Initial Comments:
A focused fundamental survey was conducted July 29-30, 2025, 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 four and the sample consisted of two individuals.
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 interview, it was determined that the facility failed to ensure that restrictive interventions were implemented only with the informed written consent of the guardian. This applied to one (#1) of two individuals in the sample. Findings included:
A record review was completed for Individual #1 on July 30, 2025. This review revealed a behavior management plan (BMP), dated May 1, 2025, which incorporated the use of the medications prozac and seroquel. This review failed to reveal that informed written consent was obtained from the guardian for Individual #1's BMP.
An interview was conducted with the qualified intellectual disabilities professional (QIDP) on July 30, 2025, at 1:53 PM. At this time, the QIDP confirmed that there was no documentation that written informed consent was obtained from Individual #1's guardian for the use of prozac and seroquel as part of the BMP.
Plan of Correction:0124 McGuire Memorial will ensure the rights of all clients. McGuire will inform each client, parent, or legal guardian, of the client's medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment.
Written Informed consent for individual #1 was mailed to and obtained from the guardian for the Behavior Management Plan (BMP) dated 5/2/2025 on 7/30/2025. The written consent was review by the Human Right Committee at the bimonthly meeting Monday August 4, 2025
Going forward, McGuire Memorial will ensure that all BMPs are implemented only after the Licensed Behavior Specialist has verified the presence of written informed consent from the guardian.
All professional staff that is responsible for obtaining consent from guardians in the community home program including the behavior specialist for individual #1 will undergo retraining on the current Policy and Procedure for Informed Consent. Documentation of all training of these professional staff will be maintained. The Director of the community home program will conduct the retraining. The retraining will be completed on or before September 25, 2025.
As a part of the systematic correction process for the facility, the following occurred or will occur as noted:
- The other individuals in the home had updated written informed consent obtained from their legal guardians on 7/30/2025. All of those consents were reviewed at the Human Rights Committee on 8/4/2025.
- A written check sheet documenting all procedural steps necessary for informed consent with dates will be created by the Licensed Behavior Specialist. The Licensed Behavior Specialist will be responsible for the completion of the check sheet. This check list will be created and implemented by September 25, 2025 for all informed consent required in the home going forward.
- The QIDP will be responsible to on a quarterly basis to verify through review of the check sheet and written documentation, that any written informed consents needed during the quarter were completed fully.
- Any completed informed consents for will be reviewed monthly over the next four months by the Director of Community Homes beginning October 1, 2025 to confirm proper informed consent is present.
483.420(a)(4) STANDARD
PROTECTION OF CLIENTS RIGHTS
Name - Component - 00
The facility must ensure the rights of all clients. Therefore, the facility must allow individual clients to manage their financial affairs and teach them to do so to the extent of their capabilities.
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that all individuals are provided training in financial self-management. This applied to one (#1) of two individuals in the sample. Findings included:
A record review was completed for Individual #1 on July 30, 2025. This review revealed goal plans in the areas of community outings, medication administration, and personal hygiene. This review failed to reveal a goal plan to provide Individual #1 the opportunity for training in financial self-management.
An interview was conducted with the qualified intellectual disabilities professional (QIDP) on July 30, 2025, at 11:45 AM. At this time, the QIDP confirmed that Individual #1 did not have an active goal in the area of financial self-management.
Plan of Correction:McGuire Memorial will ensure the rights of all clients. Therefore McGuire Memorial will allow individual clients to manage their financial affairs and teach them to do so to the extent of their capabilities.
The QIDP update the functional comprehensive assessment regarding individual # 1 in the area of her financial skills. The assessment of her current financial skills will be completed on or before 8/30/2025. Based on the outcome of the assessment the QIDP will develop and implement a functional financial goal regarding management of her money. The QIDP will be responsible to train all staff on the implementation of the financial goal. Once the QIDP has all training implemented, the plan will be implemented no later than September 15, 2025. The QIDP will be trained by the Director of the Community Homes on the need for each individual in the facility to have a financial management goal in place. The Director and/ or Assistant Director of Community Homes will conduct an audit of the training for the staff and for the implementation of the plan on or before September 30, 2025. The audits of the goal implementation will continue once a month for 6 months.
