Initial Comments:
A focused fundamental survey was conducted on February 5-6, 2024, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Requirements for Intermediate Care Facilities. The census during the survey was three and the original sample consisted of two individuals. Six deficiencies were identified.
Plan of Correction:
483.420(a)(7) STANDARD
PROTECTION OF CLIENTS RIGHTS
Name - Component - 00
The facility must ensure the rights of all clients. Therefore, the facility must ensure privacy during treatment and care of personal needs.
Observations:
Based on observation and staff interview, it was determined that the facility failed to provide privacy during administration of treatments. This was noted for one of the two individuals during an observed medication administration (Individual #3). The findings included:
A) Medication administration was observed on February 5, 2024, between 4:00 PM and 6:00 PM. At 5:25 PM, Individual #3 received nasal spray, as well as topical treatments to his face. This individual was seated in the living room with Individuals #1 and #2 present.
B) The staff administering medications (SAM) was interviewed after this administration. The SAM acknowledged that the treatments were administered without the benefit of privacy for Individual #3.
Plan of Correction:Tag 0130
Merakey Allegheny Valley School, 850 Middletown Road, makes its best effort to operate in full compliance with Federal and State Law. Nothing included in this Plan of Correction is an admission otherwise. 850 Middletown Road has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections to the merits or form of any allegations contained herein. Please note that 850 Middletown Road may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
The Facility will ensure the rights of all clients. Therefore, the facility must ensure privacy during treatment and care of personal needs.
On 2/06/24 the surveyor informed the Health Services Supervisor that while observing the med passes for individuals in the home, they noted staff had failed to provide the individual privacy when administering a nasal spray and applying facial treatment.
A medication administration practicum for the staff person who did not provide privacy for the individual at the time of the observation will be completed by February 21, 2024.
The nurses will re-train the house manager aide who administered medications at the time of survey, the house manager, and the remaining house manager aid staff in the home concerning proper procedure for completing a medication pass which includes instruction r/t privacy. This training will be completed by March 1, 2024, and will be documented on a Staff Attendance (SA) sheet. Once the training of all staff in the home is completed, this will be reported to the Residential Director for and Director of Nursing. SA sheets will be sent to the Staff Development Coordinator to verify all staff have received training.
Monitoring of medication administration to ensure all staff in the home are maintaining the individual's privacy while administering medications and treatments will be completed by the nurse, Assistant HSS (AHSS) or HSS. Documentation of this monitoring will be kept on the Medication Pass Audit form. The Medication Pass Audit is a visual observation of the staff administering medications and treatments. This visual process includes, but is not limited to, ensuring individuals privacy throughout the entire medication/treatment administration procedure. Random AM and PM audits will occur weekly for two months. If this monitoring reveals that staff are following the Medication Administration procedure correctly, then the monitoring will begin to be tapered to bi-weekly for two months, then monthly for a period of two months, and then as needed. Med Pass Audits will begin the week of February 18, 2024.
If during this process, it has been identified that the staff observed are not administering medications as per policy training will be provided individually to that staff person and random audits will be increased in frequency. Staff who fail to follow policy will be referred to the ICF Administrator for corrective action.
The ICF Administrator and HSS will review all completed Med Pass Audits monthly to ensure the audits are completed as scheduled.
483.420(d)(2) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to ensure allegations of abuse, neglect, or mistreatment were reported immediately to facility administration. This was noted for three out of four allegations of neglect. The findings included:
A) Facility incidents and investigations were reviewed on February 5, 2024. This review revealed an allegation of neglect for staff sleeping on March 15, 2023. Witness statements revealed that the house manager entered the staff office in the home at 5:00 AM and found the only staff on duty asleep. Further review of the investigation report revealed that the house manager did not report this allegation of neglect to facility administration until 12:10 PM that same day.
B) The administrator was interviewed on February 5, 2024, at 11:00 AM. The administrator confirmed that the above-mentioned allegation of neglect was not immediately reported to facility administration.
