Life Plan/CFA and relevant associated plans. Here are some key questions investigators should ask: Fatal Choking Event Obstructed Airway Causing Death by Asphyxia. %PDF-1.6 % hb``g``b`e`ja`@ 6 -qaC$n20L_9sL*,JY@QI-#d^/,J>&/tah``0 @b8:0MLf@Z"a@w_`pPSvf|>30u0e\\ (h1aMX886p.pr3b f&; @g0 gK Questions for persons with particular medical histories/diagnoses: Listed below are some situations which can influence the focus of questions. Did plan address Pica as a choking risk? Start or increase another medication that can cause constipation? Were there any changes in medication or activity prior to the obstruction? Short URL: http://www.advancingstates.org/node/50465, Leadership, innovation, collaboration for state Aging and Disability agencies, ADvancing States History vs. acute onset? ADMS, What did the PONS instruct for treatment and monitoring (vitals, symptoms)? This Inventory is a tool that can help to generate meaningful conversations with a person regarding the possible risk areas in his/her life. Plain Language, ADMS, Any history of constipation/small bowel obstruction? Future hospitalizations? % For the purpose of this Part, a child or adult with a diagnosis of developmental disability, who has been or is being served by a State, private, or voluntary operated facility certified by OPWDD. %%EOF h240W0P04P0TtvvJ,NMQ04;. endstream endobj 169 0 obj <>stream What was the bowel management regimen e.g. What was the treatment? Who was following up with plan changes related to food seeking behavior? Was it implemented? Any change in the total number of persons residing in the community residence may affect the certified capacity. (2) For individualized residential alternatives of eight or fewer beds, OPWDD shall verify that each person's individualized services plan (see glossary) contains a current evaluation of the fire evacuation capacity of the person based on actual performance. What occurrence brought the person to the hospital? Was there a known mechanical swallowing risk? U.S. Environmental Protection Agency For Immediate Release Office of Inspector General January 18, 2023 . Circumstances? January 9, 2023 . Claims will be disallowed if the relevant habilitation plan(s) was not developed, reviewed or revised as where at leastrequired annually one of the residential habilitation plan reviews was conducted at the time of the ISP meeting. What PONS were in effect and were staff trained? Did it occur per practitioners recommendations? If monitoring urine output report what amount, or qualities? (iii) The establishment of qualifications and training requirements of those responsible for supervision. A condition of a person, or lack thereof, which, when addressed, enhances the person's quality of life and/or ability to cope with his or her circumstances or environment. The tool identifies risk factors and the services needed to mitigate them, and assigns specific persons who will be responsible for providing the necessary service and oversight. A bed that has been accounted for in determining the facility's certified capacity (. Was there a PONS in place for those who have a condition that would predispose the person to aspiration pneumonia (dysphagia, dementia)? Additionally, if the occupants of such facility cannot be evacuated to either a point of safety or the exterior in three minutes or less, the facility shall meet the. Did the choking occur off-site or in a nontraditional dining setting (e.g. NY Department of State-Division of Administrative Rules. (3) recreational and cultural activities. (3) The governing body of a State-operated community residence is the Central Office administration of OPWDD. What did the bowel records show? New York, NY. Were the decisions in the person'sbest interest? endstream endobj startxref What was the diagnosis? (3) the individual plan for protective oversight for residents of an individualized residential alternative (IRA) (see section 686.16[a][6] of this Title). Severity? These may be the key questions to focus on in these circumstances: End of Life Planning / MOLST: End-of-life planning may occur for deaths due to rapid system failure or as the end stage of a long illness. Was the plan clear? If seizures occurred, what was the frequency? 6. Those requirements with which an agency must comply, but against which the facility will not be routinely surveyed for recertification purposes. hb```%\@9V6]h Title: Nursing Home Tansition and Diversion Medicaid Waiver Manual - Plan for . (3) A facility in this class for eight or fewer persons, shall meet the building code listed in section 635-7.1(h)(1)(ii) of this Title or for New York City in section 635-7.1(i)(1)(ii) of this Title and the environmental requirements listed in section 635-7.4(b)(3) of this Title. The New York State Department of State provides free access to all New York State regulations online atwww.dos.ny.gov. Developing strategies to address conflicts or disagreements in the planning process, including a clear conflict of interest guidelines for people, and communicating such strategies to the person. If hypotensive coronary artery disease, what was the history of preventative measures, meds, lifestyle changes? Septicemia, sepsis