Initial Comments:
A monitoring survey was conducted on February 11 and 12, 2026, to determine compliance with the requirements of 42 CFR Part 483, Subpart I Requirements for Intermediate Care Facilities. The census during the survey was eight. Two deficiencies were identified.
Plan of Correction:
483.430(e)(1) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
The facility must provide each employee with initial and continuing training that enables the employee to perform his or her duties effectively, efficiently, and competently.
Observations:
Based on staff interview and documentation review, the facility failed to provide each employee with initial and continuing training that enables the employee to perform his or her duties effectively, efficiently, and competently.
The findings included:
A. The surveyor requested training documentation, to include Universal Precautions training and tracheostomy care training. In addition, the surveyor requested documentation of monthly medication pass observations from July 2025 through present. Interview with the Health Services Coordinator (HSC) on February 11, 2026, at 3:30 PM revealed the facility was unable to provide documentation on Universal Precautions training, tracheostomy care training, and monthly medication pass observations from July 2025 to present. Further interview with the HSC revealed the facililty was unable to provide any documentation that staff training had been scheduled or completed regarding Universal Precautions for staff, tracheostomy care training and monthly medication pass observations for the facility Licensed Practical Nurses (LPNs).
B. Interview with Qualified Intellectual Disability Professional (QIDP) and HSC on February 12, 2026, at 9:00 AM confirmed that the facility did not have copies of documentation or completed staff training from July 2025 to present on Universal Precautions, tracheostomy care training or monthly medication pass observations.
Plan of Correction:Licensed Practical Nurses (LPNs) and Direct Support Professionals (DSPs) will be retrained by the Health Services Coordinator (HSC) in Universal Precautions by March 6, 2026. The HSC will also train the LPNs on the Tracheostomy Care Protocol by March 6, 2026. The HSC developed a monthly medication administration skills checklist for monitoring medication passes and tracheostomy care on February 12, 2026. The HSC will complete the initial monthly monitoring utilizing these skills checklists by March 6, 2026. The HSC will complete the skills checklists with each nurse on a monthly basis and send them to the Program Manager and Program Director for review upon completion. In addition, the HSC and Qualified Intellectual Disabilities Professional (QIDP), on an ongoing basis, will email copies of training sheets and skills checklists to the facility's Licensing and Compliance Specialist who will maintain our training records in the Learning Management System (Relias). On a monthly basis, the Program Director or designee will review Relias to ensure compliance with staff training. The Program Director will train the HSC and QIDP in this process by February 27, 2026.
483.430(e)(2) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
For employees who work with clients, training must focus on skills and competencies directed toward clients' health needs.
Observations:
Based on facility investigation report review, record review and staff interview, it was determined that the facility failed to ensure that staff demonstrated the necessary skills and competencies directed towards the health needs for one individual in the sample. (Individual #1)
The findings included:
A. Individual #1
1. A review of a facility investigation report revealed on August 27, 2025, at 4:00 PM upon arrival home from the day program via van transport Individual #1 was found by the facility receiving staff to be on the van floor tipped over in his wheelchair with the Q-straints still attached to the wheelchair. However, the Q-straints were not secured to the van floor. Individual #1's wheelchair had tipped and fallen over during the transport home. The staff person who had transported Individual #1 from the day program was unaware that Individual #1's had fallen over in his wheelchair. The wheelchair had detached from the van's floor locking mechanism causing it to fall sideways onto the van floor with the individual still seated, Individual #1 was subsequently sent to the emergency room for evaluation where they received treatment for small abrasions to the face and right arm. Individual #1 was then returned to the facility later that evening.
2. Facility investigation report review and staff interview with the Qualified Intellectual Disabilities Professional (QIDP) conducted on February 12, 2026, at 9:00 AM, revealed that the staff person responsible for transporting Individual #1 from day program had failed to secure the Q-straints to the floor rail of the facility van. This failure resulted in the wheelchair falling and tipping over while on transport home from the day program. The facility's investigation determined neglect regarding this incident. The target staff in question was terminated from facility employment because of the incident.
B. QIDP was interviewed on February 12, 2026, at 10:30 AM, and confirmed that the facility failed to ensure that staff demonstrated the necessary skills and competencies directed towards the health needs of one individual during a van transport.
Plan of Correction:The Qualified Intellectual Disabilities Professional (QIDP) or designee will provide Q-straints training to Direct Support Professionals (DSPs) and Licensed Practical Nurses (LPNs) by March 6, 2026. Q-straints training will also occur upon hire and annually thereafter in order to ensure the safe transportation of our individuals. The training will include utilizing the facility's Wheelchair and Rider Securement Procedures and Checklist. In addition to the initial and annual training, the QIDP or designee will complete the checklist with each DSP and LPN on a quarterly basis to ensure competency and safety. The completed training sheets and skills checklists will be emailed to the facility's Licensing and Compliance Specialist who will maintain our training records in the Learning Management System (Relias). On a monthly basis, the Program Director or designee will review Relias to ensure compliance with staff training. The Program Director will train the HSC and QIDP in this process by February 27, 2026.
|