Initial Comments:
A focused fundamental survey was conducted March 25 and 26, 2025 to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I, Requirements for Intermediate Care Facilities. The census during the survey was three and the sample consisted of two individuals. Three deficiencies were identified as a result of the survey.
Plan of Correction:
483.420(a)(4) STANDARD
PROTECTION OF CLIENTS RIGHTS
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The facility must ensure the rights of all clients. Therefore, the facility must allow individual clients to manage their financial affairs and teach them to do so to the extent of their capabilities.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure a continuous training program in the area of financial management skills was implemented. This was noted for both individuals in the sample (Individuals #1 and #2). The findings included:
A) Goal plans for Individual #1 were reviewed on March 25-26, 2025. This review revealed a financial management training program was not implemented during the past year.
B) Goal plans for Individual #2 were reviewed on March 25-26, 2025. This review revealed a financial management training program was not implemented during the past year.
D) An interview with the Qualified Intellectual Disability Professional (QIDP) on March 26, 2025 at 1:00 PM confirmed that Individuals #1and #2 did not have a training program in the area of financial management during the past year.
Plan of Correction:In regard to Items A and B, the facility failed to implement a continuous training program in financial management skills for Individuals #1 and #2 over the past year, violating their right to receive training in managing their financial affairs according to their capabilities.
In response to this, the facility will review the annual assessment and IHP for Individuals #1 and #2 to ensure financial training plans for both individuals are outlined based on their specific needs addressed in their skills assessments. Their updated plans will include structured, goal-oriented, financial education that aligns with their cognitive and functional abilities. Additionally, we will implement a facility-wide review to ensure that all individuals are receiving financial training opportunities.
New documentation will be implemented to track participation and progress in financial skills development and all staff will be trained on how to implement Individual #1 and Individual #2's specific program goals. Regular audits and quarterly review of these programs will occur by the QIDP.
These corrective actions will be fully implemented by May 1, 2025. Effectiveness of these interventions will be evidenced by no further individuals failing to have a training plan in place to assist them in managing their financial affairs. The QIDP will have overall responsibility for these interventions.
483.440(c)(6)(iii) STANDARD
INDIVIDUAL PROGRAM PLAN
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The individual program plan must include, for those clients who lack them, training in personal skills essential for privacy and independence (including, but not limited to, toilet training, personal hygiene, dental hygiene, self-feeding, bathing, dressing, grooming, and communication of basic needs), until it has been demonstrated that the client is developmentally incapable of acquiring them.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure a continuous training program in the area of communication skills was implemented. This was noted for both individuals in the sample (Individuals #1 and #2). The findings included:
A) Goal plans for Individual #1 were reviewed on March 25-26, 2025. This review revealed a communication goal was not implemented during the past year.
B) Goal plans for Individual #2 were reviewed on March 25-26, 2025. This review revealed a communication goal was not implemented during the past year.
C) An interview with the Qualified Intellectual Disability Professional (QIDP) on March 26, 2025 at 1:00 PM confirmed that Individuals #1and #2 did not have a training program in the area of communication during the past year.
Plan of Correction:In regard to Items A and B, the facility failed to implement a continuous training program in the area of communication skills for Individuals #1 and #2 over the past year.
In response to this, the facility will review the annual assessment tool utilized for individual #1 and #2 as well as all other individuals. The facility will ensure that the assessment represents the individuals' current communication abilities by evaluating both verbal and non-verbal communication methods to determine their strengths and areas that require further development. The QIDP will update the IPP for Individual #1 and #2 to reflect the results of their assessments.
The QIDP will develop a communication goal tailored to Individual #1 and Individual #2's needs and abilities in order to support them in expressing basic needs and preferences. New documentation will be implemented to track participation and progress in communication development and all staff will be trained on how to implement Individual #1 and Individual #2's specific program goals. Regular audits and quarterly review of these programs will occur by the QIDP.
Additionally, we will implement a facility-wide review to ensure that all individuals are receiving communication training.
These corrective actions will be fully implemented by May 1, 2025. Effectiveness of these interventions will be evidenced by no further individuals failing to have a training plan related to communication in place. The QIDP will have overall responsibility for these interventions.
483.470(i)(1) STANDARD
EVACUATION DRILLS
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and under varied conditions to-
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to ensure fire drills were conducted under varied conditions. This was noted for all three shifts fire drills were conducted in the last year. The findings included:
A) Fire drills from the past year were reviewed on March 25, 2025. This review revealed:
1) On first shift, three fire drills occurred between 10:00 AM and 12:30 PM. Additionally, three fire drills occurred on Saturday and Sunday.
2) On second shift, all four fire drills occurred between 3:38 PM and 4:10 PM.
3) On third shift, two of four fire drills occurred on Friday, and two of four fire drills occurred on Saturday.
B) The Staff Supervisor was interviewed on March 26, 2024, at 1:30 PM and confirmed that the facility failed to conduct fire drills under varied conditions on all three shifts.
Plan of Correction:In regard to Item A, the facility failed to perform fire drills under varied conditions as all drills were typically conducted around similar timeframes.
The facility will implement a revised schedule for conducting evacuation drills that incorporates varied conditions. These drills will be planned for different shifts at varied times to ensure that all staff and individuals are prepared for emergency evacuations. This will be completed by 5/1/2025.
The facility will also begin using iCare Manager to schedule and monitor fire drills. This system will allow supervisors to generate reports showing that evacuation drills have been conducted under varied conditions, providing clear evidence of compliance.
By implementing a revised drill schedule, conducting staff training, and establishing an on-going monitoring and auditing process by utilizing iCare Manager's Drill module, the facility will ensure that all individuals and staff are prepared in the event an emergency situation occurs requiring evacuation.
Effectiveness of these interventions will be evidenced by no further instances where the facility fails to conduct fire drills under varied conditions and that all regulatory requirements are being met. The ICF Supervisor will have overall responsibility for these interventions.
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