Initial Comments:
A focused fundamental survey visit was completed on July 22 through 24, 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 39, and the sample consisted of
seven individuals.
Plan of Correction:
483.410(a)(1) STANDARD
GOVERNING BODY
Name - Component - 00
The governing body must exercise general policy, budget, and operating direction over the facility.
Observations:
Based on record review and interview with the acting qualified intellectual disabilities professionals (QIDP)/administrative staff, the governing body failed to exercise general operating direction over the facility to provider clients with active treatment as outlined through facility policy and procedure for two of four sample Individuals.
This practice is specific to Individual #3 and #4.
Findings include:
A review of the records for Individuals #3 and #4 was completed on 07/24/2025 from approximately 8:45 AM to 11:30 AM. These records contained a form titled
Residential Progress Monthly Report. This document is utilized by the Qualified Intellectual Disabilities Professional (QIDP) to assess data collection and relative performance of the individual in achieving the identified objectives associated with each training plan in the current Individual Program Plan (IPP). In interview with the Assistant Director of Residential Services on 07/24/2025 at approximatley 10: 30 AM, this interviewee noted that it is the facility practice for the interviewee to review these monthly reports upon completion by the QIDP for completion and accuracy. If any problems or issues are identified during that review, the reviewer will alert the QIDP regarding the missing components, and complete follow-up to ensure that the changes have been addressed.
In a review of these monthly reports for the above Individuals for the first calendar quarter of 2025, it was noted that for both of the listed Individuals, all reviews during that time period did not include a complete review of all training plans in place for said Individuals as outlined in their current IPP. Although administrative review had occurred in these instances, there was no evidence that follow-up had occurred to ensure that that the changes were implemented.
Examples of this practice are as follows
Individual # 3
A review of Individual #3's Residential Progress Monthly Reports for the months of 01/2025, 02/2025 and 03/2025, revealed the monthly reviews for each of Individual #3's training programs did not include all training plans for Individual #3 as follows:
-01/2025
Individual #3 was working on three training plans. A review of the data collection revealed these training programs were being implemented and data was being collected on three training programs: Self-Medication, Communication and Applying Lotion. However, a review of Individual #3's Residential Progress Monthly Reports, completed by the QIDP, revealed that the QIDP failed to monitor Individual #3's progress on one of the three training programs, (Applying Lotion) in the Residential Progress Monthly Report.
An oversight review of this report completed by the Assistant Director, that was undated,
identified on this document that the applying lotion training plan had not been monitored and needed to be added to this report. Continued review of this document revealed that although the missing documentation/assessment of the toothbrushing training plan data was noted, no further action was taken by the Assistant Director to ensure that the identified monitoring/assessment of the Applying lotion training plan had been completed.
-02/2025
Individual #3 was working on five training plans. A review of the data collection revealed these training programs were being implemented and data was being collected on four training programs: Self-Medication, Communication, Showering, Applying Lotion and Wiping Face. However, a review of Individual #3's Residential Progress Monthly Reports revealed that the QIDP failed to monitor Individual #3's progress on three of the five training programs, (Showering, Applying Lotion and Wiping Face) in the Residential Progress Monthly Report.
An oversight review of this report completed by the Assistant Director, no date listed, identified that the applying lotion training plan had not been monitored and needed to be added to this monthly report. Although the missing assessment of the toothbrushing training plan data was noted by the Assistant Director, no further action was taken by the
Director to ensure that the identified missing review was completed by the QIDP.
.-3/2025
Individual #3 was working on five training plans. A review of the data collection revealed these training programs were being implemented and data was being collected on four training programs: Self-Medication, Communication, Showering, Applying Lotion and Wiping Face. However, a review of Individual #3's Residential Progress Monthly Reports, completed by the QIDP, revealed that the QIDP failed to monitor Individual #3's progress on three of the five training programs, (Showering, Applying Lotion and Wiping Face) in the Residential Progress Monthly Report.
