Initial Comments:
A focused fundamental survey visit was completed on October 21and 22, 2025. The purpose of this visit was to evaluate compliance with the Requirements of 42 CFR, Part 483,
Subpart I Regulations for Intermediate Care Facilities for Individuals with Intellectual Disabilities. The census at the time of the visit was 16, and the sample consisted of five individuals.
Plan of Correction:
483.410(a)(1) STANDARD
GOVERNING BODY
Name - Component - 00
The governing body must exercise general policy, budget, and operating direction over the facility.
Observations:
Based on observation and interview with the administrative staff, the governing body failed to exercise general policy and operating direction over the facility to ensure the necessary environment to provide clients with active treatment and safety through oversight of staff deployment to include staff training efforts in this area. This practice is specific to all eight individuals residing in the home.
Findings include:
Observations completed on 10/21/2025 from approximately 7:20 AM to 7:24 AM, revealed the following.
This surveyor rang the doorbell at approximately 7:20 AM. When no one answered the door, the surveyor looked in the window at the top of the door and saw an individual sitting in a wheelchair and no staff were visible. The front door was unlocked so the surveyor entered the facility. There was a short wall to the left and a long wall down the right side. The surveyor walked past the short wall and was then able to see a female staff sitting on the opposite side of the living room with her head down and a cell phone in her hand. This staff person was facing the windows. The surveyor stood there for approximately 15 seconds and then proceeded to walk to the back of the living room. The staff person still did not respond to the surveyor in the home.
The surveyor then began walking around the home, down the back hallway, and looked into bedroom areas, walked back to the living room, through the living room, through the dining room into the kitchen doorway where a male staff person was putting dishes in the dishwasher and speaking to someone and was observed wearing earbuds. There was no other staff person observed in the kitchen area at that time. This staff person also was unaware that the surveyor was in the home.
The surveyor walked to the back room that appeared to be an activity room and there were no staff persons present in that area. The surveyor then walked back to the living room. The female staff person turned and then acknowledged the surveyor by saying, "Hello". No further questions were asked of the surveyor by this staff person. At this time, this surveyor showed the staff person the surveyor's credentials and informed her that the survey team was there to begin the annual recertification survey.
Another female staff person was observed to exit a small medication room which was located through the dining room within eyesight from where the surveyor was standing.
The door to this room remained open and a male staff person was observed who was sitting in what looked like an office chair leaning backwards. The female staff person then shut the door. The surveyor approached this female staff person and identified herself and asked this female staff person to contact someone in administration to let them know that a recertification survey was occurring. She stated she would let the nurse know. At no time was this surveyor asked to sign any type of document indicating that she was in the facility.
2. A review of the agency's Visitation Policy and Procedure Manual, effective date 02/01/2013 and last revised 11/15/2021, with an identified operational scope for the "entire division" was completed on 10/22/2025 at approximately 9:00 AM. This document included the following information under the section titled, Staff Responsibilities-Visitation:
- Staff is required to ask each visitor for his or her full name and relationship...and is required to ask for proof of identification, such as a driver's license or other photo ID.
- Staff must have all visitors...government officials, etc. sign the visitor log upon arrival and sign out upon departure.
-Visitors from the governmental agencies...must provide staff with official identification and state the purpose of the visit.
Interview with both the Assistant Director of Intermediate Care Facilities Programs and the Director of Adult Campus Residential Programs on 10/21/2025 at approximately 10:30 AM, confirmed that the staff did not follow or implement the visitation policy and procedure as outlined. No staff training on this policy was provided by the facility.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The Assistant Director and House Manager of the facility will retrain all staff members who work in the facility on the facility's visitor policy. This training will be documented on a Melmark Training Log and will be completed by 11/09/2025.
The staff member's who did not follow the facility's Visitor policy with receive disciplinary action in accordance with the facility's Employee Corrective Action policy. This will be completed by 11/14/2025.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
The deficient practice affected all individuals in the facility.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
All the employees including the Directors, Qualified Intellectual Disability Professionals (QIDP), the House Managers and staff members of the facility will be trained on the facility's visitor policy upon hire and annually thereafter. This training will be documented on a Melmark Training acknowledgment log. This practice will begin in November 2025.
