Initial Comments:
A focused fundamental survey was conducted March 30 - April 1, 2026, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was five and the sample consisted of three individuals.
Plan of Correction:
483.440(c)(6)(iii) STANDARD
INDIVIDUAL PROGRAM PLAN
Name - Component - 00
The individual program plan must include, for those clients who lack them, training in personal skills essential for privacy and independence (including, but not limited to, toilet training, personal hygiene, dental hygiene, self-feeding, bathing, dressing, grooming, and communication of basic needs), until it has been demonstrated that the client is developmentally incapable of acquiring them.
Observations:
Based on record review and interviews, it was determined that the facility failed to ensure that all individuals were accurately assessed for training in personal skills. This applied to one (#1) of three individuals in the sample. Findings included:
Record review was completed for Individual #1 on March 31, 2026. This review revealed a current comprehensive functional assessment, completed for Individual #1, upon admission, on March 31, 2025. This assessment indicated that Individual #1 is independent in most personal skills; including toileting, menstrual care, bathing, deodorant use, nasal care, undressing, skincare, and mealtime.
This assessment also revealed that Individual #1 had limited needs in the following areas of personal skills related to verbal prompting for thoroughness:
-Handwashing: Independent in this area except for verbal prompts needed for rubbing soap onto hands for full length of time and disposing of towels.
-Oral hygiene: Independent in this area except for verbal prompts needed for ensuring thorough brushing of all areas of teeth, knowing how much mouthwash to use and for how long, flossing all areas of teeth, and wiping mouth.
-Hair care: Independent in this area except for verbal prompts needed for ensuring thoroughness in brushing hair, washing, and rinsing hair.
-Shaving: Required verbal prompts in this area.
-Dressing: Independent in this area except for verbal prompts needed for selecting appropriate clothing for the activity or weather.
-Nailcare: Independent in this area except for verbal prompts needed for identifying the need for nail care and filing nails.
A review of current and past goal training programs for Individual #1 was completed as part of the record review. A goal training program with an objective to shave lower legs independently that was started on April 9, 2025, was reviewed. Individual #1 was noted to be on "Step 3" of the training program, which required shaving legs with hand over elbow assistance. Staff documentation of this goal indicated that Individual #1 had been independent in this task 18/20 times that it was implemented by staff since November 2025.
An interdisciplinary team meeting was held for Individual #1 on February 20, 2026. The summary of discussion from this meeting indicated that Individual #1 had made progress on a oral hygiene plan that was implemented at admission and noted that Individual #1 was now "overall independent" in their oral hygiene routine. At that time, the interdisciplinary team decided that a goal training program with an objective to apply ointment to hands daily independently was to be implemented. A review of this goal training program, started February 26, 2026, revealed Individual #1 to be on "Step 1" of the training program, which required applying lotion to hands with six verbal prompts. However, documentation of this goal indicated that Individual #1 had been independent in this task 22/28 times that it was implemented by staff since it started.
An interview was completed with the qualified intellectual disabilities professional (QIDP) and the senior director (SD) on March 31, 2026, at 11:00 AM. During this interview, the QIDP stated that, based on the assessment, Individual #1 needed verbal reminders to complete tasks related to personal skills. The QIDP identified shaving, nail care, and washing hair as areas, based on the assessment, where Individual #1 had needs in personal skills. The QIDP stated that Individual #1 only needed verbal reminders to complete tasks related to these areas. A follow-up interview was completed on March 31, 2026, at 11:30 AM with the QIDP and SD. At this time, they stated that they had met with Individual #1's team to review a draft of the assessment for the upcoming year and it was determined that Individual #1 did have some needs in personal skills beyond requiring verbal reminders. The QIDP and SD further stated that it was identified that staff were not correctly documenting the level of assistance Individual #1 required to complete the current goal training programs. The SD stated the documentation was not truly reflective of Individual #1's current skill level nor did the original assessment accurately identify the current needs in the area of personal skills in order to develop training programs for Individual #1. The SD and QIDP confirmed that not all goal training programs were identified as needs in Individual #1's current assessment and confirmed that the current goal programs were more of maintenance programs with verbal reminders than rigorous training programs.
Plan of Correction:Merakey/Allegheny Valley School 1994 Ewings Mill Rd. (Merakey/AVS Ewings Mill 1) makes its best effort to operate in full compliance with both Federal and state Law. Nothing included in this Plan of Correction is an admission otherwise. Merakey/AVS Ewings Mill 1 has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections to the merits or form of any allegations contained herein. Please note that Merakey/AVS Ewings Mill 1 may contest the merits and/or form of any deficiency of finding alleged below and take reasonable steps to appeal them.
For the affected individual, an updated ICF IDD Enhanced Assessment was completed April 7, 2026. A Mini IDT will be scheduled to review the updated ICF IDD Enhanced Assessment and develop appropriate needs/goal plans. This will be completed by April 21, 2026.
On April 2, 2026, the staff persons involved in completing the previous ICF IDD Enhanced Assessment were retrained by the Lead QIDP on the Assessment and Goal Plan process. Training focused on Goals to be developed according to the prioritized needs list which is based on the comprehensive functional assessment. Goal Plans are developed to ensure that the individual's skill acquisition needs are being addressed. Goal Plans are written to ensure that the Individual's Program Plan (IPP) is written in behavioral terms for reaching goals within a defined period of time. A Staff Attendance Sheet was signed by the staff who received the training and will be kept on file in the Senior Director's office.
On April 14, 2026, the Program Manager retrained all staff at Ewings Mill on goal plans. Training focused on goal plan implementation, documentation, level of assistance and Avatar. A Staff Attendance Sheet was signed by the staff who received the training and will be kept on file in the Senior Director's office.
For the potentially affected individuals at Ewings Mill 1, an ICF IDD Enhanced Assessment will be completed by the Program Lead/Program Manager by 4/30/26. A Mini IDT will be scheduled to review the updated ICF IDD Enhanced Assessment and develop appropriate needs/goal plans. This will be completed by 5/15/26.
Additionally, for all other potentially affected individuals in the Allegheny/Beaver County ICF Program, Assessment and Goal Plan training will be completed for all Program Leads and Program Managers. This training will be completed by April 30, 2026. Training will focus on Goals to be developed according to the prioritized needs list which is based on the comprehensive functional assessment. Goal Plans are developed to ensure that the individual's skill acquisition needs are being addressed. Goal Plans are written to ensure that the Individual's Program Plan (IPP) is written in behavioral terms for reaching goals within a defined period of time. The training will be documented on a Staff Attendance Sheet and signed by all staff receiving the training and will be kept in the Senior Director's office.
Also, the Social Service Director/Lead QIDP will conduct training for all QIDPs in the Allegheny/Beaver County area. The training will focus on QIDP included in the development, completion and implementation of assessments and goal plans; monthly reviewing of goal plans, goal plan flowsheets, correct assistance, success rate, target date and current step. This training will be completed by April 30, 2026. The training will be documented on a Staff Attendance Sheet and signed by all staff receiving the training and will be kept in the Senior Director's office.
In order to monitor the effectiveness of this training, the Social Service Director or designee will complete a monthly chart audit, for three months. These chart audits will be completed by July 30, 2026, Results were relayed to the Senior Director Residential. Observation sheets will be kept on file in the Senior Director's office.
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