Initial Comments:
A focused fundamental survey was conducted August 12-13, 2025, 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 five and the sample consisted of three individuals.
Plan of Correction:
483.460(k)(2) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.
Observations:
Based on observations and interviews, it was determined that the facility failed to ensure that all medications were administered without error. This applied to three individuals (#2, #4, and #5) of five residing at the facility.
Observations of part of the morning medication pass were completed on August 12, 2025, from 6:38 AM to 8:14 AM. During that time two individuals were observed to receive their medications ordered for 7:30 AM; Individuals #1 and #3. At 8:14 AM, the staff confirmed that there were still three individuals at the residence that needed medications, and stated that Individual #1 still needed to be administered the breathing treatment which would be administered after all the other medications were administered. The staff further stated that she had until 8:30 AM to complete administration. Observations of the morning routine continued from 8:14 AM to 9:00 AM. During this time, the morning staff was observed to bring Individual #4 to the medication room at 8:30 AM for medications and shut the door. At 8:33 AM, Individual #4 came out of the medication room and at 8:35 AM, Individual #2 was taken to the medication room with an adaptive straw and the door was shut. At 8:39 AM, Individual #2 came out of the medication room and Individual #5 was taken to the medication room, both staff assisted Individual #5 to sit on a chair in the room and the door was shut.
Interview with the assistant health services supervisor on August 12, 2025, at 9:30 AM, stated that she would look into the medications being administered 8:30 AM and after. Subsequent interview with the heath services supervisor (HSS) on August 13, 2025, at 8:02 AM stated that the facility considered the information brought to the AHSS's attention on August 12, 2025, as medication errors for the the above three individuals. The HSS confirmed that it is the expectation of the facility for the medications to be administered between an hour before and an hour after the ordered time. The HSS further confirmed Individuals #2, #4, and #5 received their medications beyond the permitted administration window in error.
Plan of Correction:Merakey Allegheny Valley School (AVS), 338 Centreville Pike, Slippery Rock, Pa. 16057 makes its best effort to operate in full compliance with both Federal and State law. Nothing included in this Plan of Correction is an admission otherwise. Merakey AVS, 338 Centreville Pike, has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections to its merits or form of any allegations contained herein. Please note that Merakey AVS, 338 Centreville Pike may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
TAG # 369 Medication Administration
The Med trained staff person who was responsible for administering medications on the morning of 8/12/25 when the error occurred, was then prohibited from administering medications until she received re-training in Medication Administration through remediation and Medication Administration Observations were completed. The Health Services Supervisor and/or designee will review all documents for compliance by 8/31/25.
On 8-12-25, the Medication Errors that occurred on this day during the morning medication pass were reported to the oversight agency.
On 8-13-25, the Program Lead installed a clock in the Medication Administration room for staff to reference to order to stay in compliance with the allotted time frame for administering medications.
By 8/31/25, the Health Services Supervisor and/or designee will retrain all of the Butler/Mercer County Merakey/AVS Med Trained staff on the policy requirements for proper Medication Administration. Emphasis will be placed on administering medications within the permitted time frames.
By 11/1/25, the Program Lead or another Practicum Observer designee will complete random Medication Administration Observations twice a month for 2 months to monitor for compliance of time for Medication Administration. The Medication Observation checklist will be completed at each of the observations and submitted to the Health Services Supervisor for review.
By 8/31/25, the Health Services Supervisor and/or designee will consult with the prescribing Physician and Pharmacist to re-evaluate the clients current medications at 338 Centreville Pike to determine if the appropriate morning medications could be safely moved to a different administration time frame.
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