Initial Comments:
A focused fundamental recertification survey was conducted on April 14 and 15, 2026.
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 four, and the sample consisted of two individuals.
Plan of Correction:
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 records and documentation review, and interview with facility and administrative staff, the facility failed to ensure the rights of all Individuals thorugh the provision of opportunities to participate in social, religious, and community group activities for two of two sample Individuals. This practice is specific to Individuals #1 and #2.
Findings include:
A review of the records of Individual #1 and Individual #2 were completed on 04/15/2026 from 9:00 AM to 10:30 AM. This review noted that these Individuals were not given the opportunity to participate in social, religious, and community group activities for the months of April 2025 through July 2025, September 2025 through October 2025 and January 2026 through February 2026. Individual #1 is exemplary of this practice.
Individual #1
A review of documentation regarding community outings for the period 04/01/2025 through 04/15/2026 was completed on 04/15/2026 at approximately 10:00 AM. This review revealed there were no documented community outings for the months of April 2025 through July 2025, September 2025 through October 2025 and January 2026 through February 2026.
Interview with the House Manager and Qualified Intellectual Disabilities Professional (QIDP) on 04/15/2026 at approximately 10:15 AM confirmed there were no community outings conducted during this time period and both interviewees were unable to indicate why these outings had not been completed. Additionally, the QIDP stated the agency does not have a policy regarding community outings,but noted that the facility practice is that each individual be afforded community outings at least one time per month.
Plan of Correction:The facility will ensure that clients have the opportunity to participate in social, religious and community group activities.
C1
On or before April 30, 2026, the Program Manager (PM) will retrain all Program Leads(PL) on the expectations and responsibility of ensuring that individuals are participating in varied religious, and community group activities. The training will also include the responsibility of ensuring that outings are documented on the Community Integration Return form by staff that participated in the outing, upon return from the outing, and reviewed and sent to the Qualified Intellectual Disability Professional/ Program Specialist (QIDP/PS) for review monthly. The training will be documented on a Staff Attendance (SA) sheet. A copy of the training will be sent to the Senior Director (SD) to verify completion within 5 days.
On or before May 10, 2026, the Social Services Director (SSD) or designee will retrain the QIDP/PS on the expectations of ensuring that all individuals have an opportunity to participate in varied social, religious, and community group activities. The training will also include their responsibility to ensure that they monitor the Community Integration Return forms that are sent by the Program Lead (PL) for review monthly. The training will be documented on a Staff Attendance (SA) sheet. A copy of the training will be sent to the Senior Director (SD) to verify completion within 5 days.
On or before April 25, 2026, individuals will participate in a community outing. This will be documented on the Community Integration Return form upon return from the outing and the form will be sent to the QIDP/PS for review.
C2
On or before May 6, 2026, the facility staff will be retrained on ensuring that individuals are participating in varied social, religious, and community group activities. The training will also include their responsibility to ensure that the Community Integration Return forms are completed upon their return of an outing and submitted to the Program Lead (PL) for review. The training will be documented on a Staff Attendance (SA) sheet. A copy of the training will be sent to the Senior Director (SD) to verify completion within 5 days.
C3
It is expected that all individuals will have an opportunity to participate in varied social, religious, and community group activities. The Program Lead is responsible for ensuring that everyone has the opportunity to participate in varied social, religious, and community group activities by scheduling an activity at least monthly. The activity should be a preferred activity of an individual or a new experience they may enjoy.
After there is a community outing or participation in a social or religious event, it is the responsibility of the staff who participated in the activity with the individual(s) to document the event's outcome on a Community Integration Returns Form. The information captured includes the individual's name, date/day of the trip, and the destination. The form also includes reactions of the individual as well as any practiced skill and any problems or concerns that may have occurred. The staff who complete the form will sign off on the form and submit it prior to the end of their shift for the Program Lead to review. The Program Lead ensures that the Community Integration form is completed by the end of their shift. If the Program Lead discovers that the form is not completed, they will ensure that the form is completed on the day of discovery and retrain the staff of their responsibilities to complete the Community Integration Form. The training will be kept in the employees' file. Once reviewed by the Program Lead the form is sent to the QIDP/PS for signature and review. All outings and social events are submitted at the end of the month to the QIDP/PS to be filed and to be incorporated into quarterly reports of the individual. Any anomalies found will be sent to the PM, SD and DSS to address.
C4
On or before May 15, 2026, the Program Manager (PM)/Designee will do an audit of the Community Integration Return Forms twice a month by the 15 of the month for 6 months thereafter once a month by the 15 of the month to ensure that all individuals are participating in social, religious, and community group activities each month. Any anomalies will be addressed immediately and reported to the Program Lead for address via retraining and/or corrective action. The training will be documented on a Staff Attendance (SA) sheet and will be maintained in the Staff files.
On or before May 20, 2026, the QIDP/PS will do an audit of the Community Integration Return Forms once a month by the 20th of the month for 6 months to ensure that all individuals are participating in social, religious, and community group activities each month thereafter quarterly to ensure that all individuals are participating in social, religious, and community group activities each month. Any anomalies will be addressed immediately and reported to the Program Manager to address via retraining and/or corrective action. The training will be documented on a Staff Attendance (SA) sheet and will be maintained in the Staff files.
