Initial Comments:
A focused fundamental survey visit was completed on February 19 and 20, 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:
483.440(f)(1)(i) STANDARD
PROGRAM MONITORING & CHANGE
Name - Component - 00
The individual program plan must be reviewed at least by the qualified intellectual disability professional and revised as necessary, including, but not limited to situations in which the client has successfully completed an objective or objectives identified in the individual program plan.
Observations:
Based on record review, and interview with facility and administrative staff, the Qualified Intellectual Disabilities Professional (QIDP) failed to review and revise as necessary, including, but not limited to situations in which the Individual has successfully completed an objective or objectives in the training plans for two of two sample Individuals. This practice is specific to Individuals #1 and #2.
Findings include :
A review of the records of Individuals #1 and #2 was completed on 02/20/2026 from 8:45 AM to approximately 11:30 AM. These record reviews revealed that both Individual #1 and #2 were working on training programs where documentation for these plans showed that both individuals were meeting criteria of the stated objectives.
Individual #1
Individual #1 is currently working on a training program to improve her mealtime skills. This program was implemented on 09/01/2025. Both the long term and short term goal for this training program (Step #4) is:
-Individual #1 will place her entire dirty place settings into the sink given 2 verbal prompts on 20 out of 28 days.
A review of the second page of this training plan revealed that Individual met criteria of step #3, place her dish into the sink given 2 verbal prompts on 11/01/2025. Due to being hospitalized until 12/05/2025 and then refusing to participate in this training program from 12/06 to 12/15/2025, Individual #1 did not participate in this training program until 12/16/20254. On 12/17/2025 Individual #1 began to participate in step #4: Individual #1 will place her entire dirty place settings into the sink given 2 verbal prompts on 20 out of 28 days.
A review of a document titled Goal Plan Flow sheet which documents Individual #1's prompt level needed to complete step #4, revealed that Individual #1 met criteria of step #4 (2 verbal prompts on 20 out of 24 days) on 01/08/2026. However, further review of this training program revealed that Individual #1 continues to work on step #4 as of 02/20/2026, as of the date of this review.
Interviews with the Lead Staff/House Manager the QIDP and Director of Social Services on 02/20/2026 at approximately 10:40 AM to 10:50 AM, confirmed that Individual #1 should have moved on to another training program upon meeting the long term criteria of this training plan. .
Individual #2
Individual #2 is currently working on a training program to improve personal hygiene skills. This program was implemented on 06/11/2025. The short term goal for this training program is:
-Step #5: Individual #2 will wash her entire left upper arm given H/W assistance on 20/28/days.
A review of the second page of this training plan revealed that Individual #2 met criteria of step #5, wash entire left upper arm given H/W assistance on 20/28 days on 01/04/2026.
A review of a document titled Goal Plan Flow sheet which documents Individual #2's prompt level needed to complete step #5, confirmed that Individual #2 met criteria of step #5 (H/W assistance on 20 out of 28 days) on 01/04/2026. However, further review of this training program revealed that Individual #2 continues to work on step #5 as of 02/20/2026, as of the date of this review.
Interviews with the Lead Staff/ House manager, the QIDP and Director of Social Services on 02/20/2026 at approximately 10:40 AM to 10:50 AM, confirmed that Individual #2 should have moved on to another training program upon meeting the long term criteria of this training plan.
Plan of Correction:The Qualified Intellectual Disability Professional (QIDP) will ensure that individual program plans are reviewed and revised as necessary, including but not limited to situations in which the client has successfully completed an objective or objectives identified in the individual program plan.
C1
On February 20, 2026, individual #1's training plan was reviewed by the QIDP. Step #4 was closed as completed on February 21, 2026. A new training objective was developed based on individual #1's current assessment needs and implemented on February 21, 2026, and all Direct Support Professional (DSP) were trained on the new training objective.
On February 20, 2026, individual #2's training plan was reviewed by the QIDP. Step #5 was closed as completed on February 21, 2026. A new training objective was developed based on individual #2's current assessment needs and implemented on February 21, 2026, and all Direct Support Professional (DSP) were trained on the new training objective.
On March 4 ,2026 the Social Services Director retrained the facility QIDP on program monitoring requirements. This training included required timelines for revising programs after criteria are met, documentation standards and ongoing IPP monitoring expectations. The training was documented on a Staff Attendance (SA) Sheet and forwarded to the Senior Director to verify completion
On March 5, 2026, Program Lead and DSP's were trained on the responsibility of notifying the QIDP when data shows an individual is nearing mastery of an objective. The training will be documented on a Staff Attendance (SA) Sheet and forwarded to the Senior Director to verify completion.
C2
On or before March 15, 2026, the QIDP will complete an audit of all active training programs for the remaining facility individuals. The audit will be completed on an active treatment monitoring form and sent to the Senior Director for verification. Any anomalies will be addressed by the QIDP within 5 days of discovery.
On or before March 25, 2026, the Social Service Director/ Designee will retrain all QIDP's on program monitoring requirements. This training will include required timelines for revising programs after criteria are met, documentation standards and ongoing IPP monitoring expectations. The training will be documented on a Staff Attendance (SA) Sheet and forwarded to the Senior Director to verify completion.
C3
During the implementation of a goal plan the DSP's document the success or lack of success of each program plan by noting such. The Program Lead monitors the success of each program plan and will notify the QIDP if an individual has lack of progress or is on the 2nd to last step via a "Blue slip" that notifies QIDP to initiate the next goal based on current assessment needs. When mastery is achieved the QIDP will close the objective and initiate the next step.
Beginning March 15, 2026, and for a period of three months, the QIDP will complete audits once a week of individuals' goal plans to ensure that objectives that have been met for 14 consecutive days are ready for closure or revision. Thereafter, Individual Program Plans will be reviewed each month by the QIDP to ensure that current program plans are appropriate and have been closed if necessary to move to the next step and initiate such. Any anomalies are addressed by the QIDP to ensure that the individual is continuing to receive appropriate active treatment within 5 days of discovery. QIDP initiates training as needed with DSP's to ensure that each individual program plan is continuing to be appropriate.
These audits will be documented on a goal plan status form and will be submitted to the Social Service Director/Designee for review. Audits will be sent to the Senior Director to verify completion.
C4
Beginning on March 17, 2026, for the next 6 months the Social Services Director/Designee will complete a 10% random audit of program documentation to verify timely updates to training objectives. These audits will be documented on a goal plan status form. Audits will be sent to the Senior Director to verify completion. Any anomalies will be addressed with the QIDP within 3 days of discovery to rectify the outcome.
C5
The Director of Social Services/ Designee will provide a summary from the audit outcomes of any outstanding anomalies/trends regarding timelines for revision of programs to the Senior Executive Director at the monthly executive meeting.
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