The House Supervisor for each building will review the Vistor Log one time per week to ensure all visitors signed in and signed out of the home. The supervisor review will be documented on the visitor log in the "supervisor signature" section. If a visitor signature is noticed to be missing, The House Supervisor will provide immediate feedback and training to the employees that worked on the date of the missing signature. This will be documented on a Melmark Training Log.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
The facility House Manager will review the monthly training report that shows each staff members training due dates and ensure all staff member review the facility visitor policy annually.
The assistant director of the facility or designee will complete random check in at the facility across all shifts on a weekly basis for one month to ensure the facility's visitor policy is being followed, and will ensure the "supervisor signature" section of the visitor log has been completed.
If there are any concerns noted, immediate feedback on the visitor policy will be provided to the respective staff member, and additional visits will be scheduled during that week. If there are no concerns noted after one month of random check ins across all shifts, the check ins will be reduced to once monthly varying across all shifts and will be documented on the Monthly Facility Audit Form under Visitor Policy section. This practice will begin November 2025.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective action being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Senior Director of the Facility to review on going status of correction action completion.
This process will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
483.440(c)(4)(iv) STANDARD
INDIVIDUAL PROGRAM PLAN
Name - Component - 00
The objectives of the individual program plan must be organized to reflect a developmental progression appropriate to the individual.
Observations:
Based on record review and interview with administrative staff, the facility failed to ensure the objectives of the individual program plan are organized to reflect a developmental progression appropriate to the Individual for three of three sample Individuals. This practice is specific to Individual #1, #2 and #3.
Findings included:
A review of the records for Individuals #1, #2 and #3 was completed on 10/22/2025 from 9:00 AM to 11:30 AM. This review noted that training plan objectives did not reflect a developmental progression appropriate to the individuals. The following training plans are exemplary of this practice:
Individual #1: Hand Sanitizing
A review of Individual #1's training plans, revealed this Individual is currently working on a hand sanitizing goal which states the following:
"Long Term Goal: The Individual will sanitize their hands with no more than a gestural prompt in 80% of opportunities across the ISP year." Individual #1 is currently working on Step #1 where she is required to rub her palms together with gestural prompt.
Further review of this training plan revealed a section titled, Baseline Procedures which states:
"Based on on the comprehensive functional assessment completed, the individual is able to complete steps associated with this training objective with gestural prompt. Subsequent review of Individual #1's comprehensive functional assessment (CFA) confirmed that Individual #1 is able to complete steps associated with this training plan with gestural prompt.
Based on this Individual's current skill level in this area as measured during both baseline, and the comprehensive functional assessment, there was no indication that the plan writer had constructed the objectives of this plan to reflect a developmental progression appropriate to the Individual based on assessed performance prior to implementation.
Individual #2: Putting on Socks
A review of Individual #2's training plans, revealed this Individual is currently working on a putting on socks training goal which states the following:
"Long Term Goal: The Individual will participate in putting on his socks independently in 80% of trials throughout the ISP year." Individual #2 is currently working on Step #5, putting socks on one of the feet with at least 80% accuracy to complete step independently in 8 out of 10 sessions.
Further review of this training plan revealed a section titled, Baseline Procedures which states:
"Per the CFA, [Individual #2] requires full physical prompting to put his socks on each day."
Subsequent review of Individual #2's comprehensive functional assessment (CFA) completed on 10/28/2024 confirmed that Individual #2 is able to complete steps associated with this training plan with full physical prompting.
Based on this Individual's current skill level in this area as measured during both baseline, and listed within the comprehensive functional assessment, there was no indication that the plan writer had constructed the objectives of this plan to reflect a developmental progression appropriate to the Individual based on assessed performance prior to implementation
Individual #3: Hand Sanitizing
A review of Individual #3's training plans, revealed this Individual is currently working on a hand sanitizing goal which states the following:
Short Term Objective: The Individual will complete all steps of hand sanitizing routine with 80% independence throughout the ISP year. Individual #3 is currently working on Step #2 where he is required to rub his hands together to spread hand sanitizer across both hands with at least 80% accuracy to complete step independently in 8 out of 10 sessions.