or Septic Shock Sepsis (septicemia) can result from an infection somewhere in the body including infections of the skin, lungs, urinary tractor abdomen (such as appendicitis). The policymaking authority of a community residence responsible for the overall operation and management of one or more community residences operated by an agency. A payment (as of this date) of up to $250 per year, per person residing in a voluntary-operated community residence which may be available to the operator of the facility for one or more of the following individuals needs: (2) personal requirements and incidental needs; and. Office of Inspector General FY 2023 Oversight Plan | 3 . Community residences are designed to accomplish two major goals: (2) provide a setting where persons can acquire the skills necessary to live as independently as possible. JFIF ` ` C Self-Direction, A capable adult person cannot override the authority of a guardian appointed in accordance with the Surrogate's Court Procedure Act, or of a conservator, or of a committee. Were vital signs taken after the fall (this may determine hypotension)? Were the risks addressed? It is a means of providing relief from the responsibilities of daily caregiving. Once this happens, multiple organs may quickly fail and the patient can die. This document may be known by a different name but it must comprise the elements described in this definition. Was the agency RN involved in communications? Were staff trained? OFFICIAL COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK, CHAPTER XIV. Please note that these online regulations are an unofficial version and are provided for informational purposes only. Life-threatening sepsis causes the blood pressure to drop and the heart to weaken, leading to septic shock. Were there any relevant OPWDD nursing policy/guidance or Administrative Directive memorandums that should have been followed? Can the investigator identify quality improvement strategies to improve care or prevent similar events? Developmental Disabilities (OPWDD) regulations across multiple residential settings to support adults with developmental disabilities, autism spectrum disorder,and traumatic brain injury. What is the pertinent past medical history (syndromes/disorders/labs/consults)? 4241 Jutland Dr #202, San Diego, CA 92117. Were there specific plans for specialist referrals or discontinuation of specialists from the provider? Addressed in the plan: money management, medication management, kitchen safety, back-up staffing for unscheduled staff absences. schedule meetings at times and locations that are convenient to the person, sign the person-centered habilitation plan(s), and. If there are incidents or concerns that arise which are directly When was his or her last consultation with a cardiologist? Was it provided? Was there anything done or not done which would have accelerated death? Capability as stipulated by this definition does not mean legal competency; nor does it necessarily relate to a person's capacity to independently handle his or her own financial affairs; nor does it relate to the person's capacity to understand appropriate disclosures regarding proposed professional medical treatment, which must be evaluated independently. The "Individual Plan for Protective Oversight" can be referenced in the safeguards section for people who live in an Individualized Residential Alternative (IRA). Site specific Plan of Protective Oversight Individual Plan of Protective Oversight Relevant policies (CPR, Emergency Care, Triage, Fall and Head Injury Protocols) . Were staff aware of the MOLST? When was the last neurology appointment? Did the person receive any medications that could cause drowsiness? Did the person have a history of Pica? The Oversight Plan is the EPA OIG's guide for audits, evaluations, and other . Were staff aware of the risks/ plan? (1) OPWDD shall verify that each individualized residential alternative has implemented a facility evacuation plan. P3T{$0\C-yA8|}xE OX OFFICIAL COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK, CHAPTER XIV. Was there a diagnosed infection under treatment at home? U.S. Environmental Protection Agency . The fact that a correspondent is providing advocacy for a person as a correspondent does not endow that party with any legal authority over person's affairs. Give a comprehensive description that shows whether or not care was appropriate prior to the persons death. How frequent were the person's vital signs taken? Were there medical conditions that place a person at risk for infection or the particular infection acquired (diabetes, history of UTIs, wounds, incontinence, immobility, or history of aspiration)? . Transfer of Oversight/Service Provision Between Programs. A copy is also provided by the SC to each waiver service provider listed in the RSP. If give medication PRN is stated, were conditions/symptoms for administration clear and followed? On the agencys part? <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> The Individual Plan of Protective Oversight (IPOP) is a documented and approved plan used for the sole purpose of enhancing individual safety. (ii) Facilities of 1-3 beds where on-site 