Spindletop MHMR Center, 655 8th St., Beaumont, TX,

by Harold Sanders, Surveyor

A review of the record revealed no issues with responsive to the individuals' needs forIndividual # 15. This individual receives day habilitation services, Dental, Nursing, andtransportation services.



A review of the record revealed no issues with responsive to the individuals' needs forIndividual # 16 This individual receives Host Home Companion Care services, Dental, Nursing,and transportation services.

01/ 24/ 18 @ 3: 53 PM, Record Review, Spindletop MHMR Center 655 S. 8th Street Beaumont,TX by LeRoy Phillips, Surveyor

During a review of the record for Individual# 11 it was revealed that the program provider had

maintained a system of delivering Day Habilitation, Dental, Respite, RN/ LVN Nursing, CFCPAS/ HAB and Transportation services and has been responsive to the individual's personal

goals, condition, abilities, and needs. There were no concerns noted.



maintained a system of delivering Adaptive Aids, Dental, Behavioral Support, RN/ LVN Nursing,Supervised Living services and has been responsive to the individual's personal goals,condition, abilities, and needs. There were no concerns noted.

1/ 23/ 2018 @ 6: 30PM, Interview with Betha Rinehart, Host Home provider, 130 Kenwood,

Vidor, TX, Peter Zelley, Surveyor




Surveyor interviewed Ms. Rinehart regarding the needs and characteristics of sample Individual03. Ms. Rinehart reported that Individual # 03 takes no regularly prescribed medications, only

over- the- counter PRN medications as needed. Ms. Rinehart showed surveyor a delegation

exemption form signed by provider RN Diane Thornton, indicating that she had beendetermined to be capable of administering these PRN medications without RN delegation. Ms.

Rinehart reported no illnesses or other changes to Individual # 03's condition over the pastyear.

1/ 24/ 2018 @ 9: 30AM, Record Review, Spindletop MHMR Center 655 S. 8th St., Beaumont, TX,

Peter Zelley, Surveyor

Surveyor reviewed sample Individual 03's comprehensive record and noted Individual # 03

takes no regularly prescribed medications as evidenced by review of Comprehensive NursingAssessment and most recent physician consult form dated 5/ 22/ 2017. Comprehensive NursingAssessment, dated 5/ 3/ 2017 and completed by provider RN Diane Thornton, reported nochanges to Individual # 03's medical and psychological condition. The physician consult dated5/ 22/ 2017 from Duncan Bowell MD noted no changes to Individual # 03' s treatment plan.

1/ 24/ 2018 @ 10: 45AM, Ben Rogers Employment Training Facility, 500 Canal St., Beaumont,

TX, Interview with Marcus Maple, Peter Zelley, Surveyor

Mr. Maple reported that Individual # 05 utilizes " braces" on her knees, her history of seizures,and was aware of her fall risk status. Mr. Maple reported that Individual # 05 takes nomedications while at day hab, only at home, and that Individual # 05 is approved to administerher own medication.

1/ 24/ 2018 @ 2: 00PM Interview with Paulette Champagne, PAS/ HAB provider, SpindletopMHMR Center, 655 S. 8th St., Beaumont, TX, Peter Zelley, Surveyor

Ms. Champagne reported that Individual # 05 has a history of seizures but that it "had been along time" since her last seizure episode. Ms. Champagne also identified Individual # 05's useof knee braces which she reported have helped Individual # 05 be steadier on her feet.

1/ 24/ 2018 @ 2: 30PM - Record Review, Spindletop MHMR Center, 655 S. 8th St., Beaumont,

TX, Peter Zelley, Surveyor

Comprehensive Nursing Assessment, completed by RN Diane Thornton, reported Individual# 05has a history of seizures which are controlled by medications, that Individual # 05 has a historyof falls and utilizes orthotic devices (" knee braces") to assist with stability, and had her abilityto self-medicate evaluated by RN on SAMS assessment.

Surveyor observed signatures sheets for special needs and implementation plan training for05. Surveyor noted the signatures of Paulette Champagne and Marcus Maple with respective

dates of 1/ 22/ 2018 and 11/ 21/ 2017.

1/ 24/ 18 @ 9: 35AM, Record Review, Spindletop MHMR Center, 655 S. 8th Street Beaumont,TX, by Shanesha Mitchell, Surveyor

During the record review for Individual # 09 the surveyor noted that the program providerensured that all HCS Program services were provided as identified on the Person Directed Plan




dated 6/ 2/ 17 by Brittanie DeBlanc, Service Coordinator.

1/ 24/ 18 @ 2: 15PM, Record Review, Spindletop MHMR Center, 655 S. 8th Street Beaumont, TX,by Shanesha Mitchell, Surveyor

During the record review for Individual # 10 the surveyor noted that the program provider

ensured that all HCS Program services were provided as identified on the Person Directed Plan

dated 4/ 12/ 17 by Waverley Wagstaffe, Service Coordinator.

01/ 24/ 18 @ 10: 30 AM, Record Review, Spindletop MHMR Center 655 S. 8th Street Beaumont,TX by Kevin Reed, Surveyor


maintained a system of delivering Day Habilitation, Dental, Supervised Living, RN/ LVN Nursing,and Adaptive Aid services and has been responsive to the individual's personal goals,condition, abilities, and needs. All of the aforementioned items are listed on PDP dated10/ 10/ 17. There were no concerns noted.

01/ 24/ 18 @ 2: 00 PM, Record Review, Spindletop MHMR Center 655 S. 8th Street Beaumont,TX by Kevin Reed, Surveyor


maintained a system of delivering Host Home/ Companion Care, Day Habilitation Services,RN/ LVN Nursing Services and has been responsive to the individual's personal goals, condition,abilities, and needs. All of the aforementioned items are listed on PDP dated 12/ 14/ 17. Therewere no concerns noted.

01/ 24/ 17 @ 11: 22 AM, Record, Review, Spindletop MHMR Center, 655 S. 8th Street,Beaumont, TX, by Andrew Williams, Surveyor.

