Initial Comments:
A focused fundamental survey was conducted March 24-26, 2026 to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I, Requirements for Intermediate Care Facilities. The census during the survey was six and the sample consisted of three individuals. Three deficiencies were identified as a result of the survey.
Plan of Correction:
483.420(a)(2) STANDARD
PROTECTION OF CLIENTS RIGHTS
Name - Component - 00
The facility must ensure the rights of all clients. Therefore the facility must inform each client, parent (if the client is a minor), or legal guardian, of the client's medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure written informed consent was received prior to the use of a restrictive intervention. This was noted for all six individuals in the facility (Individual #1, Individual #2, Individual #3, Individual #4, Individual #5, and Individual #6).
The findings included:
Facility walk-through and record review on March 24, 2026, revealed alarms installed on outside doors, and all personal toiletries and cleaning supplies in the facility are kept locked and are only accessible through staff due to safety concerns.
Further review revealed that no written informed consent was received prior installing door alarms and to locking the personal toiletries and cleaning supplies in the facility.
Qualified Intellectual Disabilities Professional (QIDP) was interviewed on March 24, 2026, at approximately 2:00 PM. QIDP confirmed that there was no written informed consent documented prior to the use of these restrictive interventions.
Plan of Correction:Immediately upon identification of the concern on March 24, 2026, the facility removed all door alarms from outside doors on March 24,2026. The facility then contacted everyone's emergency contact and/or representative to notify them of the concern on March 24, 2026, explain the safety measures related to securing personal hygiene items and potentially hazardous substances, and obtain verbal consent for continued safety precautions, when applicable. An emergency Human Rights Committee meeting was convened on March 25, 2026, to review these measures, ensure they were necessary for health and safety, and to formally address the lack of prior written consent. During this meeting, documentation of the previously obtained verbal consent was presented, and written informed consent was obtained and signed by each individual representative. Each individual and/or representative was informed of the nature of the safety measures, associated risks and benefits, available alternatives, and the right to refuse. All signed consents and Human Rights Committee documentation have been placed in everyone's record. Moving forward, everyone's behavior plan will include a statement that poisonous, hazardous, and personal hygiene products are secured within the home to ensure the health and safety of the individuals. These measures will be reviewed for appropriateness and least restrictive alternatives, and informed consent will be obtained and documented prior to implementation. All behavior plans containing these safety measures will be submitted to the Human Rights Committee for review and approval at the May 13, 2026, meeting. Also, all staff will be retrained on Behavior Plans in the May 19,2026 staff meeting. Brittany Diehl will be responsible for all the Behavior plans and Human Rights approvals. Amber Miller will be responsible for the retraining of the client's rights.
483.440(d)(1) STANDARD
PROGRAM IMPLEMENTATION
Name - Component - 00
As soon as the interdisciplinary team has formulated a client's individual program plan, each client must receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan.
Observations:
Based on facility investigation report review, record review and staff interview, it was determined that the facility failed to ensure staff continuously demonstrated the needed interventions and services directed towards one individual ' s enhanced supervision specified in the individual program plan. (Individual #1)
Findings included:
Review of Individual #1's record on March 24, 2026, has diagnosis of Moderate Intellectual Disability, Intermittent Explosive Disorder (IED), attention deficit hyperactivity disorder (ADHD), Anxiety, Aggression, Oppositional Defiant Disorder (ODD). Individual #1 has enhanced supervision (one-to-one staff) in her residential home and at her day program.
Review of facility day program investigation report, record review and staff interviews on March 24 and 25, 2026 revealed that on February 25, 2026, at 11:15 AM " Individual #1 was heating her food in a microwave in the kitchen area when another individual shoved her to the floor, causing her to fall onto her left side and onto her butt " . The target ' s assigned one-to-one staff immediately removed the target from the area. Individual #1 was sent out to urgent care for evaluation and diagnosed with a fall.
Record review and interview with the Day Program Specialist (DPS) on March 25, 2026 at 11:00 AM confirmed Individual #1 has enhanced supervision at day program due to behaviors of verbal and physical aggression and property destruction. The target who shoved Individual #1 to the floor, also had enhanced supervision (one-to-one staff) when the shoving and fall occurred.
Interview with (DPS) on March 25, 2026, at 11:00 AM confirmed day program staff failed to provide needed interventions and services of enhanced supervision outlined in the behavior plan for one individual. This failure resulted in the individual experiencing a fall that required urgent care evaluation.