Further review of this training plan revealed a section titled, Baseline Procedures which states:
"Based on on the baseline completed the individual is able to do the task with partial physical prompts." Subsequent review of Individual #3's comprehensive functional assessment (CFA) completed on 03/25/2025 confirmed that Individual #3 requires physical assistance to complete the process of hand washing.
Based on this Individual's current skill level in this area as measured during both baseline and listed within the comprehensive functional assessment, there was no indication that the plan writer had constructed the objectives of this plan to reflect a developmental progression appropriate to the Individual based on assessed performance prior to implementation
Interview with Assistant Director of the ICF Program completed on on 10/22/2025 at approximately 10:45 AM confirmed that the above training plans were not organized to reflect a developmental progression appropriate to each Individual.
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Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The training plans and data collection sheets for individual #1, Individual #2 and individual #3 will be updated to reflect their baseline abilities and subsequent training objectives to align with their respective developmental progression as determined by their completed Comprehensive Functional Assessment. This update will be completed by the Assistant Director of the facility or designee by 11/21/2025.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
The Assistant Director of the facility will complete an audit of training plans and outcome data collection sheets of all the other individuals in the facility and identify if their baseline abilities and training objectives align with their respective developmental progression as determined by their completed Comprehensive Functional Assessment. This audit will be documented on a Program Plan Audit Form.
Any individual baseline abilities found not to align with training objectives will be updated in their training plans. Target completion date: 12/05/2025.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The Qualified Intellectual Disabilities Professional (QIDP) of the facility will be trained by the Director of Clinical Services to ensure baseline abilities of an individual and training objectives align with an individual's developmental progression as per their respective completed Comprehensive Functional Assessment. This training will be completed by 11/14/2025 and will be documented on a Melmark Training Log.
The House Manager and all Direct Support Staff in the facility will be trained by the QIDP on the updated training plans and outcome data sheets of all individuals in the facility. This training will be completed prior to program plan implementation and documented on a Melmark Training Log.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
Prior to implementation of any individual training plan, the Assistant Director of the facility or designee will review the training plan and ensure baseline data and training objectives are in alignment with respective individual developmental progression as per their completed Comprehensive Functional Assessment.
This review will be documented on a Training Plan Audit Tool. Any concerns noted in the Training Plan Audit Tool including baseline data inaccuracies, training objectives not aligning with individual's developmental progression will be reviewed with the QIDP and retraining initiated within one week of the review. The retraining will be documented on a Melmark Training Log.
The Assistant Director of the facility or designee will complete monthly chart audits for each individual every month beginning December 2025. This monthly audit will include a section for reviewing baseline data, individual training objectives and alignment to individual developmental progression. The outcome of these chart audits will be documented on a audit checklist.
Any concerns noted in the monthly audit including inaccuracies with baseline data, training plans and alignment to an individual's developmental progression will be reviewed with the QIDP and retraining initiated within one week of the audit review.
If after retraining there are recurrent concerns, the concerns will be addressed via Melmark's progressive discipline policy where appropriate.
This practice will begin in 12/2025.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective action being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Senior Director of the Facility to review on going status of correction action completion.
This process will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
483.440(f)(1)(i) STANDARD
PROGRAM MONITORING & CHANGE
Name - Component - 00
The individual program plan must be reviewed at least by the qualified intellectual disability professional and revised as necessary, including, but not limited to situations in which the client has successfully completed an objective or objectives identified in the individual program plan.
Observations:
Based on record review, and interview with administrative staff, the Qualified Intellectual Disabilities Professional (QIDP) failed to review and revise as necessary but not limited to situations in which the Individual has successfully completed an objective or objectives in the training plans for one of one sample Individual with a communication goal.
This practice is specific to Individual #1.