An oversight review of this report by the Assistant Director, no date listed, identified on this document that the applying lotion training plan had not been monitored and needed to be added to this report. Continued review of this document revealed that although the missing documentation/assessment of the toothbrushing training plan data was noted, no further action was taken by the Assistant Director to ensure that the identified monitoring/assessment of the Showering, Applying Lotion and Wiping Face training plan had been completed.
Individual #4:
A review of Individual #4's Residential Progress Monthly Reports for the months of 01/2025, 02/2025 and 03/2025, revealed the monthly reviews for each of Individual#4's training programs did not include all three training programs for Individual #4 as follows:
-01/2025
Individual #4 was working on three training programs. A review of the data collection revealed these training programs were being implemented and data was being collected on three training programs: Toothbrushing, Self-Feeding and Communication -Making Choices.
However, a review Individual #4's Residential Progress Monthly Reports, completed by the Qualified Intellectual Disabilities Professional (QIDP) revealed that the QIDP failed to monitor Individual #4's progress on one of the three training programs, (Toothbrushing) in the Residential Progress Monthly Reports.
An oversight review of this report by the Assistant Director, no date listed, on this document, identified that the toothbrushing training plan data had not been monitored and needed to be added to this report. Continued review of this document revealed that although the missing documentation/assessment of the toothbrushing training plan was noted, no further action was taken by the Assistant Director to ensure that the identified monitoring/assessment of the toothbrushing training plan had been completed.
-02/2025
Individual #4 was working on four training programs. A review of the data collection revealed these training programs were being implemented and data was being collected on four training programs: Toothbrushing, Self-Feeding, Wiping Face and Communication -Making Choices. However, a review Individual #4's Residential Progress Monthly Reports, completed by the Qualified Intellectual Disabilities Professional (QIDP) revealed that the QIDP failed to monitor Individual #4's progress on three of the four training programs, (Toothbrushing, Self-feeding and Wiping Face) in the Residential Progress Monthly Reports.
An oversight review of this monthly report by the Assistant Director, no date listed on this document, identified on this document that the Toothbrushing, Self-feeding and Wiping Face training plan data had not been monitored and needed to be added to this report. Continued review of this document revealed that although the missing documentation/assessment of the Toothbrushing, Self-feeding and Wiping Face training plans was noted, no further action was taken by the Assistant Director to ensure that the identified monitoring/assessments of the Toothbrushing, Self-feeding and Wiping Face training plans had been completed.
-03/2025
Individual #4 was working on four training programs. A review of the data collection revealed these training programs were being implemented and data was being collected on four training programs: Toothbrushing, Self-Feeding, Wiping Face and Communication -Making Choices. However, a review Individual #4's Residential Progress Monthly Reports, completed by the Qualified Intellectual Disabilities Professional (QIDP) revealed that the QIDP failed to monitor Individual #4's progress on three of the four training programs, (Toothbrushing, Self-feeding and Wiping Face) in the Residential Progress Monthly Reports.
An oversight review of this monthly report by the Assistant Director, no date listed on this document, identified on this document that the Toothbrushing, Self-feeding and Wiping Face training plan data had not been monitored and needed to be added to this report. Continued review of this document revealed that although the missing documentation/assessment of the Toothbrushing, Self-feeding and Wiping Face training plans was noted by the Assistant Director, no further action was taken to ensure that the identified monitoring/assessments of the Toothbrushing, Self-feeding and Wiping Face training plans had been completed.
