Initial Comments:
A fundamnetal recertification survey was conducted on April 8 and 9, 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:
483.410(c)(1) STANDARD
CLIENT RECORDS
Name - Component - 00
The facility must develop and maintain a recordkeeping system that documents the client's health care, active treatment, social information, and protection of the client's rights.
Observations:
Based on a review of facility records and documentation, and interview with facility and administrative staff, the facility failed to maintain a record keeping system that documents the client's health status, active treatment, social information and protection of client's rights whose structure is an accurate functional representation of the Individuals experience within the facility. The practice applies to one of two sample Individuals, specifically Individual #1.
Findings include:
A review of the record of Individual #1 was completed on 04/09/2026 between 9:30 AM and 11:30 AM. This review revealed the following information:
1. A review of the Individual Program Plan (IPP) for Individual #1, dated 07/25/2025, under the section titled " Behavior Plan; N/A", there is a descriptive entry noting that-
" [Individual #1] currently has a behavior support plan (BSP) to target episodes of agitated behavior. The team reviewed his BSP during the annual [IPP]staffing and no changes were recommended. BSP consents were reviewed and remain valid. [Individual #1] does not take psychotropic medication." A review of a nursing summary report contained in the IPP, again notes that Individual #1 has a current BSP in place.
Subsequent review of an annual psychological clinical assessment dated 09/22/2025, indicates that Individual #1 resides at the "... Allegheny Valley School Byberry road home."...[Individual #1] has a behavior support plan that identifies agitation demonstrated but not limited to spitting, hitting, crying and throwing objects. He does not have a mental health diagnosis and does not take any psychotropic medications.... [Individual #1's] plan incorporates providing emotional support, positive reinforcement and choice to reduce target behaviors."
Within Section V of this same assessment titled comments/recommendations, the following information is listed:
" Placement at the Susquehanna group home should continue based upon [ Individual #1's] limited adaptive functioning and need for 24-hour supervision. Continuation of [Individual #1's] behavior management plan is recommended. "
In a review of current goal plans in place for Individual #1, there was no behavior support plan in place or active at this time for this Individual. When requesting documentation of the noted behavior plan for Individual #1, interview with the Qualified Intellectual Disabilities Professional (QIDP) on 04/09/2026 between 10:00 AM and 10:30 AM noted that Individual #1 has not had a behavior plan in place for since approximately 2022.
Subsequent interview during this same time period on 04/09/2026 with the agency Social Services Supervisor indicated that Individual #1 was admitted to the Byberry road residence from the Susquehanna Road residence on 09/02/2021. This interviewee also acknowledged that the above reports contained disparate information that was no longer applicable to Individual #1.
2. A review of an Occupational Therapy (OT) evaluation report, dated 03/10/2025, contained recommendations for this Individual that included the directive " [Individual #1] is not to sit at the end of the dining table during all meals." Subsequent review of the IPP for Individual #1 which was conducted on 07/30/2025, reflected the same recommendation in the"ICF Nursing Annual Health Summary IDD".
Observation of the breakfast meal on 04/08/2026 between 7:45 and 8:00 AM noted that Individual #1 was observed sitting at the end of the table during the breakfast meal. A second observation completed on this same date between 5:00 PM and 5:30 PM again noted that Individual #1 was observed seated at the end of the table during the dinner meal. During both observation periods, there were no issues or problems with Individual #1's placement at the end of the table.
When questioned regarding the recommendation by OT, interview with the Associate Senior Executive Director on 04/09/2026 between 9:45 and 10:00 AM noted that this interviewee stated that she would reach out to that department to clarify the recommendation.This interviewee did not receive a return call form the OT department during the course of the survey.
Subsequent interview with the Social Services Supervisor and the QIDP between 10:30 and 10:45 AM noted that neither of the interviewees could indicate why the specific recommendation made by OT personnel had been established. Both interviewees stated that there is no condition or situation that would preclude Individual #1 from being seated at the end of the dining table. Additionally, neither were able to indicate why this information remained active within the current IPP.
Plan of Correction:CE1
The facility will maintain a record keeping system that documents the client's health care, active treatment, social information, and protection of the client's rights whose structure is an accurate functional representation of the Individuals experience within the facility.
During the Annual Survey on April 9, 2026, it was discovered that the Clinical Assessment for Individual #1's information had not been updated. The Clinical Director immediately revised the Clinical Assessment form to reflect the correct information. On this same date after the Annual Survey Exit, the Occupational Therapist wrote an Addendum note for Individual#1 recommendation for 2025 indicating that Individual #1 is able to sit at the end of the table with no issues. The Occupational Therapist discontinued the recommendation for Individual #1 not to sit at the ends of the dining room table at home. The Occupation Therapist Note: Addendum for recommendation 2025 and added to Individual #1 Unit Chart.
