Initial Comments:
A focused fundamental survey was conducted July 5-6, 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 four and the sample consisted of two individuals. One deficiency was cited.
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 staff interview, it was determined that the facility failed to ensure medications were administered without error. This was noted for one individual (Individual #1). The findings included:
A) The morning medication administration was observed on July 5, 2023, between 6:39 AM and 7:45 AM. This observation revealed the staff administering medications (SAM) prepare Individual #1's medication at 6:50 AM. The SAM poured 20 milliliters (ml) of Valproic acid (Depakote) and then poured it into cup with other crushed medications. The surveyor reviewed the prescription label on the Valproic acid and informed the SAM that this individual is to receive 25 ml in the morning. The SAM confirmed the finding at 6:56 AM and poured an additional 5 ml and added it to the cup with other crushed medications.
B) Physician's orders for Individual #1 were reviewed on July 5, 2023, at 11:00 AM. This review revealed orders dated April 12, 2023, indicated that this individual was prescribed Valproic acid 250/5ml, 25 ml, via gastrostomy tube, at 7 AM.
Plan of Correction:
Tag 0369
Merakey Allegheny Valley School, Trail Road SFR 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. Trail Road SFR 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 Trail Road SFR may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
The Facility will confirm that the system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.
On 7/07/23 the surveyor informed the Health Services Supervisor that while observing the morning med pass for one individual in the home they noted staff had poured the wrong dose of medication. The surveyor spoke with the staff to ensure that the correct dose was given.
A medication administration practicum for the staff person who was administering medications at the time of the observation was performed on 7/07/2023 without error. This included all individuals in the home. The staff person will also sit down with the med trainer for further remediation. This will be completed by 7/21/23.
The SFR nurses will train the house manager and house manager aid staff in the home concerning proper procedure for completing a medication pass which includes administering the correct dose as per Physician Orders. This will be documented on a Staff Attendance (SA) sheet. Once the training of all staff in the home is completed, this will be reported to the Residential Director for SFRs and Director of Nursing. SA sheets will be sent to the Staff Development Coordinator to verify all staff have received training.
Monitoring of medication administration to ensure all staff in the home are administering all medications per the Physicians Orders will be completed by the nurse, Assistant HSS (AHSS) or HSS. Documentation of this monitoring will be kept on the Medication Pass Audit form. The Medication Pass Audit is a visual observation of the staff administering medications and treatments. This visual process includes, but is not limited to, ensuring individuals receive the prescribed dose of each medication throughout the entire medication administration procedure. Random AM and PM audits will occur weekly for two months. 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. Med Pass Audits will begin the week of July 17, 2023.
If during this process, it has been identified that the staff observed are not administering medications as per policy training will be provided individually to that staff person and random audits will be increased in frequency. Staff who fail to follow policy will be referred to the ICF/SFR Administrator for corrective action.
The ICF/SFR Administrator and HSS will review all completed Med Pass Audits monthly to ensure the audits are completed as scheduled.
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