Plan of Correction:Merakey Allegheny Valley School, 850 Middletown Road, makes its best effort to operate in full compliance with both Federal and State Law. Nothing included in the Plan of Correction is an admission otherwise. Merakey Allegheny Valley School, 850 Middletown Road has submitted this Plan of Correction to comply with its regulatory obligation and does not waive any objections to its merits or form any allegations contained herein. Please note that Merakey Allegheny Valley School, 850 Middletown Road 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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Merakey Allegheny Valley School, 850 Middletown Road will ensure that all allegations of mistreatment, neglect, or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.
The Administrator or designee will conduct re-training for House Manager Aides (HMA), Program Coordinator (PC) and House Manager (HM). The importance of ensuring that all allegations of mistreatment, neglect, or abuse as well as injuries of unknown source, are reported immediately to the Administrator or to other offices in accordance with State law through established procedures will be reviewed. Additional re-training for the House Manager (HM) will include specific emphasis on the need to immediately report verbally to the Administrator or designee when an allegation of abuse or neglect is made. If late reporting is identified, this will be addressed immediately via re-training or via the standard disciplinary process. Re-training will be completed and documented on a Merakey Staff Attendance Sheet (SA)by March 1st, 2024.
In order to monitor the training was effective, the Sr. Executive Director or designee will review initial EIM submissions of incidents involving abuse and neglect to ensure prompt reporting for a period of three months (March, April and May 2024). This review will occur within 24 hours of the incident being reported within the incident management system and documented within the investigative file as well as any identified necessary follow-up as determined at time of review. If late reporting is identified, this will be addressed immediately via re-training or via standard disciplinary process. The initial review period will also be extended for another three months.
483.420(d)(3) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must have evidence that all alleged violations are thoroughly investigated.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to thoroughly investigate a complaint of exploitation and neglect of service for Individual #3. This was noted for the only complaint in the past year. The findings included:
A) A review of investigative packets was performed on February 5, 2024. This review reveled a report that indicated on July 6, 2023, the facility received a report from APS [Adult Protective Services] which alleged the facility was not taking Individual #3 to his daily activities. The report indicated that this individual "is paying for these things, they [the facility] are not providing the services they are being paid for".
Review of the investigator's findings on the "five-day report" indicated "the SC is alleging that [Individual #3] is being denied services specifically horseback riding and being transported to medical appointments".
There was no documentation in the investigative packet of who or what is SC, and was SC interviewed. There was no explanation of the discrepancy of APS reporting this complaint to the facility and information from SC. There was no documentation of the complainant being contacted while the investigation was in process. (The complainant gave a statement August 12, 2023.) There was no documentation in the packet to substantiate or unsubstantiated the allegations of exploitation (not receiving services) or neglect of healthcare needs.
B) The administrator was interviewed on February 5, 2024, at 10:45 AM and confirmed the investigation was not thorough.
Plan of Correction:Merakey Allegheny Valley School, 850 Middletown Road, makes its best effort to operate in full compliance with both Federal and State Law. Nothing included in the Plan of Correction is an admission otherwise. Merakey Allegheny Valley School, 850 Middletown Road has submitted this Plan of Correction to comply with its regulatory obligation and does not waive any objections to its merits or form any allegations contained herein. Please note that Merakey Allegheny Valley School, 850 Middletown Road 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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Merakey Allegheny Valley School, 850 Middletown Road will ensure that the facility has evidence that all alleged violations are thoroughly investigated.
For the affected Individual #3, the Certified Investigator (CI) updated the 5-day notification to correctly identify the complainant as Individual #3's legal guardian. The updated 5-day notification has been filed in the Investigation Packet.
Effective immediately, all 5-day notifications will be reviewed by the Quality and Compliance Organization (QCO) Incident Supervisor for accuracy and detail prior to Administrator submission. The Incident Supervisor will in turn ensure that the 5-day notification will serve as both a reminder and verification that all identified witnesses at the 5-day mark have been interviewed or are scheduled to be interviewed within the standard 10-day expected timeframe. Should any identified witnesses not respond to Certified Investigator (CI) requests for interview, this information will be elevated to the Administrator prior to the end of ten (10) day anticipated interview completion window and documented in the final version of the Certified Investigation Report (CIR).