The Director of the Community Homes will conduct an audit for all the other individuals' records to ensure that financial management goals are in place. Any individual who does not have a current active financial goal plan will have an assessment of financial skills, and a financial goal will be developed for that individual within 30 days of the assessment.
Moving forward, starting October 1, 2025, the Director and/ or Assistant Director of Community Homes will conduct audits monthly for the next 6 months to ensure the existence and implementation of active residential goals with training in the area of financial self-management for all residents of the facility
The QIDP will as part of the annual review for each individual will complete an updated review of financial management skills. The QIDP will review the active financial management goal in place for appropriateness and update the goal as needed
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 interview, it was determined that the facility failed to ensure that all individuals were provided training in personal skills. This applied to one (#2) of two individuals in the sample. Findings included:
A record review was completed for Individual #2 on July 30, 2025. This review revealed Individual #2 had goal plans in the areas of community outings, financial self-management and self administration of medication training. This record review failed to reveal an active goal plan to provide Individual #2 training in the area of personal skills.
An interview was conducted with the qualified intellectual disabilities professional (QIDP) on July 30, 2025, at 11:30 AM. The QIDP confirmed that Individual #2 did not have an active goal in the area of personal skills.
Plan of Correction: McGuire Memorial will ensure that each resident's program plan includes, 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. These plans will be in place until it has been demonstrated that the individual is developmentally incapable of acquiring them.
To rectify the deficiency for individual #2, the QIDP of the facility will create and implement a program goal in personal skills for individual #2 on or before August 30, 2025. The QIDP will be responsible to provide training to all staff in the facility on the new goal plan for individual #2 by September 30, 2025. Starting October 1, 2025, the goal will be reviewed monthly by the QIDP for the following 3 consecutive months for ongoing appropriateness and progress.
The Director of the Community home will conduct training for the QIDP in the area of program planning regarding the expectation individuals have goals in place in the area of personal skills. Additionally, to ensure that each resident has program goals in personal skills, the Director of the Community Homes will conduct a chart audit and review the program goals for each individual in the facility to ensure an active personal skill goal is in place on or before September 15, 2025. Any individual who is found to be lacking an active goal in personal skill development, the QIDP will be responsible to create and implement personal skill goals. This will be completed on or before September 30, 2025. Any additional staff training will begin no later than October 1, 2025.
Going forward, the Director and/ or Assistant Director of Community Homes will conduct a quarterly audit for the next six months to ensure that QIDP has reviewed the active goals and is addressing concerns that arise on training in personal skills essential for privacy and independence for all residents of the facility. The audits will also be conducted to ensure that the training is being implemented by all residents of the program at least twice weekly. These audits will begin on October 1, 2025 occur twice monthly for 6 months and then monthly thereafter for the 6 months following.
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 reviews and interview, it was determined that the facility failed to ensure all programs designed to protect the individuals' rights were approved by the human rights committee (HRC). This applied to two (#1 & #2) of two individuals in the sample. Findings included:
Record reviews for Individuals #1 and #2 were completed on July 30, 2025. These reviews revealed annual routine informed consents and program notification requests forms for both individuals which included the use of video surveillance and the use of bed modifications. These reviews failed to reveal that the human rights committee reviewed and approved the use of video surveillance and the use of bed modifications for Individuals #1 and #2.
An interview was conducted with the vice president of quality management systems (VPQMS) on July 30, 2025, at 1:50 PM. The VPQMS confirmed that the HRC consents for the use of video surveillance and bed modifications for Individuals #1 and #2 were not available for review and could not be located.
