Initial Comments:
A focused fundemental survey visit was completed on June 17 and 18, 2025. 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 three, and the sample consisted of three individuals.
Plan of Correction:
483.420(a)(11) STANDARD
PROTECTION OF CLIENTS RIGHTS
Name - Component - 00
The facility must ensure the rights of all clients. Therefore, the facility must ensure that clients have the opportunity to participate in social, religious, and community group activities.
Observations:
Based on a review of facility records and documentation review, and interview with facility and administrative staff, the facility failed to ensure Individuals have the opportunity to participate in social, religious, and community group activities for three of three sample Individuals. This practice is specific to Individuals #1, #2, and #3.
Findings include:
A review of the records of three of three sample Individuals was completed on 06/18/2025 from 9:00 AM to 11:00 AM. This review noted that these Individuals were not given the opportunity to participate in social, religious, and community group activities during the period from 08/24/2024 to 03/29/2025. Individual #2 is exemplary of this practice.
Individual #2
A review of doucmentation regarding community outings for the period 06/14/2024 through 06/18/2025 was completed on 06/18/2025 at approximately 10:00 AM. This review revealed there were no documented community outings from 08/24/2024 to 03/29/2025.
Interview with the House Manager and Qualified Intellectual Disabilities Professional on 06/18/2025 at approximately 10:00 AM confirmed there there were no community outings conducted during this time period and both interviewee unable to indicate why these outings had not been completed.
Plan of Correction:The facility will ensure that clients have the opportunity to participate in social, religious and community group activities.
CE#1
On or before July 10, 2025 the Program Leads will be retrained on the expectations of ensuring that the individuals in the facility are participating in social, religious, and community group activities and the responsibility of ensuring that outings are documented on the Community Integration Return form by staff that participated in the outing, upon return from the outing, and reviewed and sent to the Qualified Intellectual Disability Professional/ Program Specialist (QIDP/PS) for review monthly. The training will be documented on a Staff Attendance (SA) sheet. A copy of the training will be sent to the Senior Director (SD) to verify completion within 5 days.
On or before July 10, 2025 the Social Services Assistant Director (ASSD) or designee will retrain the QIDP/PS on the expectations of ensuring that the individuals in the facility are participating in social, religious, and community group activities and their responsibility to ensure that that outings are documented on the Community Integration Return form completed by staff that participated in the outing upon return from the outing, and are reviewed by Program Lead (PL) and sent to the Qualified Intellectual Disability (QIDP/PS) for review monthly. The training will be documented on a Staff Attendance (SA) sheet. A copy of the training will be sent to the Senior Director (SD) to verify completion within 5 days.
On or before July 12, 2025, the individuals will participate in a community outing. This will be documented on the Community Integration Return form upon return from the outing and the form sent to the QIDP/PS for review.
CE#2
On or before July 12, 2025, the facility staff will be retrained in the completion of the Community Integration Return form to be completed upon return from an outing. 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 5 days.
CE#3
When there is a community outing or participation in a social or religious event, it is the responsibility of the staff who participated in the activity with the individual(s) to document the event's outcome on a Community Integration Returns Form. The information captured includes the individual's name, date/day of the trip, and the destination. The form also includes reactions of the individual as well as any practiced skill and any problems or concerns that may have occurred. The staff who complete the form will sign off on the form and submit it prior to the end of their shift for the Program Lead to review. The Program Lead ensures that the Community Integration form is completed by the end of their shift. If the Program Lead discovers that the form is not completed, they will ensure that the form is completed on the day of discovery and retrain the staff of their responsibilities to complete the Community Integration Form. The training will be kept in the employee's file. Once reviewed by the Program Lead the form is sent to the QIDP/PS for signature and review. All outings and social events are submitted at the end of the month to the QIDP/PS to be filed and to be incorporated into quarterly reports of the individual. Any anomalies found will be sent to the Program Manager (PM), SD and ASSD to address.
CE#4
On or before July 25, 2025, the Program Manager (PM)/Designee will do an audit of the Community Integration Return Forms twice a month by the 15 of the month for 6 months thereafter once a month by the 15 of the month to ensure that all individuals are participating in social, religious, and community group activities each month. Any anomalies will be addressed immediately and reported to the Program Lead for address via retraining and/or corrective action. The training will be documented on a Staff Attendance (SA) sheet and will be maintained in the Staff files.
On or before July 25, 2025, the QIDP/PS will do an audit of the Community Integration Return Forms once a month by the 20th of the month for 6 months to ensure that all individuals are participating in social, religious, and community group activities each month thereafter quarterly to ensure that all individuals are participating in social, religious, and community group activities each month. Any anomalies will be addressed immediately and reported to the Program Manager to address via retraining and/or corrective action. The training will be documented on a Staff Attendance (SA) sheet and will be maintained in the Staff files.
CE#5 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.
483.460(c)(4) STANDARD
NURSING SERVICES
Name - Component - 00
Nursing services must include other nursing care as prescribed by the physician or as identified by client needs.