Effective immediately, all investigation packets will be submitted to the Administrator at least 24 hours prior to the Administrative Review Committee. The Administrator will review the investigation packet before the Administrative Review Committee to identify any areas of discrepancies and/or if additional information is needed to make a determination on the investigation. A determination will not be made until all identified discrepancies have been remedied and all information needed to make a determination has been reviewed and presented.
Regarding the overall quality and thoroughness of Investigations conducted by the Quality and Compliance Organization (QCO), a Certified Investigator Workshop was facilitated by the Quality and Compliance Organization (QCO) Incident Director on January 18th, 2024. The training content focused on the investigatory standards set forth in the most recent version of the Certified Investigator Manual and included a refresher review of all key areas of the investigation process, including the importance of capturing testimonial evidence from all identified parties in a timely manner. All current QCO Certified Investigators were in attendance during the satellite workshop.
In regards to the Administrative Review process, Quality and Compliance Organization (QCO) Incident Director will conduct training in line with ODP/DOH standards specific to a comprehensive analysis and completion of the Administrative Review Committee (ARC) procedure. This training will be completed no later than March 15th, 2024.
In order to monitor that the training was effective, the Sr. Executive Director or designee will review investigative files involving abuse and neglect for a period of three months (March, April, May 2024) and as needed thereafter to ensure all required information has been collected, documented and are presented in total consistently. Review and findings follow-up will be documented within the investigative file. Any concerns identified during the review will be addressed via re-training or via standard disciplinary process. The initial review period will also be extended for three months.
483.420(d)(3) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must prevent further potential abuse while the investigation is in progress.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to ensure abuse was prevented while investigating an allegation. This was noted for three of the four allegations of neglect. The findings included:
A) Facility incidents and investigations were reviewed on February 5, 2024. This review revealed an allegation of neglect for the staff sleeping, on March 15, 2023. Witness statements revealed that the house manager (HM) entered the staff office in the home at 5:00 AM and discovered the only staff on duty, asleep. Further review of the witness statements revealed that the HM called this staff person's name to awaken them. The HM then went back upstairs to their apartment. The staff continued their duties. The target staff person continued to work alone for the remainder of the shift, until 7:00 AM.
B) The facility administrator was interviewed on February 5, 2024, at 11:00 AM. The administrator confirmed that the target continued to work alone until the end of her shift, two hours later.
Plan of Correction:Merakey Allegheny Valley School, 850 Middletown Road, makes its best effort to operate in full compliance with both Federal and State Law. Nothing included in the Plan of Correction is an admission otherwise. Merakey Allegheny Valley School, 850 Middletown Road has submitted this Plan of Correction to comply with its regulatory obligation and does not waive any objections to its merits or form any allegations contained herein. Please note that Merakey Allegheny Valley School, 850 Middletown Road may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
W155
Merakey Allegheny Valley School, 850 Middletown Road will ensure that the facility prevents further potential abuse while the investigation is in progress.
The Administrator or designee will conduct re-training for House Manager (HM) and Program Coordinator (PC) at which point the importance of preventing further potential abuse and protecting the individuals while an investigation is in progress will be reviewed. Re-training will include specific emphasis on the need for House Managers (HM) or designee to immediately remove alleged targets from the floor once an allegation of abuse or neglect is made. Once removed from the floor, House Managers (HM) or designee will not only be required to report the incident to the Administrator or designee but also confirm with the Administrator or designee that the alleged target has been removed from the floor. Re-training will be completed and documented on a Merakey Staff Attendance Sheet (SA) by March 1st, 2024.
In order to monitor that the training was effective, the Sr. Executive Director will confirm with Administrator or designee at time of report that target was removed during investigative process to prevent further potential harm. This will be recorded on a timeline within the Investigative file. Any concerns with timeliness of removal of target will be addressed via the standard disciplinary process. The Sr Executive Director will review all submissions of incidents involving abuse and neglect for a period of three months (March, April, May 2024) to ensure that alleged targets are removed from the floor once an allegation of abuse or neglect is made. If concerns are identified they will be addressed immediately via re-training or via standard disciplinary process. The initial review period will also be extended for an additional three months.
