QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
Health Inspection Results For:

There are  11 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:

A focused fundamental survey visit was completed on December 9 and 10, 2021. 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:

483.440(c)(4) STANDARD

Name - Component - 00
Within 30 days after admission, the interdisciplinary team must prepare, for each client, an individual program plan.


Based on record review and interview with the facility and administrative staff, the facility failed to prepare a Individual Program Plan within 30 days after admission for one of one sample Individual who was newly admitted to the facility. This practice is specific to Individuals #1.

Findings include:

A review of Individual #1's record completed on 12/10/2021 between 9:00 AM and
11:00 AM revealed that Individual #1 was admitted to the facility on 03/03/2021. In further review, it was noted that the post admission Individual Program Plan (IPP) was not completed until 04/05/2021, 33 days after admission to this facility.

Interview with the Program Director, on 12/10/2021 at approximately 10:00 AM, confirmed that Individual #1's IPP meeting did not occur within 30 days of admission.

Plan of Correction:

The Qualified Intellectual Disabilities Professional(QIDP) was retrained on facility policy regarding new admissions and compliance on conducting 30 day meeting prior to the 30th day from admission date. A review for individual #1' record was completed by Program Director with QIDP.
The Director of Social Service will review all new admissions and assign date for 30 day staffing. All other individual's records were reviewed for compliance with admission policy and found all records within guideline of policy.
For the next year, the Program Director along with Director of Social Services will monitor all new admissions to ensure policy adherence including the requirement of 30 day admission inclusive of functional assessments me, not to exceed the 30 day limit.
Chart auditing will be conducted by Director of Social Service quarterly and randomly to monitor QIDPs execution of policy and record finding and report to Administrator who will direct needed action.
Persons responsible: QIDP, Program Director, Director of Social Service and Administrator will ensure compliance.