Initial Comments:
A focused fundamental survey was conducted March 2-4, 2026, to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was five and the sample consisted of three individuals.
Plan of Correction:
483.420(a)(7) STANDARD
PROTECTION OF CLIENTS RIGHTS
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The facility must ensure the rights of all clients. Therefore, the facility must provide each client with the opportunity for personal privacy.
Observations:
Based on observations and interviews, it was determined that the facility failed to ensure that personal privacy was provided to all the individuals. This applied to one (#1) of five individuals living at the residence. Findings included:
Evening observations were completed in the residence on March 2, 2026, from 3:15 PM to 6:30 PM. At 3:35 PM, Individual #1 returned to the residence with her family after being with them for the weekend. At 4:42 PM, the program manager was observed going in the kitchen and told staff, who was assisting another individual with preparing the dinner vegetable, that "[Individual #1]'s mom said that [Individual #1] hasn't had a BM since Saturday, so we are going to have to watch for that." At 4:47 PM, the program manager was observed in the dining area to tell the other staff, "[Individual #1]'s mom said that she hasn't had a BM since Saturday." This statement was heard in the living room where other individuals were present. The other staff replied, "okay." During an interview with the program manager (PM) on March 2, 2026, at 6:30 PM, she acknowledged that she stated Individual #1's private information where others could hear it.
Interview with the qualified intellectual disabilities professional on March 3, 2026, 10:35 AM, confirmed that the individual's privacy should be maintained and that there is the expectation that the above information should have been kept private.
Plan of Correction:Valley Community Services will undertake corrective action to ensure compliance with the requirements of 42 CFR 483.420(a)(7) regarding the protection of client rights and personal privacy. On March 4, 2026, the QIDP trained the PM on the protection of confidential personal health information and that discussions involving an individual's medical or personal matters occur only in private areas and only with staff who have a legitimate need to know. Additionally, by April 1, 2026, the QIDP will re-train all staff on proper location for communication regarding all individuals from the West Sunbury ICF. Conversations related to an individual's health status, bowel movements, medications, or other personal information must not occur in common areas where other individuals may overhear, therefore discussion will occur in the staff office within the home or in another private space to ensure confidentiality is maintained. To ensure compliance, the QIDP and Operations Director will conduct weekly observations to ensure that all communications regarding Individuals' protected health information is conducted in a private and confidential setting, maintaining the privacy of each individual's information; this will begin on April 1, 2026, and end on September 30, 2026.
483.430(e)(1) STANDARD
STAFF TRAINING PROGRAM
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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 observations, record review in selected areas, and interview, it was determined that the facility failed to provide training to enable staff to perform their job duties effectively, efficiently, and competently. This applied to three (#1, #4, and #5) of five individuals living at the residence. Findings included:
Evening observations were completed at the residence on March 2, 2026, from 3:15 PM to 6:30 PM. During this time the dinner meal was prepared with the assistance of the individuals. The individuals were also observed to be given a choice of plastic or metal silverware, to assist in preparing their own food item textures, and to bring their place setting to the table. Individuals #1, #3, #4, and #5 chose plastic silverware and Individual #2 chose metal. At 6:08 PM, all the individuals were at the table and the staff were observed to bring all five plates of food that were prepared in the kitchen on regular flat plates. During the meal, Individual #1 was observed to bring the fork to her mouth and take a bite independently after staff scooped the food on the fork. Individuals #2, #3, and #5 were all observed to eat independently. Individual #4 was fully fed by the other staff, with the plate of food in front of Individual #4 on her wheelchair tray. At 6:15 PM, Individual #4 indicated that she didn't want to eat the carrots and the staff was observed to attempt to separate the carrots from the other pureed food items, as they were all touching.
At 6:21 PM, the staff, who was fully feeding Individual #4, turned to the right and asked Individual #5 if she could sit on her wheeled walker seat while she was assisting Individual #5 with her dinner. Individual #5 gave permission and the staff was observed to sit on the wheeled walker seat of Individual #5 and continued to assist feeding Individual #4.