Plan of Correction:McGuire Memorial will ensure that all annual routine informed consents and program notification request forms for individuals, which include any type of restrictive procedures such as video surveillance and bed modifications, are reviewed and approved by the Human Rights Committee (HRC).
The annual routine informed consents and program notification request forms for all residents of the facility, which included the use of video surveillance and bed modifications, were reviewed and approved by the HRC on August 4, 2025. The Licensed Behavior Specialist of the community home program will complete training with the QIDP of the facility on the proper criteria for Human Rights approvals for any individual with a restrictive intervention.This is to ensure such interventions are only implemented after the HRC verifies the written informed consent of the individual's guardian. This training will take place no later than September 15, 2025.
To prevent this issue from reoccurring, the QIDP will continue reviewing all restrictive procedures to ensure HRC approval has been obtained and is properly documented before the implementation of any restrictive procedure. The Director of Community Homes will conduct a retrospective review to verify that the HRC has provided written approval of these restrictive procedures. Any missing HRC verification will be obtained immediately upon discovery. These reviews will occur at least once every six months beginning October 15th and will be ongoing for one year.
483.460(l)(1) STANDARD
DRUG STORAGE AND RECORDKEEPING
Name - Component - 00
The facility must store drugs under proper conditions of security.
Observations:
Based on observations and interviews, it was determined that the facility failed to ensure that all medications were locked at all times. This applied to all individuals living at the residence. Findings included:
Observations of part of the morning medication pass were completed on July 29, 2025, from 6:05 AM to 6:48 AM. At 6:30 AM, staff started preparing Individual #2's medications. During the pour, staff dropped a capsule of omeprazole onto the floor and then stated that they would have to discard it, leaving it on the counter. At 6:43 AM, staff gathered the medications to be administered and walked to the living room to administer Individual #2's medications, leaving the pill that would be discarded on the counter. After observing staff administer Individual #2's medications and then return to the kitchen, the surveyor questioned staff regarding the policy for securing medications. The staff stated that this extra pill would be put it in a bag and left for the nurse to dispose. The surveyor asked where it should be kept until that time, the staff replied that it should be locked in the medicine cabinet.
Interview was completed with the director of medical services (DMS) on July 29, 2025, at 11:13 AM. The DMS confirmed that the capsule should have been secured prior to the staff leaving the area. The DMS further confirmed that facility policy is that medications should be secured at all times when not administering them.
Plan of Correction:McGuire Memorial will ensure that all medications are stored safely and securely at all times, in the interest of the residents' health.
The staff who did not secure the medication will be retrained by the RN of the facility on the proper procedure for handling spilled medication. This procedure states the following:
Staff are to call the on-call nurse any time a medication is refused by a resident, dropped or spilled. The staff are to inform the nurse of the name of the individual; the name and dose of the medication; if the medication was dropped, spilled, or refused; and if the medication in question was a controlled drug. The nurse on-call will instruct the staff to place the medication in a med cup, tape it shut, label it to be discarded, and place the medication in a locked medication cabinet until the medication can be retrieved by the nurses. If the medication is a controlled medication, then the medication in the taped shut med cup will be stored in the lock box inside the locked med cabinet until it can be retrieved by the nurses. This training will be completed by the RN of the facility by September 1, 2025.
To ensure that all staff are familiar with this procedure, all staff of the facility will receive training or re-training on the procedure by October 1, 2025. The Director of Health Services will review the records of this training by October 15, 2025.
Medication Administration Observations will be conducted by a Nurse or a Certified Medication Practicum Observer 1 time per week for 6 weeks; then 1 time per month for the following 90 days; then quarterly until 1 year has been reached. Any infractions will be addressed immediately and accordingly. If an infraction is not witnessed during the observation, the observer will ask staff what they would do in the event of a spilled dose to ensure they can verify knowledge and understanding of the procedure and securing of medications appropriately. The observer will document the observation.
The Director of Health Services will review all observation documentation as they are completed concluding August 15th, 2026.
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