Interview with the Assistant Director of adult Community Residential programs and the Director of Clinical Services on 07/24/2025 at approximately 11:30 AM confirmed that the above issues which had been identified by the Assistant Director who completed the review of the monthly, were not reviewed as follow-up in order to ensure that identified issues were addressed by the QIDP.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The Assistant Director of the facility reviewed all previously noted recommendations from completed monthly compliance audits for individual #3 and # 4 training plans. All noted missing components in the individual training plan from the audits will be updated by 08/08/2025.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
The Director of Adult Clinical Services will complete a review of the completed monthly compliance audit forms for all individuals in the facility from the period of May 2025 to July 2025 by 08/29/25. During this review, the Director of Adult Clinical Services will evaluate whether the recommendations and any missing components in the individual training plans from the audit notes have been addressed. Any recommendations found not to have been addressed will be corrected by the Qualified Intellectual Disability Professional (QIDP) within 2 weeks of identification.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The facility's process for post monthly compliance audits and audit recommendations has been updated.
The Qualified Intellectual Disability Professional (QIDP) will update all recommendations or corrections noted from the monthly compliance audit completed by the Assistant Director of the Facility within 1 week of receiving the completed audit form. The monthly compliance audit form captures goal objective components, both short and long-term projected outcome dates, objective criteria for success and other components in an individual training plan. The Audit forms will be completed by the 15th of every month by the Assistant Director
The QIDP will then resubmit the updated training plan with the noted recommendations completed, and attach a copy of the audit form. This will be submitted to the Assistant Director for a second review within 5 days of receiving the documents. The assistant director will verify that all changes have been made, and will document their final review on the audit form.
The Director of Adult Clinical Services will review the final audit form and confirm all changes have been made as recommended from the audits completed by the QIDP and reviewed by the Assistant Director of the Facility. This review by the Director of Adult Clinical Services will be completed by the end of every month and documented in the audit form under Director review section.
Any patterns of incomplete follow up from completed compliance audits will be addressed via Melmark's progressive corrective action policy which includes retraining, documented counseling feedback, coaching feedback, verbal written feedback and may include termination of employment.
The Director of the Facility will train the Director of Adult Clinical Services, the Assistant Director and the QIDP of the facility on the above noted audit process by 08/08/2025. Additionally, the Senior Director of the Facility will train the Director of the Adult Clinical Services on Melmark's Progressive Feedback Policy to be implemented when tasks are not completed as per trained expectations. This will include retraining, documented counseling feedback, coaching feedback, verbal and written feedback up to separation of employment. This training will be completed by 08/15/2025 and will be documented on a Melmark training log.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
A monthly compliance tracking grid has been developed to document monthly audit outcomes and corrections completion dates for each individual in the facility. The monthly compliance tracking grid captures the instructions for completion of the monthly audit, goal review section and submission dates.
The monthly compliance grid will be updated by the Assistant Director of the facility upon satisfactory completion of each individual's monthly review and associated audit corrections completed by the QIDP of the facility by the 20th of the following month.
The Director of Adult Clinical Services will review the grid by the 30th of the following month and follow up with the QIDP if there are any concerns identified or still pending from the review.
Any patterns of incomplete follow up from completed compliance audits will be addressed via Melmark's progressive corrective action policy which includes retraining, documented counseling feedback, coaching feedback, verbal and written feedback and may include termination of employment.
The Director of the Facility will train the Director of Adult Clinical Services, the Assistant Director and the QIDP of the facility on the monthly audit and compliance tracking grid by 08/08/2025.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective action being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Senior Director of the Facility to review on going status of correction action completion.
This process will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
483.420(a)(11) STANDARD
PROTECTION OF CLIENTS RIGHTS
Name - Component - 00
The facility must ensure the rights of all clients. Therefore, the facility must ensure that clients have the opportunity to participate in social, religious, and community group activities.
Observations:
Based on a review of facility documentation and interview with facility and administrative staff, the facility failed to ensure the rights of all clients through provision of opportunity to participate in social, religious and community group outings for two of four sample individuals. This practice is specific to Individuals #1 and #2
Findings included:
A review of the records of Individual #1 and #2 was completed on 07/24/2025 between 09:30 AM and 11:30 AM. This review revealed the following information regarding the frequency of outings completed for these Individuals:
Individual #1
A review of community outings for this Individual revealed that during the time period from 07/01/2024 until 7/23/2025, this Individual completed on (1) community outing on 03/29/2025 to Great Clips/Rosetree Park. There were no other community outings documented in the record.