Review of physician's orders for all the residents were completed on March 3, 2026. This review revealed that Individual #1's current physician's orders dated, January 13, 2026, included, "may use a built-up spoon/fork & high-sided bowl as needed for meals." This review further revealed that Individual #4's current physician's orders, dated January 20, 2026, included "may use high-sided, divided bowl for meals, may elevate bowl/plate as needed."
During an interview with the qualified intellectual disabilities professional (QIDP) on March 3, 2026, at 10:35 AM, the QIDP confirmed that Individuals #1 and #4 had current physician orders that they may use adaptive equipment, as stated above, for meals. She further confirmed that Individuals #1 and #4 should have been provided that mealtime adaptive equipment by the staff for their dinner to ensure that they could have eaten as independently as possible. The QIDP also confirmed, at this time, that staff should not have sat on Individual #5's walker seat or use any of the individual's personal equipment. In a subsequent interview with the QIDP completed on March 4, 2026, at 10:40 AM, the QIDP confirmed that the facility's training failed to ensure staff offered adaptive equipment at mealtime to promote independence and that staff should have refrained from using the individual's personal possessions.
Plan of Correction:Valley Community Services will undertake corrective action to ensure compliance with the requirements of 42 CFR 483.430(e)(1) regarding staff training. On March 2, 2026, the staff member observed sitting on Individual #5's walker received immediate one-on-one retraining from the QIDP addressing professional boundaries, proper use of residents' personal belongings and mobility devices, promotion of independence during activities of daily living, and maintaining residents' dignity and rights. By April 1, 2026, all staff will be trained regarding appropriate professional boundaries, including the expectation that staff will not sit on or use individuals' personal mobility devices or personal belongings. Because the concerns involved staff communication practices and implementation of physician orders, all individuals residing in the home were considered potentially at risk. On March 2, 2026, the staff members who did not offer adaptive equipment and only provided plastic cutlery during dinner received immediate one-on-one retraining from the QIDP, which addressed ensuring individuals are offered and assisted with appropriate adaptive equipment for meals. By April 1, 2026, all staff will be retrained on client rights, confidentiality, adaptive equipment use, promotion of independence during activities of daily living, adherence to physician orders, and maintaining professional boundaries with individuals' personal equipment and belongings. In addition, the QIDP and nursing reviewed physician orders for all individuals and determined adaptive dining equipment orders are present for individuals #1 and #4. Nursing will train all staff on the proper use of the adaptive equipment such as built-up utensils and high-sided or divided bowls to ensure they are consistently provided as ordered to support individuals in eating as independently as possible. All staff will be trained by nursing by April 1st, 2026.
To ensure ongoing compliance, the PM and QIDP will each conduct biweekly observations for 6 consecutive months beginning on April 1st, 2026, and ending on September 30th, 2026, to monitor staff communication practices, privacy protections, mealtime assistance practices, and appropriate use of adaptive equipment. Valley Community Services will provide employees with initial and continuing training that enables the employee to perform his or her duties effectively, efficiently, and competently. For new hires, the Program Manager will conduct training on individual rights and confidentiality, proper use of adaptive equipment, promotion of independence during activities of daily living, adherence to physician orders, and maintaining professional boundaries with individuals' personal belongings and mobility devices; new training may be added to promote further growth and development for staff. The Program Manager will submit new hire trainings to the QIDP for review to ensure completion and compliance of training; this will be ongoing. For existing staff, the Program Manager will provide refresher training and re-education semi-annually. These trainings will focus on individual rights and confidentiality, proper use of adaptive equipment, promotion of independence during activities of daily living, adherence to physician orders, and maintaining professional boundaries with individuals' personal belongings and mobility devices, as well as updates on organizational policies, professional conduct expectations, communication practices, and any changes in residents' care plans or physician orders; new trainings will be added as warranted. To ensure compliance, the QIDP will monitor the semi-annual training conducted by the Program Manager by reviewing trainings and correlating signed staff training sheets; this will be ongoing.
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