During the review of Individual # 14' s record revealed that the program provider was

continuously responsive to the individual's needs as identified by the service planning teamand documented in the Person Directed Plan dated 4/ 5/ 17 written by Alandria Perry, ServiceCoordinator.

01/ 24/ 17 @ 2: 24 PM, Record, Review, Spindletop MHMR Center, 655 S. 8th Street, Beaumont,TX, by Andrew Williams, Surveyor

During the review of Individual # 13' s record revealed that the program provider was

continuously responsive to the individual's needs as identified by the service planning teamand documented in the Person Directed Plan dated 3/ 29/ 17 written by Dena Johnson, ServiceCoordinator.

1/ 24/ 18 @ 2: 32 PM, Record Review, Spindletop MHMR Center, 655 S. 8th Street, Beaumont,TX, by Marcus D. Hill, Surveyor

During a record review for Individual # 02, the Person Directed Plan dated 10/ 17/ 17 completed

by Alandria Perry, Service Coordinator indicated that the individual desired Dental, RegisteredNurse, Licensed Vocational Nurse, Adaptive Aids, Community First Choice and Transportationservices. Review of the individual's Service Delivery Logs, Nursing Service Logs, and routine




monitoring notes indicated that the program provider was responsive to the needs of theindividual as she desired. No concerns were noted.

1/ 23/ 18 @ 11: 21 AM, Record Review, Spindletop MHMR Center, 655 S. 8th Street, Beaumont,TX, by Marcus D. Hill, Surveyor

During a record review for Individual # 17, the Person Directed Plan dated 12/ 5/ 17 completed

by Brittanie DeBlanc, Service Coordinator indicated that the individual desired Day Habilitation,Dental, Registered Nurse, Transportation and Community First Choice services. Review of the

individual the individual's Service Delivery Logs, Nursing Service Logs, and routine monitoringnotes indicated that the program provider was responsive to the needs of the individual as hedesired. No concerns were noted.

1/ 24/ 18 @ 9: 2OAM, Record Review, Spindletop MHMR Center, 655 South 8th Street,Beaumont, TX by Johnny Cox, Surveyor

During the Comprehensive Record Review for Individual # 18, the surveyor observed a PersonDirected Plan ( PDP), dated 6/ 15/ 17 and listed Registered Nursing, Day Habilitation, Respite,Dental, Transportation, and Supported Home Living as approved services. The surveyor

observed that all of the services have been delivered in a way that was continuouslyresponsive to changes in Individual # 18' s personal goals, condition, abilities, and needs as

identified by the service planning team.

01/ 24/ 18 @ 9: 5OAM, Record Review, Spindletop MHMR Center, 655 S. 8th Street Beaumont,TX, Frances Mason, RN, Surveyor

During a review of the record for Individual # 06 revealed that the program provider

maintained a system of delivering Dental, RN/ LVN Nursing services and had been responsive tothe individual's personal goals, confrlition, abilities, and needs. There were no concerns noted.

01/ 24/ 18 @ 10: 53AM, Record Review, Spindletop MHMR Center, 655 S. 8th Street Beaumont,TX, Frances Mason, RN, Surveyor

During a review of the record for Individual # 07 revealed that the program provider

maintained a system of delivering Behavioral Support Services, Dental, RN Nursing services,and Host Home Care and had been responsive to the individual's personal goals, condition,abilities, and needs. There were no concerns noted.

Conclusion:

Based on the evidence presented through record review, the program provider presented

evidence of maintaining a system of delivering HCS Program services and CFC services thatare continuously responsive to changes in the individual's personal goals, condition, abilities,and needs as identified by the services planning team and recommendations made by theRegistered Dietitian ( RD), Tara R. A nutritional assessment completed on 11/ 15/ 16 indicated

recommendations that included: following a diet of 1800-2000 calorie weight reduction, low-fat/ low cholesterol and GERD therapy, encouraging increased hydration, encouraging increasedintake of fruits and vegetables, taking a multi-vitamin with iron daily, avoiding grapefruitproducts, completing physical activity five times weekly for a period of 30 minutes, providingin-service training and education on the recommended nutritional therapy, and adding 4 hoursof dietary units to the individual's subsequent Individualized Plan of Care ( IPC) were being




followed up on. Additional records were reviewed for Individual # FLWUP 01, and Individuals

s01, 02, 03, 04, 05,06, 07,08, 09, 10, 11, 12, 13, 14, 15,16, 17,18 and there were no concerns. The

program provider presented a policy that stated the Spindletop MHMR Center shall implementprocedures for ensuring that Dietary Assessments are reviewed by the Service Planning TeamSPT) and implemented as agreed upon by the SPT. If there are any changes to the plan they

will be made accordingly. The implementation plan will then be sent to the service coordinator

within the appropriate time frame and reviewed and signed by appropriate parties. A copy ofthe policy has been included in the evidence folder.


This item was corrected prior to visit.

Status: Follow- Up: Corrected Prior to Visit

9. 177( d)( 1)( A) Certification Principles: Staff Member and Service Provider Requirem

d) A program provider must:

1) conduct initial and periodic training that ensures:

A) staff members and service providers are qualified to deliver services as required bythe current needs and characteristics of the individuals to whom they deliverservices, including the use of restraint in accordance with § 9. 179 of this

subchapter ( relating to Certification Principles: Restraint); and





This principle was cited for Individual # 11.

During an interview on 11/ 8/ 16 with the direct care staff, Randolph O. at approximately 5: 00p. m. at location code 3GH, he indicated that individual # 11 did not have a Behavior SupportPlan ( BSP). He stated that there was one in the past for property destruction and cursing, butthe BSP was discontinued because these were no longer problems. During a record review on11/ 9/ 16 at the program provider's office located at 655 S. 8th Street in Beaumont, Texas, aBehavior Support Plan dated 4/ 4/ 16 was revealed that targeted the maladaptive behaviors of

physical aggression, property destruction, verbal aggression and unauthorized departure.There was no evidence revealed that the noted BSP was being followed at Individual # 11' shome. During a debriefing with the program provider on 11/ 9/ 16 at 4: 55 p. m., Program

Director, Karan S. did not provide a response on why the BSP was not being followed. On11/ 10/ 16, Licensed Psychological Associate Steven F. presented a document titled " On the Job

Training Attendance Roster" dated 11/ 9/ 16 that indicated signatures of staff trained onindividual # 11' s BSP. The signature sheet did not include the direct care staff, Randolph O. In

addition, there remained no evidence that the individual's Behavior Support Plan wasimplemented in the individual's home. No additional evidence was presented prior to the end of

the survey.




by Kevin Reed, Surveyor

The record reviekr revealed evidence that re- training for Direct flare Staff Randolph Owens

was conducted on 11/ 25/ 2016 and the individual's Behavior Support Plan is being implementedin the individual's home per Person Directed Plan dated 11/ 19/ 2016 and nursing notes dated12/ 20/ 16, 01/ 15/ 17, 06/ 2017 and 11/ 20/ 2017.




