Initial Comments:
A focused fundamental survey was conducted April 26-27, 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:
483.440(c)(5)(iv) STANDARD
INDIVIDUAL PROGRAM PLAN
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Each written training program designed to implement the objectives in the individual program plan must specify the type of data and frequency of data collection necessary to be able to assess progress toward the desired objectives.
Observations:
Based on a record review and interview, it was determined that the facility failed to collect data with enough frequency to adequately measure the individuals' progress towards activity goal plans as identified in the individual program plan. This applied to one (#1) of two individuals in the core sample. Findings included:
A record review was completed for Individual #1 on April 27, 2023. This record revealed that Individual #1 had two activity plans identified as needs in the individual program plan as follows:
A. An activity plan to discuss knowledge of anti-victimization was initiated on June 20, 2022, and was to be implemented "as needed when a physical I to I [individual to individual] has happened." The record revealed that there were no data sheets available since September 2022, and the data sheets in the record prior to September were blank. An interview was conducted with the qualified intellectual disabilities professional (QIDP) on April 27, 2023, at 11:13AM. The QIDP identified three occurrences during the past year where this activity plan should have been implemented, most recently on April 14, 2023.
B. An activity plan to discuss appropriate social skills as a way of appropriately dealing with anger, frustration, and disappointment was initiated on June 23, 2022. This activity plan was to be implemented three days a week. The record revealed that there were no data sheets available since September 2022, and the data sheets in the record prior to September were blank. An interview was conducted with the QIDP on April 27, 2023, at 11:15AM. The QIDP confirmed the there was no data collected on this activity plan for the past several months to address this need.
An interview was conducted with the administrator on April 27, 2023, at 1:05PM. The administrator confirmed that the expectation is for all activity plans to be implemented as written.
Plan of Correction:Allegheny Valley School Snyder Drive 2 SFR makes its best effort to operate in full compliance with both Federal and State Law. Nothing included in this Plan of Correction is an admission otherwise. AVS/Snyder Drive 2 has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections to the merits or form of any allegations contained herein. Please note that AVS/Snyder Drive 2 may contest the merits and/or form of any deficiency or findings alleged below and take reasonable steps to appeal them.
On May 4, 2023, the house manager was retrained on the definition of active treatment and the implementation and collection of data to adequately measure progress. Also on May 4, 2023, the HM, Administrator, QIDP and lead QIDP met on each of the individuals in the home to review the goal plans and documentation. After this, they will meet one time per month for four months with the House Manager, and QIDP to review the goal plans. Any concerns will be relayed to the Administrator for follow-up.
483.470(i)(1) STANDARD
EVACUATION DRILLS
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and under varied conditions to-
Observations:
Based on a review of facility provided fire drill reports and interview, it was determined that the facility failed to ensure that fire evacuation drills were practiced under varied conditions. This applied to all residents at the facility. Findings included:
A review of facility provided fire drill reports for the past 12 months was completed on April 26, 2023. This review revealed five of the six exits at the residence were practiced during monthly fire drills. This review failed to reveal that the garage exit was practiced during a fire drill in the past 12 months.
An interview was conducted with the administrator on April 27, 2023, at 1:10 PM. The administrator confirmed that it is the expectation that the garage exit should have been practiced as a fire drill exit in the past 12 months.
Plan of Correction:Allegheny Valley School Snyder Drive 2 SFR makes its best effort to operate in full compliance with both Federal and State Law. Nothing included in this Plan of Correction is an admission otherwise. AVS/Snyder Drive 2 has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections to the merits or form of any allegations contained herein. Please note that AVS/Snyder Drive 2 may contest the merits and/or form of any deficiency or findings alleged below and take reasonable steps to appeal them.
On April 28, 2023, at 11am, the house manager conducted a fire drill, and all four individuals utilized the garage exit.
On April 28, 2023, the house manager (HM) was retrained by the Administrator on ensuring fire drills utilize all exits. The Administrator explained how to use the fire drill schedule and the time frame given to ensure we are meeting the standard of all exits being used and rotated throughout the year. A staff attendance (SA) sheet was signed by the HM and sent to the Administrator.
The Administrator will review the fire drills monthly for six months. This monitoring will be maintained in the Administrator's office for verification of review. If concerns are identified on the fire drills, the Administrator will address the concern directly to the HM, and the drill will be repeated, if necessary.
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