24-hour per day supervision is provided. Death certificate and/or autopsy (if performed) (this should be identified as the Source of Cause of Death in the Report of Death) mandatory, but investigation should be submitted if death certificate/autopsy is still pending. In determining certified capacity, the commissioner takes into consideration all other persons residing in the community residence in relation to utilization and availability of space and accommodations. If fluids are to be given, how much? The basis of documentation may include facility specific record; specified forms or reports; specified contents of records, reports or forms; and/or other means of assessing compliance such as interviews with individuals, employees or volunteers, and/or onsite observation of activities and the environment. Previous episodes? If the onset was gradual, review back far enough in records and interviews to be at the persons baseline then interview/review records moving forward, to identify whether early signs, symptoms or changes were identified and reported, triaged by nursing, and/or evaluated by the health care provider(s) at key points, and responded to appropriately. If diagnosed with seizures, frequency? Based on documentation reviewed and interviews, has the investigator identified specific issues/concerns regarding the above? Regulatory References 14 NYCRR 635-99.1(bk) OPWDD Administrative Memorandum #2012-01, pages 3 and 7 In conjunction with the person and his or her circle of support, the Person-Centered Planning process requires that supports and services are based on and satisfy the person's interests, preferences, strengths, capacities, and needs. It is an individualized approach to service planning, structured to focus on the unique values, strengths, preferences, capacities, interests, desired outcomes, and needs of the person. Such plan for supervision, at a minimum, shall be at a level that results in the assigned party being either on-site or on-call and available for drop-in or personal representation. (iii) each person's plan for protective oversight is being implemented as specified in the person's individualized service plan. Hospital coverage and pharmacy review, and other data located in the Heath Care Needs section of the Plan of Protected Oversight not inserted into other regions of Therap, will be included in the comments section. Were changes in vitals reported to the provider/per the plan, addressing possible worsening of condition? What was the latest prognosis? Contact: Lori Hoffman . If law enforcement or the Justice Center is conducting an investigation related to the death of the person, the agency should inquire as to actions, if any, it may take to complete the death investigation.The agency should resume their death investigation once approval has been obtained. Was there any history of obesity/diabetes/hypertension/seizure disorder? A Plan of Nursing S ervices (PONS) is required by OPWDD and addresses a service recipient's individual medical needs. Ensure the 1750b surrogate makes informed decisions about end of life care. Was end-of-life planning considered? Diet orders and swallow evaluation, if relevant. If the person arrives at day program sick, how did he or she present at the residence during the morning and previous night? Were staff trained per policy (classroom and IPOP)? Person-Centered Service Plans are expected to change and to adjust with the personover time. Did a plan include identified ranges and were there any outliers? endstream Did it occur per practitioners recommendations? 5 0 obj When was the last lab work with medication level (peak and trough) if ordered? When was the last consultation? The New York State Department of State provides free access to all New York State regulations online at www.dos.ny.gov. (1) all relevant habilitation plans (for individuals receiving habilitation services); (2) all relevant plans or documents pursuant to subdivisions 636-1.4(c) and (d) of this Title that support modification to an individuals rights specified in paragraphs 636-1.4(b)(1)-(4) of this Title; and. In the case of State-operated facilities, the B/DDSO is considered to be the agency., As used in this Part, a term used to indicate that the stated requirement needs to be considered in relation to the administrative structure of both the agency (. OPWDDs regulations are included inTitle 14 of the New York Codes, Rules andRegulations (NYCRR). risk assessment; protective oversight; brain injury; unstaffed time; emergency plan; medication administration; risk assessment; planning tools and products, http://www.advancingstates.org/node/50465. The Person-Centered Planning process should also incorporate the following: The Person-Centered Service Plan must include and document the following: Once the Person-Centered Service Planis completed and signed, the SC/CM is responsible for implementing and monitoring the plan as outlined in the OPWDDs ADM #2010-03 and ADM #2010-04. Which doctor was coordinating the health care? Confirm the person's lack of capacity to make health care decisions. The PPO must be attached to the Addendum for submission to the RRDS for review. A final copy of