A review of the record revealed no issues with staffs' initial and periodic training for Individual15. Documentation reveals that training has been conducted and staff appear

knowledgeable. Special Needs training was completed on 07/ 14/ 2017 conducted by DianeThorton, RN for the following staff: Doris Dixon, Day Habilitation Staff.



A review of the record revealed no issues with staffs' initial and periodic training for Individual16. Documentation reveals that training has been conducted and staff appear

knowledgeable. Special Needs training was completed on 09/ 08/ 2017 conducted by MarshaRoss, RN for the following staff: Tina Smith, Host Home/ Companion Care Provider.




01/ 24/ 18 @ 4: 06 PM, Record Review, Spindletop Center 655 S. 8th Street Beaumont, TX byLeRoy Phillips, Surveyor

During a review of the Special Needs Training dated 03/ 22/ 17 by Kara Delahoussaye, RN forIndividual# 11 revealed that the program provider had conducted initial and periodic trainingto the staff members and service providers on the current needs and characteristics of this

individual. The following staff was trained: Sandy Standsbury, Day Habilitation Staff. Therewere no concerns noted.


During a review of the Special Needs Training dated 04/ 27/ 17 by Diana Thorton, RN forIndividual# 12 it was revealed that the program provider had conducted initial and periodic

training to the staff members and service providers on the current needs and characteristics ofthis individual. The following staff was trained: Annibel Wise, Direct Care Staff and AmandaHensly, RN and Jamesetta Rideaux, LVN. There were no concerns noted.

1/ 24/ 2018 @ 9: 30AM, record review, Spindletop MHMR Center, 655 5. 8th St., Beaumont, TX,

Peter Zelley, Surveyor

Comprehensive Nursing Assessment dated 5/ 3/ 2017 and completed by provider RN DianeThornton, reported that Individual # 03's physical health to be in good, stable condition with nomajor illnesses over the past year; this was confirmed through review of Individual # 03's

annual physical, completed by Duncan Bowell, M.D. and documented on physician consult formdated 5/ 22/ 2017, which recommended no change to the current treatment plan. ICAP and PDPidentified no behavioral needs or need for psychological services.

Surveyor observed signatures sheets for special needs and implementation plan training forIndividual # 03. Surveyor noted the signatures of Paulette Champagne and Marcus Maple withrespective dates of 1/ 08/ 2018 and 11/ 16/ 2017.

1/ 24/ 2018 @ 2: 30PM - record review, Spindletop MHMR Center, 655 S. 8th St., Beaumont,

TX, Peter Zelley, Surveyor

Comprehensive Nursing Assessment dated 5/ 16/ 17, completed by RN Diane Thornton,reported that individual # 05 has a history of seizures which are controlled by medications, that

05 has a history of falls and utilizes orthotic devices (" knee braces") to assist with stability,and had her ability to self-medicate evaluated by RN on SAMS assessment.Surveyor observed signatures sheets for special needs and implementation plan training forIndividual # 05. Surveyor noted the signatures of Paulette Champagne and Marcus Maple withrespective dates of 1/ 22/ 2018 and 11/ 21/ 2017.

1/ 24/ 18 @ 10: 00AM, Record Review, Spindletop MHMR Center, 655 S. 8th Street Beaumont,TX, by Kevin Reed, Surveyor

During the record review for Individual # 01 it was discovered that the program provider

conducted initial and periodic training on the current needs and characteristics on the PersonDirected Plan dated 12/ 14/ 17 by Brittanie DeBlanc, Service Coordinator. Special Needs




Training was also noted on the current Registered Nursing Comprehensive Assessment dated3/ 17/ 17 completed by Kara Delahoussaye, RN for the following staff: Mr. Sitraya Vanalla andDorothy Welton .

1/ 23/ 18 @ 4: 46PM, Face to Face Interview with Sitraya Vanalla, Host Home/ Companion Care

provider, 1902 7th Street, Port Neches, TX, by Kevin Reed, Surveyor

During the interview with Mr. Vanalla he informed the surveyor of all of Individual # 01' s

medications, diagnosis, and adaptive aids that are being utilized. He stated that all medicalappointments are current and that Individual # 01 is on a Diebetic Diet.

1/ 24/ 18 @ 2: 15PM, Record Review, SpindleTop MHMR Center, 655 S. 8th Street Beaumont,TX, by Kevin, Surveyor


conducted initial and periodic training on the current needs and characteristics noted on thePerson Directed Plan dated 10/ 10/ 17 by Brittanie DeBlanc, Service Coordinator. Special NeedsTraining was also noted on the current Registered Nursing Comprehensive Assessment dated6/ 1/ 17 completed by Kara Delahoussaye, RN for the following staff: Loretta Savoy and LucyOakley.

1/ 24/ 18 @11: 40AM, Face to Face Interview with Loretta Savoy, Direct Care staff, 655 S. 8thStreet Beaumont, TX, by Kevin Reed, Surveyor

During the interview with Ms. Savoy she informed the surveyor of all of Individual # 04' s

medications, and diagnosis, that are being utilized. She stated that she does not administermedications to Individual # 04 and he is not on any type of special diet.

