Initial Comments:
A full survey visit was completed on January 22 and 23, 2026. The purpose of this visit was to evaluate compliance with the Requirements of 42 CFR, Part 483, Subpart I Regulations for Intermediate Care Facilities for Individuals with Intellectual Disabilities. The census at the time of the visit 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 observation, record review and interview with facility and administrative staff,
the facility failed to assure that all drugs, including those that are self-administered, are administered without error for one of three individuals observed during the afternoon medication administration period. This practice is specific to Individual #2.
Findings include:
1. Observations of the afternoon medication period were completed at the residence on 01/22/2026 between 5:16 PM and 5:30 PM. During this observation at 5:26 PM, a staff person was observed punching the medication Famotidine 20 mg. (aka Pepcid) out of a blister pack for Individual #2. This staff person then crushed this medication along with three other medications in pill form, added one liquid medication and mixed them together in
Individual #2's pureed fruit at the dining room table. The staff person who was feeding Individual #2 then fed the pureed fruit to Individual #2 at approximately 5:30 PM.
A review of the blister pack's label and the Medication Administration Record (MAR) during the above medication pass for the Famotidine 20 mg. revealed the following:
-Famotidine (Pepcid) 20 mg. (GERD); 1 Tab twice daily 1/2 hour before breakfast and dinner. Times noted to be given on the MAR are 6:30 AM and 4:30 PM.
Interview with the staff person who administered the medication completed on 01/22/2026 at approximately 5:33 PM revealed that the reason they give the Famotidine with Individual #2's meal is because he will often refuse his medications.
2. A review of the record of Individual #2 was completed on 1/23/2026, from approximately 8:45 AM to 10:45 AM. This review revealed the following:
-Progress and Order Record dated 01/20/2025: Start (when available) Famotidine Tab
20 mg--Take 1 tablet by mouth twice daily, 1/2 hour before breakfast and dinner, 6:30 AM and 4:30 PM.
-Annual Physical Exam dated 04/09/2025: Included the same physician's order noted above. Also noted were the diagnoses of GERD with esophagitis and Dysphagia: oropharyngeal dysphagia with aspiration.
-90 Day Physician's Orders dated 01/21/2026 to 04/21/2026: Also included the same order of Famotidine, (sub. for Pepcid) Tab 20 mg--Take 1 tablet by mouth twice daily, 1/2 hour before breakfast and dinner (GERD).
Interview with the Assistant Health Services Supervisor on 01/23/2026 at approximately 9:00 AM revealed that she was not made aware that the medication, Famotidine, was being given at the time of Individual #2's meals due to Individual #2's refusals. This interviewee acknowledged that the medication, Famotidine 20 mg., should have been administered as per Individual #2's Physician's Orders which states, 1/2 an hour prior to breakfast and dinner.
Plan of Correction:The facility will ensure that the system for drug administration is administered without error.
#1
On or before Feb 12, 2026, the facility staff who was administering medication on January 22, 2026, will be retrained on the Alleghany Valley School (AVS) medication pass protocol to include the proper time of medication administration according to the physician's order. The training will be documented on a Training Verification Form. A copy of the training will be sent to the Senior Director to verify completion.
On or before February 6, 2026, the facility staff who was administering medication on January 22, 2026, will be observed performing a medication pass to ensure errors do not occur in the future. Any anomalies will be addressed during the observation and ensure that medication is passed according to the physician's order. The observation will be documented on a Medication Observation form and forwarded to the Senior Director to verify completion.
On January 23, 2026, the facility nurse retrained all staff on Individual #2's physician's orders for medication administration to ensure proper medication administration occurs. A copy of the training was sent to the Senior Director to verify completion within 7 days of completion.
#2
On or before February 28, 2026, the Program Lead (PL)/Designee will observe all Facility Staff who are Certified Medication Administrators at varying medication times once a week for four weeks to ensure that all medications are administered according to the written physician's order that is transcribed on the MAR. Thereafter the PL will conduct random monthly Medication Administration Observations for all the medication administration certified facility staff to ensure medications are administered according to the written physician's order that is transcribed on the MAR. These audits will be completed on the Medication Pass Audit form and forwarded to the Senior Director to verify completion.
During the observation, if there are any anomalies during the medication administration process the medication administration process will be stopped to correct the error, so it does not occur.
Staff will be retrained at that time. Training will be completed on Staff Attendance Sheets (SA). Copies of the training will be forwarded to the Senior Director to verify completion.
On or before February 10, 2026, the facility nurse will do random medication observations at varying medication times once a week for four weeks thereafter once a month for 3 months to ensure that all medications are administered according to the written physician's order that is transcribed on the MAR. During the observation, if there are any anomalies during the medication administration process the medication administration process will be stopped to correct the error, so it does not occur.
Staff will be retrained at that time. Training will be completed on Staff Attendance Sheets (SA). Copies of the training will be forwarded to the Senior Director to verify completion.
The facility nurse will retrain all staff on physician's orders for medication administration and how their medications should be administered for the remaining individuals in the facility by February 16, 2026. A copy of the training will be sent to the Senior Director to verify completion within 7 days of completion.
The Program Lead will retrain all facility med-certified staff by February 16, 2026, on the completion of a proper AVS medication pass protocol to include the include the proper time of medication administration according to the physician's order. The training will be documented on a Staff Attendance (SA) sheet. A copy of the training will be sent to the Senior Director to verify completion within 7 days of completion.