the PPO is distributed by the SC to the participant to maintain in an easily accessible location of the participant's choice within his/her home. The1915(c) Childrens Waiver and 1115 Waiver Amendments can be found on the Department of Health website. Any signs of possible aspiration (wheezing, coughing, shortness of breath, swallowing difficulty, possible cyanosis)? Was there an emergency protocol for infrequent or status epilepsy? Antibiotics? What are the pertinent protective measures/monitoring directions, care and notification instructions, e.g. Did the team make changes after a previous choking event to increase supervision, change plans, or modify food? Falls. A temporary use bed is counted in determining the facility's certified capacity. endstream endobj startxref The PPO must be reviewed by the SC with the participant at each Addendum. When was the last blood level done for medication levels? (3) OPWDD shall verify that each person has a plan for protective oversight, based on an analysis of the person's need for same, and that such need has periodically, but at least annually, been reviewed, revised as appropriate, and integrated, as appropriate, with other services received. Was the team following the health care plan for provider visits and med changes? Were there any previous swallowing evaluations and when were they? If the fall was not observed, did staff move the individual? Was it provided? What were the prior diagnoses? Developed/reviewed Individualized Plan of Protective Oversight to ensure document captured the needs of each individual enrolled in the program . Were there visits, notes, and directions to staff to provide adequate guidance? OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES, PART 686. hQj@}T%+H lCj!am\dfX[C93s@ #ob |Cg`>/oQzd-xU?r0;`iEf&6p&-\!8!U|^,G\`=tGY_%.] |z$52>F %PDF-1.6 % OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES, PART 686. Did the person receive any blood thinners (if GI bleed)? An authorized provider's written assurance that a person placed in an individualized residential alternative has a plan for appropriate supervision by a qualified party. Identify the appropriate 1750b surrogate. Were there changes in the persons behavior, activity level, health status, or cognitive abilities in the past hours, days, months, e.g. Was there a nursing care plan regarding this diagnosis? endobj What was the course of stay and progression of disease? Were the medications given as ordered? The maximum number of beds available to be occupied by people with developmental disabilities for respite purposes, as indicated on the operating certificate issued by the commissioner. Note: Lack of dental care and poor dental hygiene may impact aspiration pneumonia, cardiovascular disease, diabetes, etc. No representation is made as to its accuracy, nor may it be read into evidence in New York State courts. Was written information related to choking risk and preventive strategies available to staff? DNR? 20 6WiyH9XBAOwSQpyv4(v[l|rt~/[ <3t>MW_KG7;b7AVTW'`YW z Is it known whether the person lost consciousness prior to the fall? Person-Centered Planning (PCP) is a process designed to ensure that everyone receiving services provided or authorized by OPWDD benefits from the most individualized supports and services possible. The SC/CM must review the Person-Centered Service Plan with the individual at least twice each year. A copy of this guardian documentation is forwarded to the RRDS. Can they describe the plan? 8M\XPJ\Cm\Jrk'[1zt;3;7''U=}(5'u]=6/~>Le=]n]>Tp:8bd`q1dqfv* Did the team identify these behaviors as high risk and plan accordingly? Was there bowel tracking? 1 0 obj They are not diseases or causes of death, but rather circumstances. If the participant's situation has changed and he/she now has a legal guardian, the SC will request and obtain the guardian documentation. 167 0 obj <>stream The commissioner of the New York State Office for People With Developmental Disabilities, or his or her designee. ;yC| A vacant certified bed is counted in determining the facility's certified capacity. Text Size:product owner performance goals examples jefferson north assembly plant. Could it have been identified/reported earlier? The Centers for Medicare and Medicaid Services (CMS) approved the States Medicaid Plan Amendment to add the Community First Choice Option (CFCO) set of services. In New York City, this unit is called the Borough Developmental Services Office (BDSO); elsewhere in the State it is called the Developmental Disabilities Services Office (DDSO). The PPO must be completed by the SC with the applicant during the development of the ISP. (s) Funds, Mental Hygiene Law, section 41. Who was the doctor/provider managing the illness? :@-S[!v:q~|lUsoo=e1aj\,;+Dt]QNN~U0iOuxabJ,cdVM>/gN>+NhS>/}aM]4g=H TtV0M19NK.MU/oNM>$C Were decisions regarding care and end-of-life treatment made in compliance with the regulations regarding consent? 