Individual #2
A review of community outings for this Individual revealed that during the time period from 07/01/2024 until 7/23/2025, this Individual completed three (3) community outings on the following dates:
03/192025- Drexel Lodge Park.
04/14/2025- Rosetree Park.
05/12/2025- Rosetree Park
There were no other community outings documented in her record.
Interview with the Director of Adult Campus Residential Programs on 07/24/2025 at approximately 11:45 AM confirmed that the Individuals have limited opportunities to participate in community outings and the community outings are not varied in the types of activities in the community. When questioned regarding facility policy/procedure concerning the provison of community outings to Individuals who reside at this location, this interviewee stated that the Agency does not have policy on either the provision or frequency of
community outings to promote participation in social, religious, and community group activities.
This interviewee was unable to indicate why the above Individuals were provided with one to three community outings over a 12 month period.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The QIDP and House Supervisor will evaluate individual #1 and individual #2's strengths, needs, and preferences to identify a list of appropriate outing locations. This evaluation will be completed by 08/15/2025. Based on the evaluation, the House Supervisor will ensure individual # 1 and individual #2 are scheduled to participate in a community-based outing a minimum of twice monthly.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
The Assistant Director of the Facility will review community-based outing documentation for other individuals to identify other individuals having the potential to be affected by the same deficient practice. This review will be completed by 08/15/2025 and will be documented on a Clinical Case Note. For each individual affected by the deficient practice the QIDP and House Supervisor will evaluate the individual's strengths, needs, and preferences to identify a list of appropriate outing locations. Based on the evaluation, the House Supervisor will then create a schedule of outings and ensure the individuals affected by the deficient practice participate in a community-based outing a minimum of twice monthly.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The facility's process for supporting community-based outings has been updated. The House Supervisor will submit a weekly activity list to the Assistant Director of the Facility in advance of the scheduled activities.
At the end of each week, the House Supervisor will use a copy of the same activity list to document and confirm that individuals participated in the activities as planned and submit the confirmation documentation to the Assistant Director of the Facility.
If upon review it is noted by the Assistant Director that community-based outings are not occurring at the expected frequency, a Team meeting will occur within one week of discovery to discuss and develop an action plan for correction.
The Director of the Facility will train the Assistant Director, the QIDP and the House Supervisor of the Facility on this updated process by 08/15/2025.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
The Assistant Director of the Program will complete a monthly review of all community-based outings and appropriate documentation of these outings by the 15th of the following month. This review will be documented on a Community Outing Report audit from.
If upon review, it is noted that outings are not being completed at minimum twice a month and documentation is not being completed as trained, retraining will be initiated within a week of discovery.
If continued failure to support community- based outing and documentation is noted, Melmark progressive corrective action policy will be followed. This practice will go into effect 08/2025.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective action being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Senior Director of the Facility to review on going status of correction action completion.
This process will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
483.470(i)(2)(iv) STANDARD
EVACUATION DRILLS
Name - Component - 00
The facility must investigate all problems with evacuation drills, including accidents.
Observations:
Based on record review and interview with administrative staff, the facility failed to investigate all problems with evacuation drills. This practice is specific to Melissa A & B building.
