Initial Comments:
A focused fundamental survey was conducted October 1-2, 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 four and the sample consisted of two 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, review of physician's orders, and interview it was determined that the facility failed to ensure that all medications are administered without error. This applied to one of two individuals observed during the morning medication administration pass. Findings included:
Observations of part of the morning medication pass were completed on October 1, 2025, from 6:36 AM to 7:09 AM. Individual #3 was observed at 7:05 AM to have six medications administered. At this same time, the medication trained staff confirmed that those were all the medications that Individual #3 was to receive at that time. Review of Individual #3's current physician's orders dated September 6, 2025, revealed a seventh medication, "acetylcyst" that was also ordered for 7:30 AM. This medication was not observed to be administered.
Interview with the health services supervisor (HSS) on October 1, 2025, at 9:30 AM confirmed that the medication was not given with the other 7:30 AM ordered medications. The HSS further stated that the medication administration record (MAR) was marked by the nurse for the medication trained staff to administer this medication at 6:30 AM. The HSS confirmed that the "acetylcyst" was administered too early in error and not in accordance with the physician's orders. The HSS presented Individual #3's MAR and it confirmed that the administration time was changed to 6:30 AM and it was initialed as administered by the night staff.
Plan of Correction:Merakey Allegheny Valley School (AVS) 189 Harmony Road, 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, 189 Harmony Road, Slippery Rock, PA 16057 , 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, 189 Harmony Road, Slippery Rock, PA 16057, may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
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On 10/1/25, the Medication Errors that occurred on this day during the morning medication pass were reported to the oversight agency.
The Licensed Practical Nurse that reviewed and approved the Medication Administration Record and noted the 90-day physician order's on 9/16/25 for the morning med pass on 10/1/25 was remediated by the Health Service Supervisor on the requirement of all medications written on the Medication Administration Record must match the physician order's in the medical chart. Upon completion of the remediation and review, a Supervisory Note was issued to the LPN.
By 1/31/26 the Licensed Practical Nurse responsible for the error that occurred between 9/17/25-10/1/25 will have the Health Service Supervisor and/or designee review and reconcile the Medication Administration Record prior to the start of each cycle medication start for 3 months.
By 11/1/25 Mercer/Butler's Merakey Allegheny Valley School's Nursing Department will be re-in-serviced by the Health Services Supervisor and/or designee on the 90-day Physician Order Protocol with emphasis on the requirement for all three components to match (Medication Administration Record, Physician Order, and Medication Prescription Label). A Staff Attendance Sheet will be signed by all staff in attendance for confirmation that they received the training and any and all questions were answered.
Effective 11/1/2025, random chart audits will be conducted on a monthly basis for three (3) months to verify the current Medication Administration Record matches the Physician's orders in the medical chart. The chart audits will be completed by a staff nurse within the Butler/Mercer Medical Department. The audits that are completed will be reviewed by the Health Services Supervisor and/or designee.
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