483.440(d)(1) STANDARD
PROGRAM IMPLEMENTATION
Name - Component - 00
As soon as the interdisciplinary team has formulated a client's individual program plan, each client must receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan.
Observations:
Based on record review and staff interview, it was determined that the facility failed to ensure an active treatment program was consistently implemented. This was noted for both individuals in the sample (Individuals #1 and #2). The findings included:
Goal plans for the past year were reviewed on February 6, 2024. This review revealed the following:
A) Individual #1
- A financial goal plan was initiated on March 9, 2023 and was discontinued on October 3, 2023, due to "lack of progress". Data review revealed that this goal was implemented only 18 times in a seven-month period (March-October 2023).
- An oral hygiene goal plan was initiated on December 1, 2022 and was discontinued on August 11, 2023, due to "lack of progress". Data review revealed that this goal was implemented only 40 times in a six-month period (February-August 2023).
- A bathing goal plan was initiated on March 1, 2023, and was discontinued on September 8, 2023, due to "lack of progress". Data review revealed that this goal was implemented only 16 times in a six-month period (March-September 2023).
B) Individual #2
- A financial goal plan was initiated on January 27, 2023 and was discontinued on August 11, 2023, due to "lack of progress". Data review revealed this goal was implemented only 11 times in a six-month period (March-August 2023).
- A bathing goal plan was initiated on April 20, 2022 and was discontinued on August 11, 2023 due to "lack of progress". Data review revealed this goal was implemented only 12 times in a six-month period (March-August 2023).
- A personal care goal plan was initiated on January 27, 2023 and was discontinued on August 11, 2023 due to "lack of progress". Data review revealed this goal was implemented only 20 times in a six-month period (March-August 2023).
- An oral care goal plan was imitated on August 16, 2022 and was discontinued on August 11, 2023 due to "lack of progress". Data review revealed this goal was implemented only 20 times in a six-month period (March-August 2023).
- A self-medication goal plan was initiated on March 2, 2023 and was discontinued on January 17, 2024 due to "lack of progress". Data review revealed this goal was implemented only 44 times during this time frame.
C) The qualified intellectual disabilities professional (QIDP) was interviewed on February 6, 2024, at 12:30PM. The QIDP confirmed that an active treatment program was not consistently implemented during the past year for Individuals #1 and #2.
Plan of Correction:Merakey Allegheny Valley School, 850 Middletown Road, makes its best effort to operate in full compliance with both Federal and State Law. Nothing included in the Plan of Correction is an admission otherwise. Merakey Allegheny Valley School, 850 Middletown Road has submitted this Plan of Correction to comply with its regulatory obligation and does not waive any objections to its merits or form any allegations contained herein. Please note that Merakey Allegheny Valley School, 850 Middletown Road 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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Merakey Allegheny Valley School, 850 Middletown Road will ensure that as soon as the interdisciplinary team has formulated a client's individual program plan, each client must receive a continuous active treatment program consisting of need interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan.
The Qualified Intellectual Disabilities Professional (QIDP) or designee will train the House Manager (HM) and Program Coordinator (PC) on goal plan development, implementation of goals and monitoring. Following, the House Manager (HM) or designee will train House Manager Aides (HMA) on goal plan implementation, goal plan documentation and active treatment. This training will be completed and documented on a Staff Attendance Sheet (SA) by March 1st, 2024.
In order to monitor that the training was effective, the House Manager (HM) or designee will complete documentation audits beginning March 2024, twice a week for a period of 3 months (March, April, May 2024) followed by weekly audits for a period of 3 months (June, July, August 2024). The House Manager (HM) will complete audits to review and ensure that daily documentation reflects the objectives identified within the Individual Program Plan (IPP). These audits will be documented on a Goal Plan Audit form and will be submitted to the Administrator or designee to verify completion weekly. Any concerns identified will be addressed immediately via re-training or standard disciplinary process. The Qualified Intellectual Disabilities Professional (QIDP) will complete monthly audits beginning March 2024 for a period of 6 months (March, April, May, June, July and August 2024). The Qualified Intellectual Disabilities Professional (QIDP) will complete audits to review and ensure that daily documentation reflects the objectives identified within the Individual Program Plan (IPP). These audits will be documented on a Goal Plan Audit form and will be submitted to the Administrator or designee to verify completion monthly. Any concerns identified will be addressed immediately via re-training or standard disciplinary process. The Administrator or designee will train both House Manager (HM) or designee and Qualified Intellectual Disabilities Professional (QIDP) or designee on monitoring guidelines. This training will be documented on a Staff Attendance Sheet (SA)by March 1st, 2024.
