Initial Comments:
A monitor visit was conducted on December 14-15, 2023, 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 17 and the sample consisted of one individual. Two deficiencies were cited.
Plan of Correction:
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 investigate an injury to rule out neglect. This was noted for the only individual who sustained an injury during bathing routine (Individual #1). The findings included:
A) A review of incident/accident reports from the conclusion of the focused fundamental survey (August 10, 2023) through present were reviewed. This review revealed an incident dated August 12, 2023. The report indicated that Individual #1 "hit his eyebrow against the edge of the bathtub". According to the report, a two-centimeter laceration was sustained, and bleeding was stopped with pressure. The on-call physician gave an order to send Individual #1 to the emergency department for evaluation. Tests indicated that there was no internal injury, and the laceration did not require any type of repair.
There was no documentation in the report to indicate an environmental assessment was conducted; nor a probable cause as to how this injury was sustained. The report revealed an attached memo to re-train staff that indicated "It is important to note that staff should be making use of the mats for the bathtub when assisting the individuals with their bathing routines."
Further review of the report revealed a section entitled "Signatures". This section had an area (#8) which indicated investigation required: yes or no boxes to be checked. There was no documentation an investigation was required. The residential services manager (RSM) signed the report on August 25, 2023; and the executive director (ED) signed the report on August 30, 2023. The administrative comments/summary/conclusion section was blank.
B) The administrator was interviewed on December 14, 2023, at 3:00 PM. The administrator confirmed that there was no documentation that an environmental assessment was completed to rule out neglect for Individual #1's injury. In addition, the administrator acknowledged that both the RSM and ED signed the report.
Plan of Correction: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 this 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 of 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.
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Merakey Allegheny Valley School, 1291 Middletown Road will ensure that all alleged violations are thoroughly investigated.
On December 14th, 2023, an investigation for Individual #1 was initiated, submitted within the incident reporting system and assigned a Certified Investigator.
Re-training will be conducted by the Administrator with the Residential Shift Manager and Assistant Residential Shift Manager reviewing thorough completion of internal incident reports. Focus will be on the importance of ensuring appropriate notifications are completed/documented, an environmental assessment is completed, probable cause of sustained injury will be identified, and appropriate follow-up completed. Training will be completed by January 5th, 2024 and documented on a Staff Attendance Sheet.
In order to monitor that the training was effective, all internal incident reports will be presented to the Administrator or designee who will be responsible for reviewing for completeness as well as ensuring appropriate notifications are completed/documented, an environmental assessment is completed, probable cause of sustained injury will be identified, and appropriate follow-up completed within 10 working days. In addition to the 5-day notification currently received. During review, if an issue is identified, the Administrator or designee will address immediately with the Residential Shift Manager or designee. Any issues identified will be expected to be corrected by the Residential Shift Manager or designee within 5 working days. Any concerns noted will be reported to the Sr. Executive Director for further follow-up.
483.470(d)(3) STANDARD
CLIENT BATHROOMS
Name - Component - 00
The facility must, in areas of the facility where clients who have not been trained to regulate water temperature are exposed to hot water, ensure that the temperature of the water does not exceed 110 degrees Fahrenheit.
Observations:
Based on observation, documentation review, and staff interview, it was determined that the facility failed to ensure water temperatures did not exceed 110 degrees Fahrenheit. This was noted in the East Hall client bathroom in the facility. The findings included:
A) On December 14, 2023, at 2:20 PM, the assistant residential services manager (ARSM) accompanied this surveyor to the client bathroom to take the water temperature of the bathtub and the two sinks. The temperature in the two sinks were measured at 115- and 116-degrees Fahrenheit. At this time, the temperature in the bathtub was 101 degrees Fahrenheit. The ARSM confirmed the water temperatures in the two sinks were above 110 degrees Fahrenheit.
B) Facility water temperature documentation from August 11, 2023, through present, was reviewed on December 16, 2023. This documentation revealed water temperatures measuring above 110 degrees Fahrenheit as listed below:
- First shift: three times - Second shift: eight times
- Third shift: 38 times, with temperature documented as high as 122.8 degrees Fahrenheit.
C) The residential services manager (RSM) was interviewed on December 15, 2023, at 2:00 PM. The RSM confirmed the water temperatures in the East Hall bathroom were above 110 degrees Fahrenheit for the above-mentioned number of times on each shift. In addition, the facility administrator confirmed that there was no documentation of timely completed work orders to address temperatures which exceeded 110 degrees Fahrenheit.
Plan of Correction: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 this 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 of 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.
W426
Merakey Allegheny Valley School, 1291 Middletown Road will ensure that in areas of the facility where clients who have not been trained to regulate water temperature are exposed, that the temperature of the water does not exceed 110 degrees Fahrenheit.
Upon discovery of high water temperature on December 14th, 2023 the Residential Services Manager submitted a work order to the maintenance department. Staff on the floor were informed to suspend water usage from the affected water source until the water temperature was noted to be returned to acceptable range of 110 degrees F or below. The affected water source was also blocked from use and postings put in place preventing use of affected water source until addressed appropriately. Central mixing valve was adjusted. Water temperatures were checked following adjustments and confirmed within acceptable range of 110 degrees F or below.
The Facilities Maintenance Supervisor closely evaluated the central mixing valve again and it was found to be fully operable as of December 18th, 2023.
On December 20th, 2023, a revised water temperature record was implemented to include the following.
All sinks, tubs and showers in both bathroom areas will have water temperatures taken. If the water temperature is found to be above acceptable range of 110 degrees F or below, notification to the Maintenance department and Residential Shift Manager/Assistant Residential Shift Manager on-call will be contacted immediately. Date and time of notification will be recorded on water temperature record. Maintenance will complete intervention as needed and include resolution of issue and date and time this occurred on the water temperature record. Maintenance will retake the water temperature to ensure within acceptable range of 110 degrees F or below before informing Residential Shift Manager or Assistant Residential Shift Manager that water has returned to acceptable levels for use by clients. Retraining on the new water temperature record was completed by the Residential Services Manager for all staff as of December 21st, 2023. Training was documented on a Staff Attendance Sheet.
Upon review of newly implemented water temperature record by Administrator and Sr. Executive Director inconsistent documentation was identified. Training was again provided to all staff and supervisory staff on completion of water temperature recording procedures. Training will be completed by January 4th, 2024, by the Administrator. Training documented on a Staff Attendance Sheet.
In order to monitor the effectiveness of this training, the Shift Supervisor or designee will be responsible for ensuring water temperatures are obtained and subsequent reporting (notification of Residential Shift Manager/Assistant Residential Shift Manager, Maintenance and completion of water temperature record) has occurred timely and accurately. This will be incorporated into the Shift Supervisors' daily responsibilities. The Administrator or designee will be responsible for reviewing the water temperature record weekly, ensuring that water temperature procedures and format are being completed timely and accurately. Any concerns noted upon review will be immediately referred to the Sr. Executive Director for further follow-up via standard disciplinary policy.
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