1/ 24/ 18 @ 9: 35AM, Record Review, Spindletop MHMR Center, 655 S. 8th Street Beaumont,TX, by Shanesha Mitchell, Surveyor


conducted initial and periodic training on the current needs and characteristics noted on thePerson Directed Plan dated 6/ 2/ 17 by Brittanie DeBlanc, Service Coordinator. Training was alsonoted on her current Registered Nursing Comprehensive Assessment dated 6/ 1/ 17 completedby Kara Delahoussaye, RN for the following staff: Rachel Green.

1/ 24/ 18 @ 3: 46PM, Face to Face Interview with Rachel Green, Host Home/ Companion Careprovider, 4470 Woodcrest Beaumont, TX, by Shanesha Mitchell, Surveyor

During the interview with Ms. Green she informed the surveyor of all of Individual # 09's

medications, diagnosis, and adaptive aids that are being utilized. She stated that all medicalappointments are current.

1/ 24/ 18 @ 2: 15PM, Record Review, Spindletop MHMR Center, 655 S. 8th Street Beaumont, TX,by Shanesha Mitchell, Surveyor


conducted initial and periodic training on the current needs and characteristics noted on thePerson Directed Plan dated 4/ 12/ 17 by Weverley Wagstaffe, Service Coordinator. Training was




also noted on his current Registered Nursing Comprehensive Assessment dated 4/ 12/ 17 byDiana Thornton, RN for the following staff: Erick Young and Brenda Baptiste.

1/ 24/ 18 @11: 40AM, Face to Face Interview with Brenda Batiste, Community FirstChoice/ Personal Assistant Service/ Habilitation staff/Respite staff, 655 S. 8th Street Beaumont,TX, by Shanesha Mitchell, Surveyor

During the interview with Ms. Baptiste she informed the surveyor of all of Individual # 10' s

medications, and diagnosis, that are being utilized. She stated that she does not administermedications to Individual # 10 and he is not on any type of special diet.


A record review for Individual # 02 revealed a Comprehensive Nursing Assessment dated10/ 9/ 17 completed by Marsha Ross, Registered Nurse which indicated that the individual hadthe following diagnosis: Schizophrenia, Depression, Osteoporosis, Seizure Disorder, Glaucoma,Bilateral Cataracts, Tobaccoism, COPD, Arthritis; Lipid DO; and Pseudophalia. In addition, the

individual was identified as having a High Calorie Diet and took the dietary supplement Boost.A Specialized Training Signature Sheets indicated that Linda Stelly, Community First ChoiceStaff was trained on the noted needs of Individual # 02 by Marsha Ross, Registered Nurse on11/ 9/ 17.


A record review for Individual # 17 revealed a Comprehensive Nursing Assessment dated12/ 5/ 17 completed by Kara Delahoussaye, Registered Nurse which indicated that the individualhad the following diagnosis: Mild Intellectual Disability, Hypertension, Microcephalus andHydrocephalus. Specialized Training Signature Sheets indicated that Paulette Champagne,Community First Choice Staff was trained on the noted diagnosis and needs of the individualon 1/ 20/ 17, 7/ 24/ 17, 12/ 5/ 17 and 1/ 22/ 18 by Yolanda Tyler, Registered Nurse.

1/ 24/ 18 @ 9: 20AM, Record Review, Spindletop MHMR Center, 655 South 8th Street,Beaumont, TX by Johnny Cox, Surveyor

During the Comprehensive Record Review for Individual # 18, the surveyor observed a

document, titled "Staff Training" and dated 5/ 12/ 17, which indicated that Sandra Ozio, RespiteStaff, and Theresa Bob, Day Habilitation Staff, had been trained on the current needs andcharacteristics of Individual # 18, including the use of restraint.

01/ 24/ 17 @ 11: 22 AM, Record, Review, Spindletop MHMR Center, 655 S. 8th Street,Beaumont, TX, by Andrew Williams, Surveyor

During the review of Individual # 14' s record revealed that the program provider completedinitial and periodic in- service to the host home companion care provider, Debra Mauldin andday hab staff, Kim Barnes on the current needs and characteristics of the individual completedby Joseph Gobert, Unit Supervisor dated 6/ 29/ 17.

01/ 24/ 17 @ 2: 24 PM, Record, Review, Spindletop MHMR Center, 655 S. 8th Street, Beaumont,




TX, by Andrew Williams, Surveyor

During the review of Individual # 13's record revealed that the program provider completed

initial and periodic in- service to direct care staff, Cheryl Guillory and day hab staff, DorisDickson on the current needs and characteristics of the individual completed by Marsha Ross,RN, dated 5/ 17/ 17.

1/ 24/ 18 @ 9: 20AM, Face to Face Interview with Linda Wyble, Day Hab Staff, Spindletop MHMRCenter, 655 S. 8th Street, Beaumont, Texas by Frances Mason, RN Surveyor

During an interview with Ms. Wyble, Day Hab Staff there was no issues or concerns noted bythe surveyor regarding knowledge of the needs and characteristics of Individual # 06. Ms.Wyble was very knowledgeable of the needs of Individual # 06 and informed this surveyor of

the needs of this individual and of the lack of any behaviors that would require restraints. Shewas able to identify behaviors of this individual and that they were intermittent and were notsevere when any behaviors were exhibited. Ms. Wyble also informed the surveyor that thisindividual had no Behavior Support Plan.

01/ 24/ 17 @ 9: 50AM, Record, Review, Spindletop MHMR Center, 655 S. 8th Street, Beaumont,TX, by Frances Mason, RN Surveyor

During a review of the Specialized Training Signature Sheet dated 11/ 28/ 17 by Marsha Ross,RN and the Restraint and Rights Review training dated 11/ 28/ 17 by Marsha Ross, RN forIndividual# 06 revealed that the program provider had conducted initial and periodic trainingto the staff members and service providers on the current needs and characteristics of thisindividual. The following staff were trained: Lucy Oakley and Marth Ross. There were noconcerns noted.

01/ 24/ 17 @ 10: 53AM, Record, Review, Spindletop MHMR Ceiriter, 655 S. 8th Street,Beaumont, TX, by Frances Mason, RN Surveyor

During a review of the Specialized Training Signature Sheet dated 4/ 18/ 17 by Diana Thornton,RN and the Restraint and Rights Review training dated 4/ 18/ 17 by Diana Thornton, RN forIndividual# 07 revealed that the program provider had conducted initial and periodic trainingto the staff members and service providers on the current needs and characteristics of thisindividual. The following staff was trained: Ann Campbell. There were no concerns noted.