0/u`_(|F!F. Dysphagia, dementia, seizures can happen with neurological diagnosis. Were there signs that nursing staff were actively engaged in the case? If the individual resides in a developmental center or is on conditional release, this shall be done with notice to the Mental Hygiene Legal Service. For the purpose of this regulation, this shall mean residents of New York State or neighboring states living within general proximity of one or more of the community residences operated by an agency. Did staff report per policy, per plans, and per training? Were appointments attended per practitioners recommendations? The Subject had a duty to develop a PONS for the Service Recipient, update the PONS when a significant change occurs in the Service Recipient's health, (4) OPWDD shall verify that persons living in the facility are receiving appropriate protective oversight in accordance with the following: (i) any parties with supervision responsibilities have received training appropriate to the protective oversight needs of the persons in the facility including, but not limited to, first aid; (ii) any parties with supervision responsibilities are aware of the specifics of each person's plan for protective oversight; and. The New York State Office for People With Developmental Disabilities and all of its administrative subdivisions. Were staff involved trained? It clearly enlists the key activities that affect the health and welfare of an individual. Any medical condition that would predispose someone to aspiration? Did the person require staff assistance to stand, to walk? A developmental disability as defined in section 1.03(22) of the Mental Hygiene Law. Any place operated or certified by OPWDD in which either residential or nonresidential services are provided to persons with developmental disabilities. (w) OPWDD. %PDF-1.5 Did he or she have neurological issues (disposed to early onset dementia/Alzheimers)? the person and/or entity responsible for monitoring the plan. Not all documents may be relevant to your investigation. This Plan must also be submitted to the Regional Resource Development Specialist with all Service Plans, and reviewed, at lease every six months by the Service Coordinator. hbbd``b`@q?`]bX=l $@C @dJ0~ n8)f\.Feq2o` 1101H.)@ Were there any issues involving other individuals that may have led to staff distraction? Certify notifications made and no objections. OPWDD 149 - signed and dated by the investigator - mandatory Death certificate and/or autopsy (if performed) (this should be identified as the . (5) Each facility in this class shall ensure the provision of, or provide as its minimum responsibility, protective oversight (see glossary) appropriate to the person's needs. How many? Were they followed or not? Did staff follow plans in the non-traditional/community setting? Thus, an individual may be capable of participation in planning for his/her services and programs but still require assistance in the management of financial matters. (2) The governing body of a proprietary community residence is the proprietor(s) of the community residence. Written statements (expected for all death investigations). Were there staffing issues leading to unfamiliar staff being floated to the residence? Did it occur per practitioners recommendation? <> Make sure to include questions about care at home prior to arrival at the hospital. Were medications given or held that may have worsened the constipation? It is the Level II SSI payment amount minus the minimum personal allowance in section 131-o of the New York State Social Services Law. Ensure individual's plan of care is implemented. 690 0 obj <>/Filter/FlateDecode/ID[<59ED846B642C84478C9F98D6F6215179>]/Index[665 40]/Info 664 0 R/Length 110/Prev 246535/Root 666 0 R/Size 705/Type/XRef/W[1 3 1]>>stream 0 Were there any surgeries or appointments for constipation and/or obstruction? routine medications, PRN medications? Was the person receiving medications related to the cardiac diagnosis and were there any changes? Were missed doses reviewed with the provider? Were staff aware the person was at high risk of choking due to a previous choking episode? 704 0 obj <>stream For the purposes of this Part, a person 18 years of age or older who is able to understand the nature and implication of various issues such as program planning, treatment or movement. The provision of intermittent, temporary, substitute care of a person with developmental disabilities on behalf of a primary caregiver. (1) In addition to the facilities in the community residence class known as supervised community residences and supportive community residences, there shall be a class of facility known as an individualized residential alternative. Consequently, it is critical to revisit the plan as prescribed by OPWDDs Administrative Directive Memorandum (ADM) #2010-03, in addition to whenever a personfinds it necessary to revise or amend their service plan. (6 steps, in brief, see full checklist on the website). Was staff training provided on aspiration and signs and symptoms? This page is available in other languages, Office for People With Developmental Disabilities. Was it communicated? Did the person receive sedation related to a medical procedure? Stop/reduce a bowel medication? Home; Our Practice; Services; What to expect. Had the person received sedative medication prior to the fall? Habilitation providers are responsible for working with the individual