Initial Comments:
A fundamental survey visit was completed on August 21 and 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 five and the sample consisted of three individuals.
Plan of Correction:
483.460(b)(1) STANDARD
PHYSICIAN PARTICIPATION IN THE IPP
Name - Component - 00
A physician must participate in the establishment of each newly admitted client's initial individual program plan as required by §456.380 of this chapter that specifies plan of care requirements for ICFs.
Observations:
Based on record review and interview with the facility nurse and the program director, the facility failed to ensure a physican participated in the establishment of each newly admitted client's initial individual program plan to specify plan of care requirements for ICFs for one of one sample individual who was a new admission to the facility. This practice is specific to Individual #3.
Findings include:
A review of Individual #3's record was completed on 08/22/2025 from approximately 10:15 AM to 11:00 AM. This review revealed that Individual #1 was admitted to the facility on 07/01/2025. On 07/24/2025, the team held Individual #3's 30 Day post admission Individual Program Plan (IPP) meeting.
Continued review of Individual #3's record revealed there was no evidence that this individual's PCP (primary care physician) completed an assessment of this individual's medical status at the time of admission nor up to and including the date of Individual #1's IPP in order for the team to incorporate any assessments or recommendations by the PCP into Individual #3's 30 Day IPP.
Interview with both the facility nurse and the program director on 08/22/2025 at approximately 10:50 AM, confirmed that that Individual #3 did not have a physical assessment/evaluation completed by her PCP upon admission nor up to and including the date of the 30 day IPP.
Plan of Correction:CE #1: No corrective action can be completed to address the deficiency. Individual #3 did not have physician participation upon admission or up to and including the date of the 30-day Individual Program Plan (IPP) meeting.
CE #2: None of the other ICF individuals were affected by the deficiency, therefore there is no corrective action.
CE #3: The Program Director (PD) will update the ICF Admission Checklist by 9/3/25 to include the need for physician participation in ALL admissions. The Program Director (PD) will retrain all Qualified Intellectual Disabilities Professionals (QIDPs) and Nursing Department on the requirement for physician participation in ALL admissions by 9/30/25. Documentation will be the updated ICF Admission Checklist and the Requirement for physician participation sign off sheet.
CE # 4: The Residential Director (RD) will ensure the proper updates were made to the ICF Admission Checklist by 9/5/25 and will ensure all re-training on the requirement for physician participation was completed by 10/5/25. Documentation will be the Updated Admission checklist and the Requirement for physician participation sign off sheet.
CE #5. The Program Director (PD) will oversee the admission process for all ICF individuals and ensure a physical is scheduled the day of the Transitional Individual Program Plan (TIPP) meeting or by the 30-day Individual Program Plan (IPP) meeting. The Residential Director will confirm the completion of the physical date via the completed Physical examination document within 5 business days of the completed physical. Documentation will be the completed physical form.
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