Findings included:
A review of the record of Individual #1 was completed on 10/22/2025 from 9:00 AM to 11:00 AM. This review revealed a document titled Residential Monthly Progress Report, dated September 2025, and signed by the Qualified Intellectual Disability Professional (QIDP). This document included three sections: Outcome/Goal, Summary of Data and Progress toward Goal, and Actions Taken and Plans, and revealed the following information:
Outcome/Goal
Goal Name: Communication (Choice)
Long Term Objective: Individual #1 will independently choose from two items with a physical prompt with 80% of presented opportunities. Target completion date: 04/27/2026
Short Term Objective #1: Individual will complete task with 20% of presented opportunity. Achieved August 1, 2024
Short Term Objective #2: Individual will complete task with 40% of presented opportunity. Achieved November 1, 2024
Short Term Objective #3: Individual will complete task with 60% of presented opportunity. Achieved July 1, 2025
Short Term Objective #4: Individual will complete task with 80% of presented opportunity. Achieved August 1, 2025
Summary of Data and Progress toward Goal
This section included the following: "During review month, [Individual #1] has completed the steps of the communication goal with 87% accuracy at the presented prompt level."
Action Taken and Plans
This section included the following: [Individual #1] has mastered this goal.
Interview with the Associate Director of ICF Programs on 10/23/2025 at approximately 10:40 AM, confirmed the above communication goal was achieved on August 1, 2025.
This interviewee also confirmed that this training plan has continued to be implemented for eighty-two days after Individual #1 successfully achieved it, stating that a new training plan should have been implemented upon completion.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The Qualified Intellectual Disability Professional (QIDP) of the Facility will be trained to review all Long Term Objectives (LTO) based on Individual Program Plan (IPP) assessments for priority needs for individual # 1. This training will be completed by the Director of Adult Clinical Services and will be documented on a Training log by 11/14/2025.
Post the QIDP training, the QIDP will then review and move individual # 1 to the next LTO having achieved current LTO. The QIDP will then train the staff on the teaching plan highlighting the new LTO by 11/21/2025.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
The Assistant Director of the facility will complete an audit on LTO of all individuals in the facility. This audit will be completed by 12/5/2025. Through the audit, if any LTOs are determined to have been achieved and the individual was not moved on to the next step, the Assistant Director will document this on the review section of the Audit Checklist and communicate the same with the QIDP so that any need areas identified can be corrected. Need areas will be corrected within 72 hours of discovery.
3. What corrective measures or systematic changes will be put into place to ensure that the The QIDP of the facility will create training plans based on IPP assessments and individual priority needs agreed on at the IPP meeting.
The Assistant Director or Designee will review the training plans created by the QIDP prior to staff training and goal implementation. If there are any concerns from the Assistant Director's review, the Assistant Director will communicate the same with the QIDP and the training plan will be updated within two days.
Once the training plan is put in place, the QIDP and House Manager will complete weekly goal audits on LTO progress at least weekly for all the individuals in the facility. Upon meeting a LTO criteria noted in the individual program plan, the QIDP will train staff and implement the next step in the individual LTO. Any non-compliance noted will be corrected upon discovery and staff retraining completed. This practice will begin in 12/2025.
The QIDP will complete monthly goal progress summaries for the current review period by the 10th of the following month on a monthly basis.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
On a monthly basis, the QIDP will provide a training plan and a monthly goal report on each individual's progress for review by the Assistant Director. The Assistant director will document their review on a monthly report review form by the 15th of each month. This process will verify progress on LTO steps implemented at the IPP until the individual has reached the set criterion. This process will start no later than 12/01/2025.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective action being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Senior Director of the Facility to review on going status of correction action completion.
This process will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
483.450(b)(4) STANDARD
MGMT OF INAPPROPRIATE CLIENT BEHAVIOR
Name - Component - 00
The use of systematic interventions to manage inappropriate client behavior must be incorporated into the client's individual program plan, in accordance with §483.440(c)(4) and (5) of this subpart.
