Inspection Report
Routine
Deficiencies: 0
Jul 2, 2025
Visit Reason
The inspection was an unannounced routine inspection conducted to review compliance with applicable rules for an Intermediate Care Facility for Individuals with Intellectual Disabilities.
Findings
The inspection found no rule noncompliances during the visit. The licensor reviewed compliance with multiple regulatory requirements including client rights, staffing, medication management, emergency plans, and facility policies.
Report Facts
Number of rule noncompliances: 0
Inspection Report
Renewal
Deficiencies: 8
Jan 18, 2023
Visit Reason
A re-certification survey was conducted starting on 01/17/2023 and completed on 01/18/2023 to assess compliance with Intermediate Care Facilities for Individuals with Intellectual Disabilities regulations.
Findings
Multiple deficiencies were identified related to staff training, individual program plans, management of inappropriate client behavior, nursing services, drug storage and recordkeeping, and space and equipment. The facility was found not in compliance with several regulatory standards, with plans of correction submitted and approved.
Deficiencies (8)
| Description |
|---|
| Staff must be able to demonstrate the skills and techniques necessary to implement the individual program plans for each client. |
| Individual program plans did not state specific objectives necessary to meet client needs as identified by comprehensive assessments. |
| Individual program plans did not include opportunities for client choice and self-management. |
| Program documentation did not show continuous active treatment programs for all sampled clients. |
| Management of inappropriate client behavior did not incorporate systematic interventions into individual program plans for all sampled clients. |
| Nursing services did not include implementing appropriate protective and preventive health measures including infection control. |
| Drug storage and recordkeeping did not ensure all drugs and biologicals were locked except when being prepared for administration. |
| Facility did not furnish and teach clients to use devices identified by the interdisciplinary team as needed. |
Report Facts
Deficiencies cited: 8
Clients sampled: 8
Plan of Correction approval date: Feb 22, 2023
Plan of Correction completion date: Mar 18, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danielle McKissen | HPS III | Approved the Plan of Correction. |
| Heather Miller | Administrator | Signed the initial comments and report. |
Report
Jun 13, 2024
File
20240613-checklist-618009.pdf
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