Initial Comments:
A focused fundamental survey visit was completed on November 19 and 20, 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:
483.440(f)(2) STANDARD
PROGRAM MONITORING & CHANGE
Name - Component - 00
At least annually, the comprehensive functional assessment of each client must be reviewed by the interdisciplinary team for relevancy and updated as needed.
Observations:
Based on record review and interview with the administrative staff, the interdisciplinary team failed to at least annually, complete the comprehensive functional assessment of each client for relevancy and update as needed for one of three sample individuals. This practice is specific to Individual #2.
Findings included:
1. A review of the record for Individual #2 was completed on 11/20/2025, between
9:30 AM until 11:00 PM. This review revealed a Individual Program Plan (IPP), dated 11/14/2025. In further review, there was no evidence that a comprehensive functional assessment (CFA) was completed/reviewed for Individual #2, since 12/09/24.
In interview with the Director of ICF/qualified intellectual disabilities professional (QIDP) on 11/20/2025, at 9:26 AM, this interviewee confirmed that the CFA has not been completed.
Plan of Correction:CE #1: The ICF House Manager (HM) was immediately retrained on 11/20/25 by the ICF Program Director (PD) on the requirement that each individual is required to have a Comprehensive Functional Assessment completed prior to the scheduled annual Individual Program Plan meeting (IPP). The ICF House Manager (HM) completed the Comprehensive Functional Assessment for Individual #2 by the end of the business day on 11/20/25. Documentation was the completed Comprehensive Functional Assessment Requirement for Individual #2 dated 11/20/25.
CE #2: By 1/30/26, the ICF/qualified intellectual disabilities professional (QIDP) and the ICF Program Director (PD) will review the previous comprehensive functional assessment for the other four individuals residing in the home. If any comprehensive functional assessment is found to not have been completed prior to the date of the Individual Program Plan (IPP) a team meeting will be held, and an ID note will be written. Documentation will be the written ID note.
CE #3: The ICF Program Director (PD) will retrain the ICF/qualified intellectual disabilities professional (QIDP) on the requirement that each individual is required to have a Comprehensive Functional Assessment completed prior to the scheduled annual Individual Program Plan meeting by 1/30/26. The ICF/qualified intellectual disabilities professional (QIDP) will retrain the ICF House Managers (HM) on the requirement that each individual is required to have a Comprehensive Functional Assessment completed prior to the scheduled annual Individual Program Plan meeting by 2/27/26. Documentation will the Comprehensive Functional Assessment Requirement Training sign-in sheet.
CE #4. The ICF/qualified intellectual disabilities professional (QIDP) and ICF Program Director (PD) will create a chart for the next year to determine when the next Individual Program Plan meeting (IPP) occurs for each individual and the date each Comprehensive Functional assessment needs to be completed and turned into the ICF/qualified intellectual disabilities professional (QIDP). The ICF/qualified intellectual disabilities professional (QIDP) will review each Comprehensive Functional assessment for completion prior to each Individuals Program Plan meeting (IPP). Documentation will be the IPP/Assessment chart.
CE # 5: All documentation will be kept in the ICF Program Directors (PD) office in a Plan of correction binder. Once a quarter the Residential Director (RD) will meet with the ICF Program Director (PD) to review any IPP's and assessments that occurred. If at any time it is determined by the Residential Director (RD) that the Plan of Correction is not being followed performance management steps will be taken. Documentation will be the performance management step.
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