Observations:
Based on record review and interview with administrative staff, the facility failed to incorporate the use of systematic interventions to manage inappropriate behavior which are written as rigorously as other training objectives, for one of three sample Individuals who have a behavior training plan. This practice is specific to Individual #2.
Findings include:
1. A review of Individual #2's record was completed on 10/22/2025 between 8:45 AM and 11:00 AM. This review revealed that this individual has a behavior training plan dated 07/05/2024 with a review and continuation date of 09/24/2025. This plan noted this Individual exhibits elopement behavior as one of the target behaviors identified within this plan. The behavior is defined as follows:
-"Elopement: Any instance of [Individual #2] leaving the program area or building without a support person. Examples include [Individual #2] running out of his program room towards the gym, running away from the van to look for landowners, or walking out of his house to the parking lot. Does not include instances of [Individual #2] leaving the program room after requesting to go to the gym or an alternative location. Each instance of elopement ends when he returns to the original program location or scheduled location.
Under the section titled, Response to Challenging Behaviors, for the target behavior, elopement it states:
1. "Staff should call for assistance or have a means to communicate with others (e.g. 'walkie' while on campus, alert residential staff for extra support before leaving the home)."
2. "Staff should ensure safe body positioning at all times Staff should turn away- hold and stabilized, push/pull lever to redirect [Individual #2] if possible. If only one person is available, this can still be utilized but is less likely to be effective. [Individual #2] may engage in dropping once hold and stabilized has been utilized or attempted."
3. "Staff should minimize attention (refrain from commenting on the behavior or telling him to stop, drop eye contact.) Staff will maintain very close proximity to[Individual #2] if he continues to elope and staff are unable to implement a supportive guide."
Although the response to the behavior of elopement included close proximity of staff during elopement, there was no outline relative to definition of close proximity as outlined in this plan nor how and when they are to intervene in the event of Individual #2's elopement. Additionally, the behavior training plan did not include systematic interventions for staff to implement if Individual #2's elopement places him in a harmful situation.
3. Interview with the Director of Clinical Services on 10/22/2025 at approximately
10:20 AM when asked what is very "close proximity" as noted in the behavior plan, this interviewee revealed that Individual #2 is on one-to-one staffing. In further interview, this interviewee acknowledged that the use of 1:1 staffing protocol for this Individual was not incorporated within the behavior support plan.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
Individual # 2's Behavior Support Plan under section titled "antecedent management" was updated by the Director of Clinical Services of the facility to include language describing 1:1 staffing support and specific positioning and supervision expectations. The 1:1 support staff must be able to see the individual and reach them within 2-3 seconds when the individual is awake.
The "Response to Challenging Behaviors" section in individual #2's Behavior Support Plan was updated to reflect the required positioning, defined as being able to reach the individual within 2-3 seconds and physically redirect individual #2 to a safer location.
All staff will be trained by the Clinical Director or designee. This training will be documented on a Melmark Training Log and will be completed by 11/25/2025.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
The Director of Adult Clinical Services will complete an audit of all individuals in the facility with a behavior support plan and ensure 1:1 staffing ratios, supervision expectations including staff positioning are included in the plans for those individuals who require them. This audit will be completed by 11-14-2025 and documented on an audit tool.
Any individual with "elopement" identified as a target behavior for reduction will be reviewed to ensure staff response strategies are clear. The Director of Clinical Services or designee will train all staff on any changes made to any Behavior Support plan.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The Director of Clinical Services will update behavior training plan feedback forms to include 1:1 staffing, response strategies and staff positioning as an audited area for inclusion in the plan. This update will be completed by 11-14-2025.
The Qualified Intellectual Disability Professional (QIDP) will be trained by the Director of Clinical Services of the facility on how to audit behavior plans and document 1:1 staffing, response strategies. The QIDPs will be expected to complete feedback forms upon completion of any new behavior training plan and annually thereafter for all individuals with a behavior training plan.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
A behavior training plan compliance tracking grid has been developed to document behavior support plan dates, date of audits completed, plan details such as 1:1 staffing needs, staff positioning and staff actions for each individual in the facility with a behavior plan.
