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F0657
E

Failure to Hold Timely, Inclusive Interdisciplinary Care Conferences

Lima, Ohio Survey Completed on 06-09-2025

Penalty

Fine: $52,875
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that quarterly care conferences were held in a timely manner and that the required interdisciplinary team (IDT), residents, and their families or representatives were included in the process. Multiple residents with varying diagnoses, including cognitive impairment, mental health disorders, and chronic medical conditions, were affected. Documentation revealed that care conferences were either not held at the required intervals, not attended by the full IDT, or did not include the resident and/or their representative, as required by regulation and facility policy. For several residents, care conferences were documented as occurring, but interviews with the residents and their families indicated they were not aware of or did not recall being invited to or participating in these meetings. In some cases, there was no documentation that residents or their families were invited, and no input or concerns from them were recorded. For one resident, no care conferences had been held since admission, and both the resident and their spouse confirmed they had never participated in such a meeting. Staff interviews confirmed that care conferences were sometimes held without the required nursing or aide staff, and that invitations to residents and families were not consistently documented or provided with adequate notice. The facility's policy required a seven-day advance notice for care conferences, with documentation of the date, time, method of contact, and input from the resident or representative if they could not attend. However, staff acknowledged that this process was not consistently followed, and that care conferences were often scheduled based on staff availability rather than resident or family participation. As a result, the facility did not meet regulatory requirements for timely, inclusive, and interdisciplinary care planning.

Plan Of Correction

Tag: F 0657 Care conferences were held with residents / sponsors for the following residents #10, #16, #35, #5, and #6 on or before 6/25/25. Social services or designee will review all current resident records by 6/25/25 to ensure that quarterly care conferences have been completed timely. If a care conference did not occur, one will be held by 6/25/25. The administrator provided education to the social services designee on 6/17/25 regarding the timely completion of quarterly care conferences, quarterly completion, and the requirement for IDT, resident, and sponsor involvement. The administrator or designee will audit 3 resident charts for the completion of timely care conferences weekly for 4 weeks to ensure timely completion and involvement of the resident, sponsor, and IDT. Results of the audit will be reviewed by the QAPI committee for further recommendations.

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