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Merakey Allegheny Valley School, 1291 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, 1291 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, 1291 Middletown Road may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.

W154

Merakey Allegheny Valley School, 1291 Middletown Road will ensure that the facility has evidence that all alleged violations are thoroughly investigated.

Following recommendation, the Sr. Director immediately filed a suspected neglect report within the incident management reporting system for the affected, individual #6.

Re-training related to standardized process' involving incident reporting, required documentation and 5-day notification requirements will be presented to all supervisory staff to include the Director of Programs, Program Director, Program Managers, House Managers. In addition to re-training on the standardized process', supervisory staff will be trained on an additional documentation requirement to be included within the supervisors' preliminary findings. When completing the supervisors' preliminary findings, supervisory staff will be required to include an explanation to confirm that the findings do not meet the need to file an external report. Re-training will be completed by the Sr. Director or Designee by January 3rd, 2025. Additionally, Department Heads will be provided with re-training on the Office of Developmental Programs Bulletin related to Incident Management to include a review of reportable incidents. This re-training will be completed by the Sr. Director or Designee by January 3rd, 2025.

In order to monitor that the training was effective, the Sr. Director will continuously review internal incident reports ensuring that all alleged violations are reported appropriately and thoroughly investigated as necessary. Review of internal incident reports will be reflected on the report by the Sr. Directors signature. Any concerns identified during the review will be addressed via re-training or via standard disciplinary process.

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Merakey Allegheny Valley School (AVS), Hummelstown Campus 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. Merakey AVS Hummelstown Campus 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 Hummelstown Campus may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.

DRUG ADMINISTRATION:
The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.

All errors noted were by one nurse. At the time of each identified error reviewed during survey, the staff was counseled regarding the specifics of the error. In addition, on 11/13/24 the HSS and AHSS met with the nurse and took a MAR and walked step by step through the administration process. Pointers were given such as using the dot system when pouring meds, pouring in order of the MAR, turning blister cards over as each individual has received their meds providing a visual check in the med cart drawer of who still needs their medications, checking all cards at the end of each med time to make sure all blisters are empty and are initialed and dated. She also reviewed the Medication Administration protocol and signed a Staff Attendance (SA) Sheet. Since this additional training was completed, she has not had another error.

All nursing staff will receive training on Merakey's Protocols and Standards - Administration of Medication including, but limited to identifying individuals who require medication administration during the shift to prevent omissions and double-checking blister packs and med cups after dose has been removed from the card for administration to prevent wrong dose errors so that all medications are administered in compliance with the physician's orders. This training will be documented on a SA sheet and will be completed by 01/03/2025. The SA sheets will be sent to the Staff Development Coordinator to verify all nurses have received training.

Monitoring of medication administration to ensure all nursing staff are administering all medications per the Physicians Orders will be completed by the Assistant HSS (AHSS) or HSS. This will be done through random med pass audits on varied days and times. Documentation of this monitoring will be kept on the Medication Pass Audit form. The Medication Pass Audit is a visual observation of the staff performing administration of medications and treatments. This visual process includes, but is not limited to, ensuring that all drugs are administered In compliance with the physicians orders. 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.

If during this process, it has been identified that the staff observed are not administering medications as per Physician Orders and Merakey AVS Protocol, retraining will be provided individually to that person and the random audits will be increased in frequency. Staff who fail to follow policy will be referred to the Senior Director, Residential, for corrective action.