On April 14, 2026, the Interdisciplinary Team (IDT) met to discuss Individual #1 Behavior Support Plan (BSP), agreed this was a documentation error and the information should not have been transferred to current years. The Occupational Therapist addendum was noted on 4/9/26 and the reason for the previous order was discontinued. A copy of the mini-IDT form will be placed in the Unit chart and a copy sent to the Senior Director to verity completion.
On May 4, 2026, the Qualified Intellectual Disabilities Professional (QIDP) will conduct a mini-IDT with the appropriate team members to review the total IPP for Individual #1 to ensure record keeping documents the client's health care are an accurate functional representation of the record. Any needed adjustments will be corrected as an error, and the results of the review will be documented as an IPP Update in the Program Summary section of his Unit Chart. Any concerns that are identified through the meeting will be addressed to the Director of Social Services, Senior Director and appropriate team members for follow-up within 7 days. A copy of the mini-IDT any follow-up recommendation(s) will be forwarded to the Senior Director and Director of Social Services to verify completion of the recommendation(s).
CE2
On May 6, 2026, the Qualified Intellectual Disabilities Professional (QIDP) will schedule mini-IDT with the appropriate team members to review the total IPP of all of the facility Individuals to ensure record keeping documents the client's health care and accurate functional representation of the record. Any needed adjustments will be corrected as an error, and the results of the review will be documented as an IPP Update in the Program Summary section of his Unit Chart. Any concerns that are identified through the meeting will be addressed to the QIDP, Senior Director and appropriate team members for follow-up within 7 days. A copy of the mini-IDT any follow-up recommendation(s) will be forwarded to the Senior Director and Director of Social Services to verify completion of the recommendation(s).
On or before May 13, 2026, the Clinical Director will complete chart audits on all of the facility Individuals Clinical Assessments to ensure accurate documentation is noted for each Individual records. Any revisions needed will be documented on a new Clinical Assessments form and noted as a revision. Both the Clinical Assessment and the Revised Clinical Assessment will be kept in the unit chart for review.
On or before May 18, 2026, the Eastern Director of Social Services will re-train current Qualified Intellectual Developmental Professional (QIDP) and any newly hire on the requirements to review, and monitor records to ensure the document of client's health care is current, and an accurate functional representation of all of the individuals on their caseload. The emphasis will emphasize ensuring the record information is applicable to the Individual, updated documents to address the client's health care, information matches between disciplines, and an accurate functional representation of the Individuals. The training will be documented on a Staff Attendance Sheet (SA) and will be maintained in the Staff Development office and in the plan of correction file maintained by the Senior Director.
On or before May 20, 2026, the Director of Nursing will retrain the Occupational Therapist and all of the Allied Health Professional to document the reason for recommendations made on behalf of the Individual and provide training for the facility staff to carry out the request. This training will emphasize providing an accurate functional representation of the Individuals experience within the facility. The training will be documented on a Staff Attendance Sheet (SA) and will be maintained in the Staff Development office and in the plan of correction file maintained by the Senior Director.
CE3
The facility will ensure that client records accurately document each individual's health status, active treatment services, social information, and protection of rights, and that records are a true and functional representation of the individual's experience in the facility.
The Interdisciplinary Team meets to review the individual's record, including the Individual Program Plan (IPP), nursing summaries, psychological assessments, and therapy evaluations, to identify and correct conflicting, outdated, or inaccurate documentation. All references to active nursing summaries, psychological assessments, behavior support Plan (BSP), therapy evaluation, related to client's health care will be reconciled by the team at the annual staffing.
The QIDP maintains a tracking form for therapy and specialty recommendations to monitor whether recommendations are implemented, revised, or discontinued. This will ensure that no outdated or unsupported recommendations remain active in the record.
To maintain proper record system, the QIDP will systematically gather information from the IDT for review and include information received in quarterly/annual reports. The IDT meets to review the reports at the quarterly/annual staffing meetings to ensure accuracy of the information. Any concerns/issues will be noted in an email and sent to the appropriate department head for further review and address.
CE # 4
The Assistant Social Service Supervisor/designee will complete monthly audits of all the facility Individuals' records to ensure documented client's healthcare, active treatment, social information, and protection of the client's rights whose structure is an accurate functional representation of the individual's experience within the facility for the next 2 months.
Thereafter the Assistant Social Service Supervisor/designee will conduct quarterly audits reviews and send copies to the Director of Social Services and the Senior Director to verify completion. Any anomalies found will be addressed by the appropriate department head through retraining and corrective action.
CE # 5
The Director of Social Services and the Senior Director will report any outstanding concerns to the Senior Executive Director at the monthly Director's meetings for further address and systemic corrective actions when applicable.
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