1/ 23/ 18 @ 3: 30PM, Face to Face Interview with Ann Campbell, Host Home Provider/ Mother,

21277 Burrell Wingate Road, Beaumont, Texas by Frances Mason, RN Surveyor

During an interview with Mrs. Campbell Host Home Provider/Mother during a visit to the homeof Individual # 07 there were no issues or concerns noted by the surveyor regarding knowledgeof the needs and characteristics of Individual # 07. Mrs. Campbell was very knowledgeable ofthe needs of Individual # 07 and informed this surveyor of the needs of this individual and of

the lack of any behaviors that would require restraints. She was able to identify behaviors ofthis individual and that they were not severe when behaviors were exhibited. Mrs. Campbellalso informed the surveyor that this individual had no Behavior Support Plan.

Conclusion:




Based on the evidence presented through record review, this item was corrected prior to visit.

The program provider presented evidence of initial and periodic staff training for Direct CareStaff, Randolph 0. dated 11/ 25/ 2016. Additional records were reviewed for Individual # FLWUP

01, and Individuals #' s01, 02, 03, 04, 05,06, 07,08, 09, 10, 11, 12, 13, 14, 15, 16, 17,18 and there

were no concerns. The program provider presented a policy that stated the Spindletop Centershall ensure that initial and periodic training is provided for staff working with individuals toensure that staff members and services providers are qualified to deliver services as required

by the current needs and characteristics of the individuals to whom they deliver servicesincluding restraint. The RN will request orders as appropriate from the physician. The Waiver

Program Coordinator ( WPC) will include recommendations from the assessment agreed on bythe SPT in implementation plans. Training will be provided to Waiver Program Coordinator Staffbiannually on this process. A copy of the policy has been included in the evidence folder.

This item was corrected prior to visit.



9. 178( w) Certification Principles: Quality Assurance.

w) The program provider must report the death of an individual to DADS and the service

coordinator by the end of the next business day following the death or the programprovider's learning of the death and, if the program provider reasonably believes that theLAR does not know of the individual' s death, to the LAR as soon as possible, but not laterthan 24 hours after the program provider learns of the individual' s death.





Final Determination:

During a review of death report records printed from SIRE on 11/ 07/2016 at the provider'soffice ( Spindletop MHMR Services) located at 655 S. 8th Street Beaumont, TX 77708 it wasdiscovered that the provider did not notify the Department of Aging and Disability ServicesDADS) of the death of the following individuals within the prescribed 24 hour period: F0001,

F00O2 and F00O3. F0001 died on 02/ 12/ 2016 DADS notified on 02/ 19/ 2016, F00O2 died on

07/ 23/ 2016 DADS notified on 07/28/ 2016, and F00O3 died on 09/ 17/ 2016 DADS notified on09/ 20/ 2016. A face to face interview was conducted on 11/ 09/ 2016 @ 11: 55 a. m. duringdebriefing with program director; Karan S. acknowledged that she was not aware of the non-timely notification to DADS.


This principle was cited as a Systems Issue.


A review of the evidence presented by the program provider revealed that the following deathnotifications were made on time to the Health and Human Services Commission and the

Service Coordinator for the following individuals: F00O2, F00O3, F0004, F0005, and IndividualF0006. Individual F0004 died on 05/ 15/ 17 and the notifications to HHSC and the SC weremade on 5/ 15/ 17. Individual F0005 died on 12/ 15/ 17 and the notifications to HHSC and theSC were made on 12/ 18/ 17. Individual F0006 died on 12/ 31/ 17 and the notifications weremade to HHSC and the SC on 01/ 02/ 18. Individual F00O3 died on 02/ 17/ 17 and the

notifications were made to the HHSC and he SC on 02/ 20/ 17. Individual F00O2 died on

03/ 11/ 17 and the notifications were made to HHSC and the SC on 03/ 13/ 17.

01/ 23/ 18 @ 2: 55 PM, face to face interview with Karan Shay, Program Manager, SpindletopMHMR Center 655 S. 8th Street Beaumont, TX by LeRoy Phillips, Surveyor

During a face to face interview with Ms. Shay she presented a copy of a policy to thesurveyor that indicated that "Upon learning of an individual's death, the Waiver ProgramCoordinator ( WPC) will notify all service planning team members as well as thedirector/associate director/ designee and Health and Human Services Commission ( HHSC).

Notification to HHSC will be made no later than the close of business the day after becomingaware of the death. Notification will be made by faxing form 8493 to the HHSC office numberidentified on the form. Within three days of faxing form 8493 to HHSC, the WPC will submitthe following information to HHSC: most recent Person Directed Plan and ImplementationPlans, any training regarding the individual's special needs provided to service providers, lasttwo months of medications administration records, most current nursing assessment, lastthree months of nursing notes, physician orders and lab work, last three weeks of ResidentialSupport Services, Supervised Living, Supported Home Living, or Foster Companion Care notes,last week of day habilitation notes, state supported living center transition notes, hospicenotes, RN/ LVN names/ signature sample key. Training will be provided to the WPC staffbiannually on this process."




Conclusion:

Based on evidence gathered through record review, interview and observations, the programprovider presented evidence that the notifications to HHSC and the Service Coordinator (SC)

were made on time for the following deaths of individuals F0001, F00O2, F00O3, F0004, andIndividual F0005. The program provider also presented a copy of a policy to the surveyor thatindicated that "Upon learning of an individual's death, the waiver program coordinator ( WPC)will notify all service planning team members as well as the director/associatedirector/designee and Health and Human Services Commission ( HHSC). Notification to HHSC

will be made no later than the close of business the day after becoming aware of the death.Notification will be made by faxing form 8493 to the HHSC office number identified on theform. Within three days of faxing form 8493 to HHSC, the WPC will submit the followinginformation to HHSC: most recent Person Directed Plan and Implementation Plans, any trainingregarding the individual's special needs provided to service providers, last two months ofmedications administration records, most current nursing assessment, last three months ofnursing notes, physician orders and lab work, last three weeks of Residential Support Services,

Supervised Living, Supported Home Living, or Foster Companion Care notes, last week of dayhabilitation notes, state Supported Living Center transition notes, hospice notes, RN/ LVNnames/ signature sample key. Training will be provided to the WPC staff biannually on thisprocess." A copy of the policy is included as evidence with this report.



