Vibra Hospital of Denver-Porter Campus

PLAN OF CORRECTION – DO2C11PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE OR AS A SUPPORTED LIVING PROGRAM, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE. 1. A description of how the licensee will correct each identified deficiency. A full care plan audit was performed following the survey to ensure that all participant care plans and assessments are updated in accordance with state requirements. The facility will ensure care plans for each participant are updated according to the regulatory requirements. Care plans are completed prior to admission, updated within 30 days of admission to reflect any new changes since moving in, and updated twice per year (including the annual review) after the participant’s care plan/assessment and person-centered planning meetings. Care plans and assessments are also updated any time there is a change of condition to include notable changes in physical, cognitive or behavioral needs or as requested by the participant. These meetings listed above include the participant, the facility Administrator, the facility Assistant Director, the participant’s legal representative/guardian (if any), other family members or individuals of the participant’s choosing, and the case management agency if applicable. Input is also obtained from the facility’s medical navigator, and other support professionals who work closely with the participant and the facility if deemed necessary. An audit of in-home and community activities and the posting of these activities on the activity calendar was completed following the survey. The participants conduct a monthly facility meeting to plan group activities. The participants of the facility like to go shopping and we will continue with this activity. Other group community outings based on input from participants will continue to be offered such as movies, bowling, sporting events, going out to eat, etc. Yoga Therapy by a certified brain injury specialist occurs twice per month in the facility and music therapy is scheduled once per month in the facility. These activities will continue. The participants will also continue to be offered structured activities in the home twice a day (in the morning and afternoon) that reflect each of their specific individualized service plans and person-centered goals. Staff work with each participant to provide activities that support their specific care plan goals. Staff document the various activities performed towards achievement of these goals and monthly percentage-based outcome reports measuring the progress made are able to be generated. Activities that are often a part of a participant’s individual goals that staff work on twice a day include things such as working on household skills, cooking, baking, budgeting, volunteering, job skills, personal hygiene skills, working on rehabilitation skills involving their brain injury, etc. All of these activities will continue. The facility will also continue to coordinate group activities within the home which have historically included book club, trivia, puzzles, board games, music, exercise, and other activities that support individuals with brain injuries and are reflective of the participants’ varied wants and desires. The activity calendars will remain posted and reflect these outside activity offerings and internal activity offerings that are offered on a group basis. Staff will continue to record participation in these activities in the case notes of participants and individualized service plans and update changes of condition and progress toward personal goals and independence in these care plans. 2. A description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. The Assistant Director or Lead staff of the facility will monitor each participant’s conditions in the home and update their care plan as needed based on their physical, cognitive and behavioral needs. The Assistant Director or Lead staff will undertake a weekly check to confirm all care plans have been monitored and updated as needed for the first month, and thereafter will do so bi-weekly for the following two months. A confirmation of such checks being performed will be filed and included as part of the facility’s monthly quality management program updates. After three months care plan and assessment updates per state requirements will remain ongoing in the facility. The facility Administrator will review these reports by the Assistant Director or Lead staff bi-weekly for the first month and once a month for the following two months to ensure that care plans are being updated according to requirements. The facility Administrator will summarize these reviews in the monthly quality management program documentation. The Assistant Director or Lead staff of the facility will also ensure that the activity calendar is updated and posted weekly to include all group participant activities within the facility and in the community. The Assistant Director or Lead staff will also confirm that staff are completing the twice a day personalized participant activities and are documenting these activities within the participant case notes. The Assistant Director or Lead staff will complete a weekly report of the above confirmations for the first month and a bi-weekly report for the following two months, which be filed and included as part of the monthly quality management program review and updates. The Administrator of the home will review the Assistant Director or Lead staff’s reports on a monthly basis for three months to ensure that activities are being offered, posted and updated and that proper documentation of these activities is occurring. The Administrator will include her monthly check of the Assistant Director or Lead staff’s work in the monthly quality management program updates and report. Regular community and in-home activities will remain ongoing for the facility per state requirements. 3. A completion date that shall be no longer than thirty (30) calendar days from the issuance of the deficiency list, unless otherwise required or approved by the Department. The facility will have implemented all corrective actions described in the plan of correction by 12/20/23.