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 observation, record review and staff interview, it was determined that the facility failed to administer medications without error. This was noted for both observed medication administrations. The findings included:
A) Medication administration was observed on February 5, 2024, between 5:00 AM and 7:30 AM. During this observation, Individual #1 received numerous medications via Jejunostomy tube (J-tube). Review of the physician ' s orders dated January 31, 2024, prescribed Loratadine, 10 milliliters (mls) via j-port daily at 7:00 AM for allergies. This medication was not observed to be administered.
The Health Services Supervisor (HSS) was interviewed on February 5, 2024, at 10:45 AM. The HSS acknowledged that the medication Loratadine was omitted during the morning medication administration.
B) Medication administration was observed on February 5, 2024, between 4:00 PM and 6:00 PM. This observation revealed the staff administering medications (SAM) administered two sprays of Flonase to each of Individual #3's nostrils. The prescription label indicated one spray to each nostril.
The SAM was interviewed immediately after this administration, at 5:20 PM. The SAM confirmed that two sprays were administered to each nostril. Review of Individual #3 ' s physician ' s orders dated December 13, 2023, prescribed Flonase, one spray to each nostril.
Plan of Correction:Tag 0369
Merakey Allegheny Valley School, 850 Middletown Road makes its best effort to operate in full compliance with Federal and State Law. Nothing included in this Plan of Correction is an admission otherwise. 850 Middletown Road has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections to the merits or form of any allegations contained herein. Please note that 850 Middletown Road may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
The Facility will confirm that the system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.
On 2/05/24 and 2/06/24 the surveyor informed the Health Services Supervisor that while observing the med passes for individuals in the home, they noted staff had failed to administer Loratadine during the morning med pass and the wrong dose of Flonase.
A medication administration practicum for the staff person who omitted a medication at the time of the observation was performed on February 8, 2024 without error. A medication administration practicum for the staff person who administered the wrong dose of medication at the time of the observation will be completed by February 21, 2024.
The nurses will re-train the house manager aide who administered medications at the time of survey, the house manager and the remaining house manager aid staff in the home concerning proper procedure for completing a medication pass which includes identifying all meds that need to be administered during each med pass and administering the correct dose of each medication as per Physician Orders. This training will be completed by March 1, 2024 and will be documented on a Staff Attendance (SA) sheet. Once the training of all staff in the home is completed, this will be reported to the Residential Director for and Director of Nursing. SA sheets will be sent to the Staff Development Coordinator to verify all staff have received training.
Monitoring of medication administration to ensure all staff in the home are administering all medications per the Physicians Orders will be completed by the nurse, Assistant HSS (AHSS) or HSS. Documentation of this monitoring will be kept on the Medication Pass Audit form. The Medication Pass Audit is a visual observation of the staff administering medications and treatments. This visual process includes, but is not limited to, ensuring individuals receive the prescribed dose of each medication throughout the entire medication administration procedure. Random AM and PM audits will occur weekly for two months. If this monitoring reveals that staff are following the Medication Administration procedure correctly, then the monitoring will begin to be tapered to bi-weekly for two months, then monthly for a period of two months, and then as needed. Med Pass Audits will begin the week of February 18, 2024.
If during this process, it has been identified that the staff observed are not administering medications as per policy training will be provided individually to that staff person and random audits will be increased in frequency. Staff who fail to follow policy will be referred to the ICF Administrator for corrective action.
The ICF Administrator and HSS will review all completed Med Pass Audits monthly to ensure the audits are completed as scheduled.
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