NEW ITEMS OF NONCOMPLIANCE:

9. 174( a)( 31)( 3)( ii) Certification Principles: Service Delivery.a) The program provider must:

31) ensure that nursing is provided in accordance with the individual' s PDP; IPC;implementation plan; Texas Occupations Code, Chapter 301 ( Nursing Practice Act); 22

TAC Chapter 217 ( relating to Licensure, Peer Assistance, and Practice); 22 TACChapter 224 ( relating to Delegation of Nursing Tasks by Registered ProfessionalNurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute CareEnvironments); 22 TAC Chapter 225 ( relating to RN Delegation to UnlicensedPersonnel and Tasks Not Requiring Delegation in Independent Living Environments forClients with Stable and Predictable Conditions); and Appendix C of the HCS Program

waiver application approved by CMS and found at www. dads. state. tx. us and consistsof performing health care activities and monitoring the individual' s health conditions,including:

J) an RN doing the following:ii) documenting information from performance of a nursing assessment;



Spindletop Center 1007211 / 140 Annual 1/ 23/ 2018 - 1/ 25/ 201€


This principle was cited for Individual # 06

1/ 24/ 18 @ 9: 50AM, Record Review, Spindletop MHMR Center 655 S. 8th Street, Beaumont,Texas by Frances Mason, RN Surveyor

Record review of Individual 06' s Comprehensive Nursing Assessment ( CNA) completed on

11/ 14/ 17 by Marsha Ross, RN identified that for the Client Responsible Adult (CRA) page, theClient Responsible Adult box had no checks in any of the checkboxes that would identify howIndividual # 06' s Client Responsible Adult/ Guardian would participate in the management of herhealthcare.

1/ 24/ 18 @ 12: 15PM, Face to Face Interview with Marsha Ross, RN, Spindletop MHMR Center655 S. 8th Street, Beaumont, Texas by Frances Mason, RN Surveyor

Ms. Thornton, RN did not provide a reason for the Client Responsible Adult page beingincomplete. She indicated that she would go to Individual 06' s home and ensure that the Client

Responsible Adult page was completed by the individual's mother/guardian. Instruction wasprovided by the surveyor that to correct this citation during the visit that a documented policywith a monitoring system was needed to ensure that all future Comprehensive NurseAssessments would be complete prior to being filed in their system.

1/ 25/ 18 @ 9: 45AM, Face to Face Interview with Marsha Ross, RN, Spindletop MHMR Center655 S. 8th Street, Beaumont, Texas by Frances Mason, RN Surveyor

Marsha Ross, RN presented a revised and completed Client Responsible Adult page of theComprehensive Nurse Assessment with completion date of 1/ 24/ 18. The document was signedby the mother/guardian of Individual # 06 on 1/ 24/ 18. The date of completion of the originalComprehensive Nursb Assessment was 11/ 14/ 17. Observation of the Client Responsible Adult

page identified that all necessary decisions were checked by the mother/guardian.

This principle was cited for Individual # 07

1/ 24/ 18 @ 10: 53AM, Record Review, Spindletop MHMR Center 655 S. 8th Street, Beaumont,Texas by Frances Mason, RN Surveyor

Record review of Individual # 07's Comprehensive Nursing Assessment ( CNA) completed on3/ 16/ 17 by Diana Thornton, RN identified that the Client Responsible Adult ( CRA) page, upperbox was incomplete as evidenced by no checkboxes were checked to identify how Individual

07 would participate in the management of his healthcare. The next section for the Client

Responsible Adult failed to indicate if the Client Responsible Adult would be making decisionsonly and not directing care or if the Client Responsible Adult agreed to train unlicensedpersonnel in the proper performance of tasks identified as HMA' s. All of the checkboxes for

these decisions were blank. The only thing completed in this section was the Client ResponsibleAdult's signature and date signed.

1/ 24/ 18 @ 2: 20PM, Face to Face Interview with Diana Thornton, RN, Spindletop MHMR Center655 S. 8th Street, Beaumont, Texas by Frances Mason, RN Surveyor

Ms. Thornton, RN did not provide a reason for the Client Responsible Adult page beingRLID 14936 Page 16 of 22



incomplete. She indicated that she would go to Individual # 07's home and ensure that the

Client Responsible Adult page was completed by the Individual and his mother. Instruction wasprovided by the surveyor that to correct this citation during the visit that a documented policywith a monitoring system was needed to ensure that all future Comprehensive NurseAssessments would be complete prior to being filed in their system.

1/ 25/ 18 @ 9: 30AM, Face to Face Interview with Diana Thornton, RN, Spindletop MHMR Center655 S. 8th Street, Beaumont, Texas by Frances Mason, RN Surveyor

Diana Thornton, RN presented a revised and completed Client Responsible Adult page of theComprehensive Nurse Assessment with completion date of 1/ 24/ 18. The document was signedby Individual # 07 and by Individual # 07's mother on 1/ 24/ 18. The date on the originaldocument was 3/ 16/ 17. Observation of this page identified that all necessary decisions werechecked.

1/ 25/ 18 @ 9: 40AM, Face to Face Interview with Kara Delahoussaye, RN, Spindletop MHMRCenter 655 S. 8th Street, Beaumont, Texas by Frances Mason, RN Surveyor

Ms. Delahoussaye, RN presented a policy titled, " Completion of Registered NurseComprehensive Assessment." Ms. Delahoussaye, RN indicated that the policy included amonitoring system to ensure that all Comprehensive Nurse Assessments submitted by theprovider's RNs in the future would be reviewed by the Customer Service Representative toensure that they were completed in their entirety.

