Initial Comments:
A focused fundamental survey was conducted February 13-14, 2024, 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 eight and the sample consisted of three individuals.
Plan of Correction:
483.470(d)(3) STANDARD
CLIENT BATHROOMS
Name - Component - 00
The facility must, in areas of the facility where clients who have not been trained to regulate water temperature are exposed to hot water, ensure that the temperature of the water does not exceed 110 degrees Fahrenheit.
Observations:
Based on observations and interview, it was determined that the facility failed to ensure that water temperatures did not exceed 110 degrees. This applied to two of two water sources tested at the residence. Findings included:
Observations were completed at the residence on February 13, 2024, from 5:50 AM until 8:10 AM. During this time, the surveyors observed a sign in the kitchen which advised staff to be mindful of high water temperatures. At 7:38 AM, the water temperature was tested at the right bathroom sink, which had a reading of 116 degrees. At 7:40 AM, the water temperature was tested at the bathroom shower, which had a reading of 112.8 degrees.
An interview with the house manager (HM) and qualified intellectual disabilities professional (QIDP) was conducted on February 13, 2024, at 8:06 AM. At this time, the QIDP checked the water temperature again with the facility's thermometer. The QIDP confirmed that the water temperature at the right bathroom sink measured 114.8 degrees and the water temperature at the bathroom shower measured 111.2 degrees. The HM and QIDP confirmed that these temperatures exceeded 110 degrees and that they would contact the maintenance department immediately to address the high temperature.
Plan of Correction:It is the responsibility of Valley Community Services to ensure the safety of the individuals we serve. This will be accomplished by the following:
On 2/14/24 the local heating and plumbing business was contacted and scheduled to assess the hot water at the Belle Vernon ICF on 2/22/24. Belle Vernon ICF water temperatures are still needing to be regulated due to inconsistent water temperature readings at this time. The Facilities Director has been notified of the ongoing water temperature fluctuations and the local plumbing and heating business is being contacted to re-evaluate the water temperature concern. The re-evaluation will be completed by 3/12/24.
On 2/14/24 the Program Manager of the Belle Vernon ICF was trained by the OD / QIDP on checking the house's water temperature prior to individuals showering as well as using other water sources in the house to ensure that it does not exceed 110 degrees. If the water temperature is greater than 110 degrees, the Program Manager is to contact the Facilities Director. The Facilities Director will contact the local plumbing and heating business to evaluate the water temperature.
The individuals were notified by the Belle Vernon ICF Program Manager on 2/27/24 of the water temperature regulation concerns and encouraged to allow the staff to check the water temperature prior to contact with the home's water sources. All staff will be trained on using a digital thermometer to check the water temperature before the individuals have any contact with the water. If the water temperature exceeds 110 degrees, the staff are to contact the Program Manager and the Program Manager will contact the Facilities Director who will contact the local heating and plumbing business to assess the water temperature. This staff training was implemented on 2/22/24 and will be completed by 3/1/24.
On 2/20/24, all ICF Program Managers were trained on completing water temperature checks on a monthly basis which includes contacting the Facilities Director if the water temperature is greater than 110 degrees. The Facilities Director will contact the local plumbing and heating business to evaluate the water temperature. This process will begin on 3/1/24 and will end on 12/1/24. The ICF Operations Directors will monitor the Program Managers monthly water temperature checks. This monitoring will begin on 3/1/24 and will end on 12/1/24.
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