Initial Comments:
A focused fundamental survey was conducted June 2-4, 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 52 and the sample consisted of six 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 reviews and interviews, it was determined that the facility failed to ensure that individuals were provided training in the area of personal skills. This applied to two (#3 and #6) of six individuals in the sample. Findings included:
1. Record review for Individual #3 was completed on June 3, 2026. This review revealed current training programs for Individual #3 in the areas of medication administration, speech language development, social development, and activities of daily living - coin recognition. This review also revealed a comprehensive functional assessment, dated January 9, 2026, which identified that Individual #3 had needs in the area of personal skills including: bathing, dressing, mealtime, toothbrushing, and toileting. This review failed to reveal a training program for Individual #3 in the area of personal skills.
An interview was conducted with the qualified intellectual disabilities professional (QIDP) on June 4, 2026, at 10:22 AM. The QIDP confirmed that Individual #3 had identified needs in the area of personal skills and further confirmed that Individual #3 did not have a training program in the area of personal skills.
2. A record review for Individual #6 was completed on June 4, 2026. This review revealed current training programs for Individual #6 in the areas of medication administration, speech language development, social development, activities of daily living - coin recognition and activities of daily living - puling blanket down on bed. Further review revealed a functional assessment for Individual #6, dated July 22, 2025. This assessment revealed that Individual #6 had identified needs in the area of personal skills which included: mealtime, dressing/undressing, tooth brushing, and grooming. This review failed to reveal a training program for Individual #6 in the area of personal skills.
An interview was conducted with the QIDP and director of intermediate care facilities on June 4, 2026, at 10:40 AM. The QIDP confirmed that Individual #6 does not have a personal skill goal related to identified personal skill needs in Individual #6's assessment.
Plan of Correction:The facility will ensure that a personal care training plan is developed and implemented for any individual who demonstrates a need for personal care skill development, including Individual #3, Individual #6, and all other individuals supported by the agency, unless the Functional Assessment demonstrates that the individual is developmentally incapable of acquiring the skill.
On June 10, 2026, the Director of Residential Services provided training to all Qualified Intellectual Disability Professionals (QIDPs) regarding the development and implementation of personal care training plans based on needs identified through the Functional Assessment process.
For Individual #3 and Individual #6, personal care training plans will be developed and implemented by June 16, 2026, based on the needs identified in their most recent Functional Assessments.
To ensure ongoing compliance, each QIDP will review the individuals on their caseload during the next quarterly progress review to verify that a personal care training plan is in place based on the needs that have been identified in the most recent Functional Assessment. If no training plan is present, one will be developed and implemented unless the Functional Assessment documents that the individual is developmentally incapable of acquiring the skill.
The Director of Residential Services will monitor compliance through random audit checks to ensure that personal care training plans are consistently developed and implemented when indicated by the Functional Assessment. The Director of Residential Services will audit 10% of the charts once a month for six months.
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