1/ 25/ 18 @ 9: 45AM, Record Review, Spindeltop MHMR Center 655 S. 8th Street, Beaumont,Texas by Frances Mason, RN Surveyor

The surveyor reviewed the policy titled, " Completion of Registered Nurse Comprehensive

Assessment" that had been presented by Kara Delahoussay , RN on 1/ 25/ 18. The policyindicated that all Comprehensive Nurse Assessments would be complete when submitted bythe RN's. The policy contained a monitoring system that required the RN' s ComprehensiveNurse Assessments to be checked by the Customer Service Representative to ensure that eachpage of Comprehensive Nurse Assessments was complete and all signatures obtained. To

maintain evidence of the completed monitoring the policy indicated that the Customer ServiceRepresentative would initial and date the upper right hand corner of each ComprehensiveNurse Assessment.

This principle was cited for Individual # 02.


During a record review for Individual # 02, the Comprehensive Nursing Assessment ( CNA)dated 10/ 9/ 17 completed by Marsha Ross included the signature of Individual # 02 as

participating in decisions about her overall healthcare management. However, the boxes

which would indicate the level of assistance the individual desired in making healthcaredecisions were unchecked.

1/ 24/ 18 @ 3: 47 PM, Face to Face Interview with Marsha Ross, Registered Nurse, SpindeltopMHMR Center, 655 S. 8th Street, Beaumont, TX, by Marcus D. Hill, Surveyor




Ms. Ross was asked to present evidence of a complete Comprehensive Nursing Assessmentwhich indicated the level of decision making Individual # 02 desired regarding her healthcare.Ms. Ross acknowledged the concern and stated that she would look into updating theComprehensive Nursing Assessment.


Kara Delahoussaye, Registered Nurse presented a policy titled Completion of Registered NurseComprehensive Nursing Assessment ( CNA) dated 1/ 24/ 18. The policy indicated that allindividuals would have a completed CNA upon enrollment, annually and when there was asignificant change in an individual's health status. The monitoring system included theRegistered Nurse who completed the CNA would ensure that all appropriate boxes are checkedand signatures were present where necessary throughout the assessment. The completedCNA would then be submitted to the Customer Service Representative ( CSR) who will review

the assessment to ensure it is completed, all applicable boxes are checked and signatures havebeen obtained. Each completed CNA will be initialed and dated by the CSR prior to filing in theindividual's record.


A document titled Review of Comprehensive Nursing Assessment by RN dated 1/ 24/ 18completed by Marsha Ross, Registered Nurse was reviewed. The document indicated that thenurse met face to face with Individual # 02 who stated that she was able to make her owndecisions regarding her healthcare and would train all assistive personnel in her healthmaintenance activities. An updated Participants in Comprehensive Nursing Assessment pagedated 1/ 24/ 18 also completed by Marsha Ross, Registered Nurse was also reviewed with allappropriate boxes checked and included the individual's signature.



During a record review for Individual # 17, a Comprehensive Nursing Assessment ( CNA) dated12/ 5/ 17 completed by Kara Delahoussaye, Registered Nurse was revealed. The CNA was

signed by the individual's Client Responsible Adult, Erma Cooper and all appropriate boxeswhich indicated the level of decision making regarding the individual's healthcare werechecked. No concerns were noted.


A review of the record for Individual# 04 revealed a completed Comprehensive NursingAssessment dated 10/ 09/ 17 by Kara Delahoussaye, RN. There were no concerns noted.





A review of the record for Individual# 01 revealed a completed Comprehensive NursingAssessment dated 03/ 17/ 17 by Kenneka Hill, RN. There were no concerns noted.

1/ 24/ 2018 @ 9: 30AM, record review, Spindletop MHMR Center, 655 S. 8th St., Beaumont, TX,

Peter Zelley, SurveyorDuring the record review for Individual # 03 it was revealed that her Nursing ComprehensiveAssessment dated 5/ 3/ 17 completed by Diane Thornton included all required information.

1/ 24/ 2018 @ 2: 30PM, record review, Spindletop MHMR Center, 655 S. 8th St., Beaumont, TX,

Peter Zelley, SurveyorDuring the record review for Individual # 05 it was revealed that her Nursing ComprehensiveAssessment dated 5/ 16/ 17 completed by Diane Thornton included all required information.



A review of the record revealed no issues with Comprehensive Nursing Assessment forIndividual # 15. The Comprehensive Nursing Assessment written by Marsha Ross on06/ 07/ 2017 was complete and no issues were revealed.



A review of the record revealed no issues with Comprehensive Nursing Assessment forIndividual # 16. The Comprehensive Nursing Assessment written by Marsha Ross on06/ 17/2017 was complete and no issues were revealed.


A review of the record for Individual# 11 revealed a completed Comprehensive NursingAssessment dated 10/ 12/ 17 by Joseph Zak, RN. There were no concerns noted.


A review of the record for Individual# 12 revealed a completed Comprehensive NursingAssessment dated 11/ 06/ 17 by Amanda Hensley, RN. There were no concerns noted.

1/ 24/ 18 @ 9: 35AM, Record Review, SpindleTop MHMR Center, 655 S. 8th Street Beaumont,TX, by Shanesha Mitchell, Surveyor

During the record review for Individual # 09 it was revealed that her Nursing ComprehensiveAssessment dated 6/ 1/ 17 completed by Kara Delehonssaye, RN included all requireddocumentation.

1/ 24/ 18 @ 2: 15PM, Record Review, SpindleTop MHMR Center, 655 S. 8th Street Beaumont,TX, by Shanesha Mitchell, Surveyor




During the record review for Individual # 10 it was revealed that his Nursing ComprehensiveAssessment dated 6/ 1/ 17 completed by Diana Thornton, RN included all requireddocumentation.

01/ 24/ 17 @ 11: 22 AM, Record, Review, Spindletop MHMR Center, 655 S. 8th Street,Beaumont, TX, by Andrew Williams, Surveyor

During the review of Individual # 14' s Comprehensive Nursing Assessment ( ComprehensiveNurse Assessment) completed by Diana Thornton, RN dated 6/ 1/ 17 revealed a completedComprehensive Nurse Assessment that also included a signature from the Client ResponsibleAdult dated 6/ 13/ 17.