C5
The Senior Director will be responsible for monitoring the process and reporting any discrepancies and corrective actions taken to the Senior Executive Director at the monthly Director's meetings.
483.460(k)(2) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.
Observations:
Based on observation, interview with facility and administrative staff, and review of facility records, the facility failed to ensure that drugs are administered without error for one of two sample Individuals. This practice is specific to Individual #1.
Findings include:
1. Observations completed on 04/14/2026 between 7:20 AM until 8:00 AM revealed that Individual #1 was escorted into the kitchen area by staff. The staff then proceeded to prepare scheduled medications to administer to this Individual. The staff person removed a bin contained all medication prescribed for this Individual. This staff then removed those medications that were either capsule or pill form into one cup, and poured all liquid medications into another cup.
This staff then removed a capsule of Omeprazole (Priolosec) 20 mg, from the first medication cup, and proceeded to crush the remaining pills left in the medication cup. Staff then poured the crushed medications into a cup of applesauce, and proceeded to open the capsule of Omeprazole and sprinkle the contents over the applesauce and crushed medications. Staff spoon fed Individual #1 the medications, and returned medication back to a locked cabinet.
Interview with the staff administering the medication confirmed that Individual #1 had already eaten his breakfast. This interviewee stated that the third shift staff feed the Individuals breakfast before the first shift staff arrive at 7:00 AM.
2. A review of Individual #1's medication administration record (MAR) was completed on 04/14/2026 between 8:00 AM and 08:15 AM. This review noted that the medication of Omeprazole (Priolosec) 20 mg capsule is to be opened and sprinkle contents in applesauce and give by mouth 1/2 hour before breakfast, for his diagnosis of Gastro Esophageal Reflux Disorder (GERD). Continued review of Individual #1's record on 04/15/2026 between 9:00 AM and 10:00 AM, revealed a 90 Day Physician's Order, dated 03/04/2026 - 06/04/2026. This 90 day Physician's Order again noted that Individual #1 is prescribed Omeprazole 20 mg and instructs staff to open the Omeprazole capsule sprinkle contents over applesauce and give by mouth 1/2 hour before breakfast.
3. Interview with Senior Executive Director on 04/14/2026 at approximately 9:15 AM and the Health Care Coordinator on 04/15/2026 at approximately 09:30 AM confirmed that the medication of Omeprazole 20 mg (Priolosec) is ordered to be given 1/2 hour before breakfast. Both interviewees also confirmed that the administration of this medication on 04/14/2026 was not in accordance with the current Physician's order as written.
Plan of Correction:The facility will ensure that the system for drug administration is administered without error.
C1
An Incident Report and Medication Debriefing form was completed by the facility staff for individual #1 on April 14, 2026, to address the medication error that occurred due to late administration. The incident was reported to the Enterprise Incident Management System.
On April 15, 2026, the facility staff who was administering medication on April 14, 2026, was retrained on the Alleghany Valley School (AVS) medication pass protocol to include the proper time of medication administration according to the physician's order. The training was documented on a Training Verification Form. A copy of the training was also sent to the Senior Director to verify completion.
On April 14, 2026, individual #1's medication time was changed to 6:00am so medication can be administered prior to breakfast. The facility nurse retrained all staff on Individual #1's new physician's orders for medication administration to ensure proper medication administration occurs. A copy of the training was sent to the Senior Director to verify completion within 7 days of completion.
On or before April 28, 2026, the facility staff who administered medication on April 14, 2026, will be observed performing a medication pass to ensure errors do not occur in the future. Any anomalies will be addressed during the observation and ensure that medication is passed according to the physician's order. The observation will be documented on a Medication Observation form and forwarded to the Senior Director to verify completion.
On or before April 30, 2026, the facility nurse will do random medication observations at varying medication times once a week for four weeks thereafter once a month for 3 months to ensure that all medications are administered for all individuals according to the written physician's order that is transcribed on the MAR. During the observation, if there are any anomalies during the medication administration process the medication administration process will be stopped to correct the error, so it does not occur. Staff will be retrained at that time. Training will be completed on Staff Attendance Sheets (SA). Copies of the training will be forwarded to the Senior Director to verify completion.
C2
The facility nurse will retrain all staff on physician's orders for medication administration and how their medications should be administered for the remaining individuals in the facility by April 30, 2026. A copy of the training will be sent to the Senior Director to verify completion within 7 days of completion.
The Program Lead will retrain all facility med-certified staff by April 30, 2026, on the completion of a proper AVS medication pass protocol to include the include the proper time of medication administration according to the physician's order. The training will be documented on a Staff Attendance (SA) sheet. A copy of the training will be sent to the Senior Director to verify completion within 7 days of completion.