The Director of Adult Clinical Services will train the Qualified Intellectual Disability Professional (QIDP) on how to document behavior support plan dates, dates of audits completed and plan details such as 1:1 staffing needs, staffing positioning and staff actions for each individual in the facility with a behavior plan.
The QIDP will complete behavior training plan audits and document their audits in the compliance tracking grid every six months.
The Director of Adult Clinical Services will randomly audit two behavior training plan completed and documented by the QIDP within 10 days of the QIDP's audit. Any concerns noted from the audit will be corrected within two days of discovery.
Any patterns of incomplete follow up from completed compliance audits will be addressed via Melmark's progressive corrective action policy which includes retraining, documented counseling feedback, coaching feedback, verbal and written feedback and may include termination of employment.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective action being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Senior Director of the Facility to review on going status of correction action completion.
This process will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
at least quarterly for each shift of personnel.
Observations:
Based on record review and interview with administrative staff, the facility failed to hold quarterly evacuation drills for each shift of personnel. This practice is specific to the
first shift of personnel during the time period April 2025 through June 2025.
Findings included:
A review of the facility's evacuation drills for the period from 11/2024 through 10/2025 was completed on 10/21/2025 from approximately 2:00 PM to 2:30 PM. This review revealed that evacuation drills were not held quarterly for each shift of personnel during the second quarter of 2025 as follows:
04/09/2025 through 06/2025:
04/09/2025 4:30 AM (3rd Shift: 11:00 AM to 7:00 PM)
05/06/2025 8:26 PM (2nd Shift: 3:00 PM to 11:00 PM)
06/10/2025 8:45 PM (2nd Shift: 3:00 PM to 11:00 PM)
Interview with the Assistant Director of ICF Programs completed on 10/21/2025 at approximately 2:40 PM, confirmed the evacuation drill was not held on first shift during the second quarter of 2025.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The facility will conduct a fire drill on the first shift, defined as 7:00 AM to 3:00 PM. The time of the fire drill will be varied from the previous fire drills conducted in the course of the year. The fire drill will occur any day in the month of November 2025 at 8:00 AM.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
This deficient practice affected all residents in the facility.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The Qualified Intellectual Disability Professionals (QIDP) and House Supervisors of the facility will be trained on the expectation of fire drills being conducted at least for each shift within a quarter, defined as 7am to 3pm, 3pm to 11pm and 11pm to 7am and held during varied times. This training will be conducted by the Director of the facility and documented on a Melmark Training log by 11/06/2025.
The above training will include a review of the fire drill schedule for the entire year for all facilities. The schedule will indicate the shift that each facility should conduct the monthly fire drill. Each fire drill will be scheduled to occur at varied shifts throughout the year. All QIDP and House Supervisors of the facility will be trained on the fire drill schedule. This training will be documented on the Melmark Training log by 11/06/2025.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
All Assistant Directors of the facilities will be trained on the expectation of fire drills being conducted at least for each shift within a quarter, defined as 7am to 3pm, 3pm to 11pm and 11pm to 7am and held during varied times. This training will be conducted by the Director of the facility and documented on a Melmark Training log by 11/05/2025.
The above training will include a review of the fire drill schedule for the entire year for all facilities. The schedule will indicate the shift that each facility should conduct the monthly fire drill. Each fire drill will be scheduled to occur at varied shifts throughout the year. All Assistant Directors of the facilities will be trained on the fire drill schedule. This training will be documented on the Melmark Training log by 11/05/2025.
The Assistant Director or designee will be trained on how review fire drills once conducted. The review of completed monthly drills will need to be completed by the 15th date of each month to verify that the fire drill was completed at the scheduled shift and varied time as per the fire drill schedule. If the Assistant Director identifies a fire drill that was not conducted during the correct shift and time, the facility will conduct another fire drill as per the fire drill schedule by the end of the specific month in review. This practice will begin in November 2025.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective action being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Senior Director of the Facility to review on going status of correction action completion.
This process will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
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