01/ 24/ 17 @ 2: 24 PM, Record, Review, Spindletop MHMR Center, 655 S. 8th Street, Beaumont,TX, by Andrew Williams, Surveyor

During the review of Individual # 13' s Comprehensive Nursing Assessment ( ComprehensiveNurse Assessment) completed by Marsha Ross, RN dated 3/ 28/ 17 revealed a completedComprehensive Nurse Assessment that also included a signature from the Client ResponsibleAdult dated 3/ 29/ 17.

1/ 24/ 18 @ 9: 20AM, Record Review, Spindletop MHMR Center, 655 South 8th Street,Beaumont, TX by Johnny Cox, Surveyor

During the Comprehensive Record Review for Individual # 18, the surveyor observed a

Comprehensive Nursing Assessment ( Comprehensive Nurse Assessment), dated 5/ 3/ 17 andsigned by Marsha Ross, Registered Nurse, in which all components where completed. No

concerns were noted.

Conclusion:

Based on record reviews and interviews this item was corrected during the visit. The programprovider ensured nursing staff updated Individual # 02' s Comprehensive Nursing Assessmentthat was completed by Marsha Ross, Registered Nurse dated 1/ 24/ 18 which included thecorresponding boxes checked to specify the individual's level of healthcare decision making.The Comprehensive Nurse Assessments for Individual # 06 and Individual # 07 had

revisions/ updates to each Comprehensive Nurse Assessment Client Responsible Adult pages.The completed Client Responsible Adult page for Individual # 06 was presented by MarshaRoss, RN and had the completion date as 1/ 24/ 18. The Comprehensive Nurse Assessment forIndividual # 07 had the Client Responsible Adult completed and was presented by DianaThornton, RN as completed on 1/ 24/ 18. A policy titled, " Completion of Registered Nurse

Comprehensive Assessment" was presented by Kara Delahoussaye, RN on 1/ 25/ 18 thatcontained a monitoring system to ensure that all future Comprehensive Nurse Assessmentscompleted by the RNs were complete and all signatures obtained. This policy was written andeffective on 1/ 24/ 18. A copy of the policy is included with the evidence with this report.

This item was corrected during visit.Status: Corrected During Visit




9. 178( y) Certification Principles: Quality Assurance.y) A program provider must enter critical incident data in the DADS data system no later than

30 calendar days after the last day of the month being reported in accordance with the HCSProvider User Guide.






01/ 23/ 18 @ 10: 00 AM Record Review, Spindletop MHMR Center 655 S. 8th Street Beaumont,TX by Kevin Reed, Surveyor

A review of HHSC database system inquiry on 01/ 12/ 18 revealed that the program provider didnot report critical incident data in the DADS data system no later than 30 calendar days afterthe last day of the month being reported in accordance with the HCS Provider User Guide. The

following month was entered late:

January 2017 ( late)/ entered on 03/ 01/ 2017

April 2017 ( late)/ entered on 06/ 09/ 2017

01/ 24/ 18 @ 12: 00 PM Face to Face Interview, Karan Shay, Program Director, SpindletopMHMR Center 655 S. 8th Street Beaumont, TX by Kevin Reed, Surveyor

During the debriefing conference Mrs. Shay, acknowledged that the data was not enteredwithin 30 days following the last day of the month and that she had difficulties entering thedata due to the updating of the computer system.

Conclusion:

Based on the evidence gathered through record review of the CARE Data system and face to

face interview this item is being corrected during visit as there were only two months enteredlate. All other months were entered on time. The entry for January 2017 was not entereduntil March 01, 2017 and April 2017 was not entered until June 09, 2017. The provider has a

policy in place to ensure timely reporting of critical incidents and has successfully enteredcritical incident data on time from 12/ 2016 and 02/ 2017 thru 03/ 2017 and 05/2017 thru12/ 2017. The Surveyor reviewed the policy that contained the following detailed instructions:Staff is required to report any critical incidents that result in substantial disruption of theprogram operation involving or potentially affecting individuals enrolled in the HCS program.Staff is expected to take immediate action to resolve and to report to the appropriate stateand/ or law enforcement entities when necessary. Spindletop MHMR and its staff membersagrees to cooperate with and assist HHSC, DADS, and any state or federal agency chargedwith the duty of identifying, investigating, sanctioning or prosecuting suspected fraud andabuse, including the Office of Inspector General at HHSC. The Program Manager will review all

service delivery logs, behavioral data sheets, Medication Administration Records, and incidentreports on a weekly basis to obtain the information necessary to enter critical incidents. TheProgram Manager will enter all critical incidents for the previous month, on the first day of thecurrent month. A copy of the policy has been placed in the evidence folder.

This principle was corrected prior to visit.

Status: Corrected During Visi

Facilitator: A .//. . IA 41 idAla Date:L

RLID 149361•

224/1/)/

T ACAd i 1, e iartment or Aging

rvicesCauen15sw s

and Disability SeJon Wcizenbaum

Dear HCS Waiver Provider:

We are constantly looking at ways to improve the quality of our services. You,consumer of our services, can provide the best possible feedback so that we maya

s

a

towards our goal. y trive

To assist us with this, please complete the survey at this link:htt Is://

www.surve is onke . eoni/r/WSCConlmentCard

You may also access the survey from our Waiver Program Provider webpages.For HCS: h ://

www.dads.state.tx.us/ groviders/HCS/ index.cfmroviders/HCS/ index.cfmFor TxHmL: htt.:// vvwW.dads.state.tx.us/ srov://vvwW.dads. state. tx.us/ sroviders/TxlimL/index.cfmPlease feel free to write any additional thoughts in the " Comments" sectionofthe survey. at the bottom

Thank you for your contribution.

Sincerely,

William Medina

Unit Manager, Waiver Survey and CertificationRegulatory ServicesDepartment ofAging& Disability Services

701 W 5ist St + PA.04149030 Ilan Teki't7'87t41-9036 * ( 512) 43114011 t wc t ttLisAn Equal Opportunity Employer and Provider

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