#3
The Program Lead completes Medication Administration Record (MAR) reviews and Medication observations for each medication certified staff member every 6 months. This process must include review of the MAR indicating the proper way the medication should be administered and observation of the administration to verify that staff are administering medication properly. Medication Observations will be Maintained in the employee file. Any anomalies during medication observations will be immediately addressed during the observation and will require another observation within 7 days and a Medication Error Debriefing with the staff who made the error. Any MAR anomalies noted by PL will be addressed within 7 days.
#4
The Program Manager will review ongoing Medication observation audits during regularly scheduled individual supervision over the next six (6) months with the Program Lead to identify additional barriers and training opportunities for staff. Any anomalies will be reported to the Senior Director for resolution.
C5
The Senior Director will be responsible for monitoring the process and reporting any discrepancies and corrective actions taken to the Senior Executive Director at the monthly Director's meetings.
483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
at least quarterly for each shift of personnel.
Observations:
Based on a review of facility documentation and interview with administrative staff, the facility failed to hold evacuation drills at least quarterly for each shift of personnel. This practice is specific to the second shift of personnel for the period from January 2025 to December 2025.
Findings include:
A review of fire drill reports for the period from January 2025 to December 2025 was completed on 01//22/2025 between 8:05 AM and 8:25 AM. This review revealed that there was no fire drill completed for the second shift of personnel, defined as 3:00 PM to 11:00 PM
during both the third quarter (July through September), and fourth quarter (October through December) of the calendar year.
Interview with the Associate Executive Director on 01/22/2026 at approximately 9:45 AM confirmed that the above mentioned fire drills were missing for the third and fourth quarter of the calendar year.
Plan of Correction:The facility will ensure that evacuation drills are held at least quarterly for each shift personnel.
#1
On or before February 10, 2026, the Senior Director will meet and do formal Supervision with the Program Manager to train the Program Manager regarding State and Federal regulations and agency policies pertaining to fire drills/emergency evacuations. The training will emphasize conducting and documenting a fire drill on each shift (1st, 2nd and 3rd shifts) every quarter for each shift personnel following the scheduled guidelines that are in place and ensuring that the Program Leads hold drills by the 15th of the month to ensure ample time to run a drill if one is missing or needs to be repeated once submitted to the Program Manager for review. The training will be documented on a Staff Attendance Sheet to verify completion. The Staff Attendance sheet will be filed in the Staff Development department.
On or before February 10, 2026, the Program Manager (PM)/Designee will meet and do formal Supervision with the Program Lead and retrain the Program Lead (PL) regarding State and Federal regulations and agency policies pertaining to fire drills/emergency evacuations. The training will emphasize conducting and documenting a fire drill on each shift (1st, 2nd and 3rd shifts) every quarter for each shift personnel following the scheduled guidelines that are in place. Program Leads will be encouraged to hold drills by the 15th of the month to ensure ample time to run a drill if one is missing or needs to be repeated. The training will be documented on a Supervision Form and Staff Attendance Sheet to verify completion. The Staff Attendance sheet will be filed in the Staff Development department, and a copy will be forwarded to the Senior Director to verify completion.
#2
On or before February 15, 2026, the Program Lead will conduct a fire drill in accordance with schedule. This fire drill/emergency evacuation was documented on a Monthly Fire Drill Audit form and submitted to the Program Manager for review. The Program Manager (PM) will review the submitted fire drill to verify that the Program Lead completed the drill/evaluation according to State and Federal regulations and the agency's fire drill scheduled guidelines. Since all Individuals were affected, these corrective actions stand for both potential and affected individuals.
#3
Upon completion of the evacuation drill and by the 15th day of the month, the Program Lead will submit a copy of the evacuation drill to the Program Manager for review. Upon receipt and by the 20th of the month, the Program Manager will review the evacuation drill to ensure all required elements have been met including verifying that the evacuation drill was conducted at different times of the day and varying quarterly for each shift personnel as set forth in the Evacuation Drills Scheduling Guidelines as well as proper exit route were taken based on the fire location. After review, the Program Manager will either approve or reject the submitted evacuation drill. If the evacuation drill is found to be unsatisfactory, it will be rejected, and the PM will direct the Program Lead to repeat the evacuation drill within seven days and until it meets the requirements in accordance with State and Federal regulations in addition to the agency policies and protocols. Any concerns noted will be addressed with further training and/or employee counseling and corrective action.
#4
On a monthly basis by the 25th of the month, the Senior Director will audit all approved evacuation drills for the next 6 months. The audit will confirm that all approved evacuation drills are conducted under various conditions and timeframes pursuant to the Evacuation Drills Scheduling Guidelines, and in accordance with State and Federal regulations. During the Senior Directors review, if concerns are identified with the varied conditions and/or the Evacuation Drills Scheduling Guidelines are not followed, they will require that another drill is conducted to maintain compliance with State and Federal regulations and agency policy. Any anomalies will be addressed with training and counseling and corrective action.
#5
The Senior Director will present a summary of all audit outcomes to the Senior Executive Director at the monthly executive operations meeting chaired by the Senior Executive Director, who will address any outlying issues with the system
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