Findings include:
A review of the facility's evacuation drills for the period from 07/2024 through 06/2025 was completed on 07/22/2025 from approximately 10:15 AM to 10:45 AM. This review indicated that on three of the 12 evacuation drills reviewed for each residence building, residence building A and residence building B, evacuees exited through an area near or directly outside the designated fire area when a closer exit was available. This practice occurred on one out of 12 drills in Building A and three out of 12 drills in Building B as noted below:
Building A:
-10/11/2024 on Shift 3 defined as 11 PM - 7:00 AM
Building B:
-08/14/2024 on Shift 2 defined as 3 PM to 11 PM
-10/11/2024 on Shift 3, defined as 11 PM - 7 AM
-05/07/2025 on Shift 2 defined as 3 PM to 11 PM
An example of this practice of exiting through an area near or directly outside the fire area in each building is as follows:
Building A:
A review of an evacuation dated 10/11/2024 at 12:00 AM revealed all eight individuals were in their bedrooms when the fire alarm sounded. The fire location was identified as the front living room. All eight individuals exited from their bedrooms into the hallway, through the entrance to the front living room, which placed them in proximity to the designated fire, then turning right down the hallway to the kitchen, exiting through the kitchen doors to the outside.
Building B:
A review of an evacuation dated 10/11/2025 at 12:00 AM revealed all eight individuals were in their bedrooms when the fire alarm sounded. The fire location was identified as the front living room. All eight individuals were noted to have exited through the front living room, which placed them in proximity to the designated fire, then turning right down the hallway to the kitchen, exiting through the kitchen doors to the outside.
Observation of the area outside of the bedroms on 07/22/2025 at approximately 7:45 AM
noted that there was a seperate exit area in the rear family room when exiting out of the bedroom doors thorugh a set of exterior double doors in a rear family room which would have been closer and away from the location of the fire.
Interview with the Assistant Director on 07/22/2025 at approximately 10:30 AM,
revealed that both the Administrative Assistant and the Assistant Director each review the evacuation reports monthly prior to finalization of the report. This interviewee confirmed that despite the avaliability of alternate exits for evacuation that were not located near the designated fire, neither reviewer identified the evacuation drills in which Individuals exited the building from either near the designated fire area or through the designated fire area.
.
Plan of Correction:1. How corrective actions will be accomplished for those individuals identified in deficiency statements:
The Director of the Facility will review facility floor maps and ensure all exits are clearly identified for use during fire drill evacuations. This review will include applicable exits for individual # 1, #2, #3, and # 4.
2. How the facility will identify other individuals having the potential to be affected by the same deficient practice:
The Assistant Director of the Facility will review all facility floor maps and ensure all exits are clearly identified for use during fire drill evacuations. This review will include applicable exits for all other individuals with a potential to be affected by this deficient practice.
3. What corrective measures or systematic changes will be put into place to ensure that the deficient practice will not recur:
The Director of the Facility will review the facility floor map. This review will include training to the facility's staff, house supervisors, Assistant Directors on the expectation for all individuals and staff to exit the building via the closest safe exit to the individual during all fire drills. This training will be will be completed by 08/22/2025 and documented on a Melmark Training Log.
The House Supervisor or Shift Supervisor of the Facility will conduct observations of evacuation drills each month and document their observation in the "comments" section of the fire drill form. If observation reveals that evacuation from the building during the fire drill was not through the closest safe exit, staff will receive additional training on proper fire drill evacuation procedures and the fire drill will be repeated before the last day of the specific month. This additional training will be documented on a Melmark Training log. Continued failure to implement fire drill evacuation procedures as trained will result in progressive corrective action and may include termination of employment.
4. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur:
The Assistant Director of the Facility will review completed fire drill no later than the 20th of each month. The Assistant Director of the facility will sign off on the forms to verify this review. If upon review, errors in evacuation procedures are noted, the Assistant Director will provide additional training to the House Supervisor regarding proper evacuation procedures and the drill will be repeated before the last day of the specific month. This additional training will be documented on a Training log. Continued failure to implement fire drill evacuation procedures as trained will result in progressive corrective action.
5. Identify by position, who will be responsible for monitoring the corrective action:
The Director of the Facility is responsible for the oversight of all corrective action being completed in the appropriate time line as outlined in the plan of correction. This will be accomplished through monthly meetings with the Senior Director of the Facility to review on going status of correction action completion.
This process will be documented in a Monthly Director Supervision Meeting form. If any responsible party fails to complete an assigned task, disciplinary action policy will be followed.
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