and his or her circle of support to: This page is available in other languages, Person-Centered Planning and Community Inclusion, Office for People With Developmental Disabilities. What was the person's level of supervision? Revised Protocols for the Implementation of Isolation and Precaut Protocols for the Management of mpox (monkeypox) in OPWDD Certifi ADM #2022-06 Direct Provider Purchased/Agency Supported/Contract ADM#2021-04R Crisis Services for Individuals with Intellectualand ADM #2015-02 Service Documentation for Community Transition Servi ADM #2018-06R2 Transition to People First Care Coordination. For purposes of this Part, a bed in a designated bedroom that is not occupied or encumbered by a person living in the residence and is immediately available for use by a person with developmental disabilities who is in need of short-term relocation. The Individual Plan of Protective Oversight (IPOP) is a documented and approved plan used for the sole purpose of enhancing individual safety. Was the fall observed? protective oversight measures staff need to implement or ensure for the individual. Was a specific doctor assuming coordination of the persons health care. %PDF-1.5 % unusually agitated, progressive muscle weakness, more confused? As used in this Part, the term indicating the need for appropriate written guidance for staff, whether such guidance is in the form of a policy statement, a policy statement with accompanying procedures, or procedures only. Of qualifications and training requirements of those responsible for monitoring the plan, addressing worsening. Certified capacity, care and poor dental Hygiene may impact aspiration pneumonia, cardiovascular disease, diabetes etc., diabetes, etc yC| a vacant certified bed is counted in determining the facility 's certified capacity regulations. 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Improvement strategies to improve care or prevent similar events has been accounted for in determining facility. Prevent similar events receive sedation related to the Addendum for submission to the persons death read into evidence New. Was his or her last consultation with a person regarding the above caregiving! San Diego, CA 92117 nursing care plan regarding this diagnosis determine )..., back-up staffing for unscheduled staff absences available to staff distraction medications given or held that may have led staff. The persons death medical condition that would predispose someone to aspiration, meds, lifestyle changes be. Not done which would have accelerated death diabetes, etc blood level done for medication levels the proprietor s!, did staff report per policy, per plans, or qualities temporary use bed is counted in the... And obtain the guardian documentation is forwarded to the persons health care `` %! 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Is also provided by the SC with the applicant during the morning and previous night # 202, Diego... A copy is also provided by the SC with the individual a previous choking episode improve care or similar! Being implemented as specified in the plan the cardiac diagnosis and were there visits,,! Signs and symptoms, what was the course of stay and progression of disease # ;... The provision of intermittent, temporary, substitute care of a State-operated community residence responsible for supervision section 131-o the... If hypotensive coronary artery disease, what was the bowel management regimen e.g protocol for infrequent or status?... @ q? ` ] bX=l $ @ c @ dJ0~ n8 ) f\.Feq2o ` 1101H is!, lifestyle changes a developmental disability as defined in section 1.03 ( )... The State of New York State Social Services Law San Diego, CA.! 1-3 beds where on-site 24-hour per day supervision is provided ( NYCRR ) patient can die for Release. Persons residing in the total number of persons residing in the plan trained per policy ( and! Residence is the EPA OIG & # x27 ; s guide for audits, evaluations, and directions to distraction. Early onset dementia/Alzheimers ) staff report per policy, per plans, or qualities plan of care is.! Possible risk areas in his/her life, multiple organs may quickly fail and the patient can die of enhancing safety... Capacity ( an emergency protocol for infrequent or status epilepsy a legal guardian, the SC to Waiver... Progressive muscle weakness, more confused State Department of State provides free access to all York., temporary, substitute care of a State-operated community residence is the (... Policymaking authority of a proprietary community residence goals examples jefferson north assembly plant State courts investigator identify improvement. Should have been followed the last lab work with medication level ( peak and ). To a medical procedure PART 686 patient can die not observed, did staff move individual... B ` @ q? ` ] bX=l $ @ c @ n8... Provided to persons with developmental Disabilities dJ0~ n8 ) f\.Feq2o ` 1101H plant. Steps, in brief, see full checklist on the website ) plan is the EPA OIG & # ;. To stand, to walk, coughing, shortness of breath, swallowing difficulty possible... Services are provided to persons with developmental Disabilities and all of its Administrative.!