Initial Comments:
A focused fundamental survey was conducted May 20-21, 2026, 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:
483.430(e)(2) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
For employees who work with clients, training must focus on skills and competencies directed toward clients' health needs.
Observations:
Based on observations, record review, and interview, it was determined that the facility failed to ensure that staff demonstrated the necessary skills and competencies directed towards the dietary needs of the individuals. This applied to one (#4) of five individuals residing at the facility. Findings included:
Observations at the residence were completed on May 20, 2026, from 5:30 AM to 7:45 AM. During this time, the breakfast meal was observed. At 5:44 AM, Individual #4 was observed to receive their breakfast, which consisted of fruit loops cereal with milk, a cup of juice, and an additional cup of milk.
A review of physician's orders for Individual #4, dated May 12, 2026, was completed on May 20, 2026, for the purpose of reconciling the observation of the morning medication administration. This review revealed a diet order that included, "high fiber diet with bran at breakfast."
An interview was conducted with the senior director (SD) on May 20, 2026, at 10:35 AM. The SD was questioned regarding the form in which Individual #4 receives bran at breakfast. The SD stated that Individual #4 receives raisin bran cereal at breakfast. The SD then confirmed that staff failed to provide Individual #4 with the dietary needs as ordered by the physician during the above breakfast observation.
Plan of Correction:Merakey/Allegheny Valley School 195 Wildwood Rd (Merakey/AVS Wildwood) 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 Wildwood 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 Merakey/AVS Wildwood may contest the merits and/or form of any deficiency of finding alleged below and take reasonable steps to appeal them.
On May 22, 2026, the staff members involved at the Wildwood SFR received retraining from the Senior Director on Individual #4's feeding profile and current diet order. In addition, staff also received retraining on all feeding profiles and diet orders for all individuals residing at the Wildwood SFR. Training focused on diet orders/feeding profiles for all individuals, with specific focus placed on individuals with additional supplements such as bran. This was completed May 25, 2026. A Staff Attendance Sheet was signed by the staff who received the training and will be kept on file in the Senior Director's office.
In order to monitor the effectiveness of this training, the facility will complete two Mealtime Audits, using the Mealtime Evaluator Worksheet, each month, from June 2026 to August 2026 (total of 6 observations). Personnel completing the audits will include the QIDP, Program Lead and Program Manager. Mealtime Audit will include monitoring for appropriate diet orders followed and ensure that bran is offered. Any issues noted during the audit process will be addressed immediately and reported to the Senior Director. Any concerns requiring further evaluation will be referred to the OT. The completed audit documentation will be sent to and kept on file in the Senior Director's office.
Ongoing monitoring of mealtimes at the Wildwood SFR will be completed by the Program Manager, Program Lead or QIDP monthly, using the Mealtime Evaluator Worksheet. Any issues noted during the audits will be addressed immediately and reported to the Senior Director. A summary of the observation will be sent to the Senior Director for review.
For other potentially affected individuals, training will be completed for all Allegheny and Beaver County ICF homes regarding feeding profiles and dietary orders with specific focus placed on bran. This training will be completed at the Western Regional Meeting scheduled for June 16, 2026. The Program Leads will then be responsible for training their subordinate staff. Additionally, one Mealtime Audit will be completed by the Program Managers and/or the Program Leads for each home, using the Mealtime Evaluator Worksheet. Audits will be due by July 17, 2026. Any issues noted during the audit process will be addressed immediately. Any concerns requiring further evaluation will be referred to the OT. A Staff Attendance Sheet will be signed by all staff receiving. Staff Attendance Sheets and Mealtime Audit forms will be kept on file in the Senior Director's office.
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