Plan of Correction:Step By Step, Inc. will ensure that a Certified Investigator completes a thorough investigation into the incident involving Individual #1 by May 11, 2026. Upon completion of the investigation, Step By Step, Inc. will maintain copies of all incident reports in a binder located at Pringle Street ICF/ID.
Moving forward staff at the Day Program will complete an incident report and the supervisor will put it in the PUPS system. The Qualified Intellectual Disabilities Professional (QIDP) will review all incident reports monthly during staff meetings to ensure appropriate follow-up, documentation, and compliance with incident management procedures. Each Incident Management Meeting, Program will be added to the event and expected to be present through virtual or in person to discuss any incidents that occur at the Day Program.
Step By Step, Inc. is committed to ensuring the health, safety, and protection of all individuals served. Immediate action will be taken to address any incident to ensure the safety of the individuals involved. Going forward, Step By Step, Inc. will continue to conduct thorough investigations for all incidents that require investigation to identify contributing factors, implement corrective actions when necessary, and prevent recurrence. All Step By Step Inc. individuals service notes, along with all other individuals' documentation, are now completed and stored electronically within our PUPS Electronic Health Record online platform. Our EHR is fully secure and HIPPA compliant. This program not only enhances Step By Step Inc's services but also propels us into the future of care for individuals. In a rapidly evolving healthcare landscape, the adoption of electronic health records is pivotal to ensuring we provide the highest quality of care and support to our individuals. With the implementation of this state-of-the-art system, we are committed to streamlining processes, improving communication, and ultimately, making a significant impact on the lives of those we serve.
Also, Day Program staff who was with the individuals will get retraining on the behavior plans, incident management, ISP's and supervision levels, Preventing and De-escalating Crisis Situations. All these trainings will be completed by May 11, 2026. Debra McGlynn will be responsible for ensuring the trainings get completed. Amber Miller will ensure the investigation is completed by May 11, 2026.
483.440(f)(3)(i) STANDARD
PROGRAM MONITORING & CHANGE
Name - Component - 00
The committee should review, approve, and monitor individual programs designed to manage inappropriate behavior and other programs that, in the opinion of the committee, involve risks to client protection and rights.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure human rights committee (HRC) approval was received prior to the use of a restrictive intervention. This was noted for all six individuals at the facility (Individual #1, Individual #2, Individual #3, Individual #4, Individual #5, and Individual #6).
The findings included:
Facility walk-through and record review on March 24, 2026, revealed door alarms installed on outside doors and all personal toiletries and cleaning supplies in the facility are kept locked and are only accessible through staff due to safety concerns.
Further review revealed no current documentation that HRC approval was received prior to installing door alarms or locking the personal toiletries and cleaning supplies in the facility.Intellectual Disabilities Professional (QIDP) was interviewed on March 24, 2026, at approximately 2:00 PM. QIDP confirmed that there was no documented HRC approval prior to the implementation of these restrictive procedures.
Plan of Correction:Immediately upon identification of the concern on March 24, 2026, the facility removed all door alarms from outside doors on March 24,2026. The facility then contacted everyone's emergency contact and/or representative to notify them of the concern on March 24, 2026, explain the safety measures related to securing personal hygiene items and potentially hazardous substances, and obtain verbal consent for continued safety precautions, when applicable. An emergency Human Rights Committee meeting was convened on March 25, 2026, to review these measures, ensure they were necessary for health and safety, and to formally address the lack of prior written consent. During this meeting, documentation of the previously obtained verbal consent was presented, and written informed consent was obtained and signed by each individual representative. Each individual and/or representative was informed of the nature of the safety measures, associated risks and benefits, available alternatives, and the right to refuse. All signed consents and Human Rights Committee documentation have been placed in everyone's record. Moving forward, everyone's behavior plan will include a statement that poisonous, hazardous, and personal hygiene products are secured within the home to ensure the health and safety of the individuals. These measures will be reviewed for appropriateness and least restrictive alternatives, and informed consent will be obtained and documented prior to implementation. All behavior plans containing these safety measures will be submitted to the Human Rights Committee for review and approval at the May 13, 2026, meeting. Also, all staff will be retrained on Behavior Plans in the May 19,2026 staff meeting. Brittany Diehl will be responsible for all the Behavior plans and Human Rights approvals. Amber Miller will be responsible for the retraining of the client's rights.
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