Observations:
Based on observations, record review and interview with administrative staff, the facility failed to include other nursing services as prescribed by the physician or as identified by client needs for two of three sample Individual who are prescribed a laxative. This practice is specific to Individuals #1 and #3.
Findings include:
1. Observation of the medication administration process completed on 06/17/2025 from
7:15 AM to 8:05 AM revealed the following:
-Individual #1 received 17 grams. of polyethylene Glycol 3350 (generic form of MiraLAX) in a plastic cup/container of applesauce with a foil label which stated 4 ounces. While administering the medication, the staff person stated that "The facility nurse told her that although the Medication Administration Record (MAR) states that the Polyethylene Glycol 3350 should be administered in fluids, it was okay for her to administer the medication in applesauce if that is the method Individual #1 prefers." The staff person then proceeded to administer the Polyethylene Glycol 3350, 17 mg. in 4 ounces of applesauce without difficulty. The staff person then offered Individual #1 a drink which this individual refused.
-Individual #3 received 17 grams. of polyethylene Glycol 3350 (generic form of MiraLAX) in a plastic cup/container of applesauce with a foil label which stated 4 ounces.
2. A review of the medication Administration Record (MAR), and the label on the bottle
of the generic Miralax revealed that both the MAR and the label on the bottle stated the following for each individual:
-Individual #1: Polyethylene Glycol 3350 (17 grams/cap filled to line) in 8 ounces of liquid.
-Individual #3: Polyethylene Glycol 3350 (17 grams/cap filled to line) in 8 ounces of applesauce.
A review of the records of Individuals #1 and Individual#3 was completed on 06/18/2025 from approximately 9:00 AM to 11:00 AM. This review revealed the following current Physician's Orders dated 04/25/2025 to 07/25/2025 for both Individuals:
-Individual #1: Polyethylene Glycol 3350 Mix 17 mg. in 8 ounces of liquid and administer by mouth
-Individual #3: Polyethylene Glycol 3350 Mix 17 mg. in 8 ounces of applesauce and administer by mouth.
Interview with the Assistant Health Services Supervisor completed on 06/18/2025 at 9:40AM, confirmed the staff should follow the physician's orders as written in the MAR when administering medications. This interviewee also confirmed that the facility nurse, should have had the physician change the physician's orders for Individual #1 if Individual #1 prefers to take the Polyethylene Glycol 3350 in applesauce and not in fluids.
Plan of Correction:The facility will ensure that Nursing services includes other nursing care as prescribed by the physician or as identified by client needs.
CE#1
On June 18, 2025, a Mini -IDT meeting was held to discuss individual #1's preference of receiving her Polyethylene Glycol 3350 (MiraLAX) in applesauce. The meeting was documented on a mini-IDT form and forwarded to the Senior Director (SD) to verify completion. Any recommendations will be noted and implemented accordingly.
On June 19, 2025, a physician's order was written to discontinue Polyethylene Glycol 3350 (MiraLAX) mix 17 grams in 8oz of liquid and to start Polyethylene Glycol 3350 (MiraLAX) mix 17 grams in 4oz of apple sauce.
On June 18, 2025, a Mini-IDT meeting was held to discuss individual #3's preference of receiving her Polyethylene Glycol 3350 (MiraLAX) in 4oz of applesauce opposed to 8 oz of apple sauce. The meeting was documented on a mini-IDT form and forwarded to the Senior Director (SD) to verify completion. Any recommendations will be noted and implemented accordingly.
On June 19, 2025, a physician's order was written to discontinue Polyethylene Glycol 3350 (MiraLAX) mix 17 grams in 8oz of apple sauce and start Polyethylene Glycol 3350 (MiraLAX) mix 17 grams in 4 oz. of apple sauce.
On or before July 10, 2025, the facility nurse will train the facility staff on the new physician's orders for individual #1 and individual #3. All training will be documented on Staff Attendance Sheets (SA) and maintained in the nursing Office. Copies of the training will be forwarded to the Senior Director to verify completion.
CE#2
On June 18, 2025, a Mini -IDT meeting was held for the remaining individual in the facility to discuss her current physician's order when receiving her medication and if any anomalies have been discovered due to preferences. The meeting was documented on a mini-IDT form and forwarded to the Senior Director (SD) to verify completion. Any recommendations will be noted and implemented accordingly.
On or before July 10, 2025, the facility nurse will train the facility staff on the physician's orders of all medications for all facility individuals to ensure proper administration. All training will be documented on Staff Attendance Sheets (SA) and maintained in the nursing Office. Copies of the training will be forwarded to the Senior Director to verify completion.
On or before July 10, 2025, the Program Lead (PL) will retrain all facility staff who are certified to provide medication management in the Medication Administration Protocol highlighting the 5 rights of Medication This includes: Right Dose; Right Time; Right Person; Right Medication; Right Route; Right Position; Right Form and Right Technique. If any of these "rights" have not been completed according to physician's orders. All training will be documented on Staff Attendance Sheets (SA) and maintained in the nursing Office. Copies of the training will be forwarded to the Senior Director to verify completion.