C3
All individuals have physicians' orders to administer medications for various hours of the day. Staff ensure that all individuals receive their medication according to physician's orders with the ability to administer an hour before or an hour later. If the scheduled time interferes with individual routine the team can request a new order that may accommodate their routine if possible. Once the order is placed the Program Lead completes Medication Administration Record (MAR) reviews and Medication observations for each medication certified staff member every 6 months. This process must include reviewing the MAR indicating time of administration and observation of the administration to verify that staff are administering medication properly as prescribed in the right time frame. Medication Observations will be Maintained in the employee file. Any anomalies during medication observations will be immediately addressed during the observation and will require another observation within 7 days and a Medication Error Debriefing with the staff who made the error. Any MAR anomalies will be reported and addressed within 7 days.
C4
As of May 20, 2026, the Program Manager will review and monitor the Medication Administration Record (MAR) reviews and Medication observation forms that were completed for each medication certified staff member in the facility every 6 months to verify completion and that staff are administering medication properly and as prescribed in the right time frame. Any anomalies noted will the addressed with the Program Lead to confirm if additional medication observations are warranted. Program Manager will inform Senior Director of noted concerns and corrective actions that were taken.
C5
The Senior Director will be responsible for monitoring the process and reporting any discrepancies and corrective actions taken to the Senior Executive Director at the monthly Director's meetings.
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
at least quarterly for each shift of personnel.
Observations:
Based on a review of facility documentation and interview with administrative staff, the facility failed to hold evacuation drills at least quarterly for each shift of personnel. This practice is specific to the second shift of personnel for the period from April 2025 to March 2026.
Findings include:
A review of fire drill reports for the period from April 2025 to March 2026 was completed on 04/14/2026 between 8:05 AM and 8:25 AM. This review revealed that there was no fire drill completed for the second shift of personnel, defined as 3:00 PM to 11:00 PM
during the third quarter (July through September) of the calendar year.
Interview with the Program Lead /house manager and Senior Executive Director on 04/14/2026 at approximately 8:25 AM and 9:15 AM, respectively, confirmed that the above mentioned fire drill were missing for the third quarter of the calendar year.
Plan of Correction:The facility will ensure that evacuation drills are held at least quarterly for each shift personnel.
C1
The Senior Director met with Program Managers on April 20, 2026, to review current guideline schedule to ensure all quarters are met for each shift personnel and they were updated as needed.
On April 21, 2026, the Senior Director met with Program Leads retrain regarding State and Federal regulations and agency policies pertaining to fire drills/emergency evacuations. The training emphasized conducting and documenting a fire drill on each shift (1st, 2nd and 3rd shifts) varying times on each shift every quarter to include each shift personnel and ensuring they follow the new scheduled guidelines that were updated and are in place. The training also included ensuring that they hold drills by the 15th of the month to ensure ample time to run a drill if one is missing or needs to be repeated once submitted to the Program Manager for review. The training will be documented on a Staff Attendance Sheet to verify completion. The Staff Attendance sheet will be filed in the Staff Development department.
C2
On or before May 15, 2026, the Program Lead will conduct a fire drill in accordance with schedule. This fire drill/emergency evacuation was documented on a Monthly Fire Drill Audit form and submitted to the Program Manager for review. The Program Manager (PM) will review the submitted fire drill to verify that the Program Lead completed the drill/evaluation according to State and Federal regulations and the agency's current fire drill schedule guidelines. If the drill is not completed as scheduled on the current scheduling guidelines the Program Manager will instruct the Program Lead to reconduct a drill repeat the evacuation drill within seven days and until it meets the requirements in accordance with State and Federal training and/or employee counseling and corrective action. Since all Individuals were affected, these corrective actions stand for both potential and affected individuals.
C3
Prior to the 15th of the month the Program Lead will review the current Evacuation Drill Schedule prior to completion to the drill to ensure that they conduct the drill in accordance to the current schedule and within time frames noted. Upon completion of the evacuation drill and by the 15th day of the month, the Program Lead will submit a copy of the evacuation drill to the Program Manager for review. Upon receipt and by the 20th of the month, the Program Manager will review the evacuation drill to ensure all required elements have been met including verifying that the evacuation drill was conducted at different times of the day and varying quarterly for each shift personnel as set forth in the current Evacuation Drills Scheduling Guidelines. After review, the Program Manager will either approve or reject the submitted evacuation drill. If the evacuation drill is found to be unsatisfactory, it will be rejected, and the PM will direct the Program Lead to repeat the evacuation drill within seven days and until it meets the requirements in accordance with State and Federal
training and/or employee counseling and corrective action.
C4
On a monthly basis by the 25th of the month, the Senior Director will audit all approved evacuation drills for the next 6 months. The audit will confirm that all approved evacuation drills are conducted under various conditions and timeframes pursuant to the Evacuation Drills Scheduling Guidelines, and in accordance with State and Federal regulations. During the Senior Directors review, if concerns are identified with the varied conditions and/or the Evacuation Drills Scheduling Guidelines are not followed, they will require that another drill is conducted to maintain compliance with State and Federal regulations and agency policy within 5 days. Any anomalies will be addressed with training and counseling and corrective action.
C5
The Senior Director will present a summary of all audit outcomes to the Senior Executive Director at the monthly executive operations meeting chaired by the Senior Executive Director, who will address any outlying issues with the system
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