Initial Comments:
A focused fundamental survey was conducted October 25-26, 2023, 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 four and the core sample consisted of two individuals.
Plan of Correction:
483.430(a) STANDARD
QIDP
Name - Component - 00
Each client's active treatment program must be integrated, coordinated and monitored by a qualified intellectual disability professional who-
Observations:
Based on observations, record review, and interview, it was determined that the facility failed to ensure the qualified intellectual disabilities professional (QIDP) coordinated and monitored each individual's program plans. This applied to one (#1) of two individuals in the core sample. Findings included:
Observations were completed at the residence of the breakfast meal on October 25, 2023, from 6:55 AM to 7:45 AM and the dinner meal on October 25, 2023, from 4:54 PM to 5:30 PM. During these observations, Individual #1 was observed to eat sitting in a regular chair with no armrests. A lunch meal was observed at the day program on October 25, 2023, from 11:10 AM to 11:35 AM. During this observation, Individual #1 was observed to eat lunch sitting in a regular chair with no armrests and utilizing a built-up tray.
A record review for Individual #1 was completed on October 26, 2023. This review revealed an occupational therapy assessment, dated May 3, 2023, which stated that Individual #1, should be "seated in an arm chair and pushed close to table." This assessment recommended a trial of a mini built-up tray at meals due to staff concerns with head/neck positioning. This assessment also revealed that the occupational therapist (OT) was to make a home visit to assess the need for a more supportive high-back arm chair to assist Individual #1 with positioning. Further record review of Individual #1's feeding profile, dated May 24, 2023, stated that they should be positioned in an "arm chair at table."
An interview with the administrator was completed on October 26, 2023, at 10:40 AM. At this time, the administrator stated that there are no arm chairs available in the home.
An interview with the OT was completed on October 26, 2023, at 11:08 AM. At this time, the OT stated that Individual #1 should use an arm chair at all meals to assist with positioning, both at the residence and at the day program. The OT further stated that a follow-up assessment with Individual #1 was completed on September 14, 2023. The OT stated that at that time it was determined that the mini built-up tray should be used on an as needed basis during meals at the residence and the day program. The OT further stated that it was determined during this assessment that a more supportive high-back arm chair for positioning was not needed. The OT confirmed that there was no documentation of this assessment and they did not communicate their assessment results with Individual #1's interdisciplinary team. The OT also confirmed at this time that they had not updated Individual #1's feeding profile to reflect these findings.
An interview with the QIDP was completed on October 26, 2023, at 11:28 AM. At this time, the QIDP confirmed that they had not followed-up on the recommendations from Individual #1's May 3, 2023, occupational therapy assessment. The QIDP further confirmed that that proper coordination and monitoring had not occurred for Individual #1 regarding the OT's recommendations of arm chair use at meals and the follow-up OT assessment regarding the mini built-up tray trial and the possible need for a more supportive high-back arm chair.
Plan of Correction:Allegheny Valley School Pine Hollow II SFR makes its best effort to operate in full compliance with both Federal and State regulations. Nothing included in the Plan of Correction is an admission otherwise.
AVS Pine Hollow II SFR has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections contained herein. Please note that AVS Pine Hollow II SFR may contest the merits and/o form of any deficiency or finding alleged below and take responsible steps to appeal them.
On 10/26/23, an armchair and a mini built-up tray were delivered to the home for Individual #1 to utilize during mealtime as outlined in his feeding profile.
On 10/27/23 a Mini-IIDT was held with individual #1 to discuss OT feeding recommendations. At that time, it was discussed to amend the use of the mini built-up tray during mealtimes from as needed and add this as daily adaptive equipment needed for meals. The Occupational Therapist completed IPP update and updated feeding profile at that time. All care staff working at Pine Hollow RR were retrained on Individual #1's new feeding profile. A copy of the training sheet was sent to the Administrator and will be maintained by the Administrator.
The facility will monitor the corrective actions by completing four (4) Mealtime Audits from November to January and will include the Residential and Day Program locations. Personnel completing the audits will include the QIDP, House Manager and Administrator. Mealtime Audit will include monitoring for required adaptive equipment. Any issues noted during the audit process will be addressed immediately. Any concerns requiring further evaluation will be referred to the OT. The completed audit documentation will be sent to the Administrator and maintained by the Administrator.
On 11/2/23, all service plans for individuals residing at 908 Pine Hollow Road RR were reviewed by the Social Services Director and Lead QIDP to ensure that all recommendations from Annual Services Plans Meetings were addressed with appropriate follow-up. No outstanding recommendations were noted at this time.
For other potentially affected individuals, the Social Services Director completed training with all QIDPs in the Western Region on 11/6/23 regarding the Annual Service Plan Policy. Training outlined that after the completion of the Service Plan Summary, the QIDP will attach the Recommendation Tracking Form and send to the Lead QIDP for monitoring to ensure that all recommendations for Annual Service meeting have been addressed. This monitoring of the Recommendation Tracking Form by Lead QIDP will be on-going for all Annual Service Plans. The signed training sheet for this will be maintained by the SSD and copy will be sent to Administrator.
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