The facility nurse that let the facility staff know that they were able to administer medication contradictory to the physician's order is no longer with Merakey Alleghany Valley School.
On or before July 11, 2025, the Assistant Health Services Supervisor (AHSS) will retrain all facility nurses the protocol of if a staff brings it to their attention that an individual is not successful or does not prefer the technique of the prescribed order the facility nurse will bring this to the attention of the physician to re-evaluate the method that the individual is receiving their medication. The facility nurse will then obtain a new physician's order if feasible. The new order should be written in the MAR and the facility staff should be alerted to those changes through training upon the change of the order. All training will be documented on
CE#3
If an individual is prescribed a medication by a physician there is a physician order that notes the prescribed medication dosage, route, time and technique to include the way the medication should be taken such as crushed, with a liquid or food. This is transcribed to the Medication Administration Record (MAR) for the facility staff who are certified to provide medication management to follow the order. If an individual is not successful or does not prefer the technique of the prescribed order the staff should bring this to the attention of the nurse. The facility nurse will bring this to the attention of the physician to re-evaluate the method that the individual is receiving their medication. The facility nurse will obtain a new physician's order if feasible. The new order is written in the MAR and the facility staff are to be alerted to those changes through training upon the change of the order. If the change is not feasible the Interdisciplinary team will meet and discuss any possible alternatives and represent those to the physician for possible solutions. The meeting is documented on a mini-IDT form and distributed to the team. Any changes will be updated, and staff will be trained with recommendations if this applies.
CE#4
On or before July 15, 2025, the Program Lead (PL), Region Nurse 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 of 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.
#5
The Senior Director will be responsible for monitoring the process and report any discrepancies and corrective actions taken to the Senior Executive Director at the monthly Director's meetings.
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483.470(i)(1) STANDARD
EVACUATION DRILLS
Name - Component - 00
at least quarterly for each shift of personnel.
Observations:
Based on review of facility documentation and interview with administrative staff, the facility failed to ensure that evacuation drills were conducted at least quarterly for each shift of personnel. This practice is specific for second and third shift of personnel.
Findings include:
A review of evacuation drills for the period 07/2024 through 06/2025, was conducted on 06/17/2025 from approximately 8:25 AM to 8:45 AM. This review revealed there were no evacuation drills completed for the following shifts of personnel:
Third calander quarter of 2024 ( 7/2024 to 9/2024 )
- no fire drill conducted for the second shift of personnel defined as 3:00 PM to 11:00 PM
Fourth calander quarter of 2024 ( 10/2024 to 12/2024).
- no fire drill conducted for the third shift of personnel ( 11:00 PM to 7:00 AM )
Interview with the Senior Director was conducted on 06/17/2025, at approximately 9:45 AM. This interviewee acknowledged that the above two noted evacuation drills for the second and third shift for the specified quarters were not conducted as required.
Plan of Correction:The facility will ensure that evacuation drills are conducted at least quarterly for each shift of personnel.
CE#1
On or before July 9, 2025, the Program Manager (PM)/Designee will 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, varying the times to cover the entire shift. 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 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.
CE#2
On or before July 15, 2025, the Program Lead will conduct a fire drill in accordance to schedule. This fire drill/emergency evacuation was documented on a Monthly Fire Drill Audit form and submitted to the electronic drop box. The Program Manager (PM) will review the submitted fire drill. The Audit will confirm that the Program Lead completed the drill/evaluation according to State and Federal regulations and the agency's fire drill guidelines. Since all Individuals were affected, these corrective actions stand for both potential and affected individuals.
On or before July 10, 2025, the Program Manager or designee will retrain all Program Leads 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-7:00am-3:00pm, 2nd -3:00pm -11:00pm and 3rd shifts- 11:00pm-7:00am) every quarter, varying the times to cover the entire shift. The time of the fire drill will be identified by writing in the time the drill within the shift identifier section at the bottom of the form. The time of the drill will also be indicated in the description by stating that the drill was performed on 1st, 2nd, or 3rd shift. And the submission of the Fire Drill prior to the 15th of the month to the electronic drop box 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 and a copy will be forwarded to the Senior Director to verify completion.
CE#3
The Evacuation Drill Verification System (EDVS) will be used to collect, review, and maintain the required elements of the evacuation drill. 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 EDVS for review. The Program Manager will receive an automated email from the EDVS notifying him of a new evacuation drill submission. 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. The EDVS audits will serve as the means to monitor that the corrective actions remain effective.
C4
On or before July 25, 2025, monthly the Program Manager /Designee will audit all evacuation drills. The audit will confirm that all 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 PM review, if concerns are identified with the varied conditions and/or the Evacuation Drills Scheduling Guidelines were not followed, the PM 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 employee counseling and corrective action. On a monthly basis by the 20th of the month, the Senior Director will audit all approved evacuation drills within the EDVS. 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 employee counseling and corrective action.
C5 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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