Initial Comments:
A focused fundamental survey was conducted September 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 original consisted of two individuals. Three deficiencies were cited.
Plan of Correction:
483.420(d)(2) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to ensure all allegations of abuse, neglect, or mistreatment were reported immediately to administration. This was noted for one of the two incidents of neglect in the past year (Individual #3). The findings included:
Investigations from the past year were reviewed on September 5-6, 2023. This review revealed the following:
A) An incident of possible neglect for Individual #3 occurred on May 1, 2023, at 7:30 PM. This individual was being transferred via mechanical Hoyer lift from her wheelchair to her bed. During this transfer, Individual #3 fell out of the Hoyer sling and onto the floor. Further review of this investigation packet revealed that administration was not notified of this incident until May 2, 2023, at 8:30 AM.
B) The facility administrator was interviewed on September 5, 2023, at 1:00 PM. The administrator confirmed that the allegation of neglect for Individual #3 was not immediately reported to administration.
Plan of Correction:Merakey Allegheny Valley School, 880 Poplar Street 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, 880 Poplar Street 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, 880 Poplar Street may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
W153
Merakey Allegheny Valley School, 880 Poplar Street will ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.
The Administrator or designee will conduct re-training for all Direct Support Professionals, House Managers, site level Certified Investigators and Point Persons by October 6th,2023 at which point the importance of ensuring that all allegations of mistreatment, neglect or abuse as well as injuries of unknown source, are reported immediately to the Administrator or to other offices in accordance with State law through established procedures will be reviewed. Additional re-training for House Managers will include specific emphasis on the need to immediately report verbally to the Administrator or designee when an allegation of abuse or neglect is made. Additional re-training for site level Certified Investigators and Point Persons will include specific emphasis regarding the on-going need to identify late reporting, including during the Administrative review. Late reporting will be addressed immediately via re-training or via the standard disciplinary process. Re-training will be documented on a Merakey Staff Attendance Sheet (SA).
In order to monitor the training was effective, the Sr. Regional Director or designee will review initial EIM submissions of incidents involving abuse and neglect to ensure prompt reporting for a period of six months (October, November, December 2023 and January, February, March 2024). If late reporting is identified, this will be addressed immediately via re-training or via standard disciplinary process. This review will be documented within the investigative file as well as any identified necessary follow-up as determined at time of review.
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 ensure all allegations of abuse, neglect, or mistreatment were thoroughly investigated. This was noted for one of the two incidents of neglect in the past year (Individual #3). The findings included:
Investigations from the past year were reviewed on September 5-6, 2023. This review revealed the following:
A) An incident of possible neglect for Individual #3 occurred on May 1, 2023, at 7:30 PM. The investigation packet revealed that this individual was being transferred via mechanical Hoyer lift from her wheelchair to her bed. During this transfer, Individual #3 fell out of the Hoyer sling and onto the floor. Administration was not notified of this incident until May 2, 2023, at 8:30 AM. The investigation packet did not address the late reporting of an allegation of neglect to administration. In addition, there was no preventative measure developed to prevent future occurrence of late reporting to administration.
Further review revealed that the investigation packet included a summary of a witness statement from the target which indicated the staff "walked over her body for injuries". Upon surveyor request for additional witness statements that were not included in the investigation packet, it was discovered that the witness statement from the target staff stated, "I looked over her body for injuries".
B) The administrator was interviewed on September 5, 2023, at 1:10 PM. The administrator confirmed that the investigation into an allegation of neglect for Individual #3 did not address the above-mentioned information. The administrator confirmed that this investigation was not thorough.
Plan of Correction:Merakey Allegheny Valley School, 880 Poplar Street 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, 880 Poplar Street 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, 880 Poplar Street 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, 880 Poplar Street will ensure that the facility has evidence that all alleged violations are thoroughly investigated.
The Administrator or designee will conduct re-training for all site level Certified Investigators and Point Persons by October 6th,2023 at which point the importance of ensuring that all alleged violations are thoroughly investigated will be reviewed. Re-training will include specific emphasis on the need to obtain case files prior to scheduling the findings presentation and administrative review, allowing time to ensure all required information has been collected, documented, and are presented in total consistently. Upon review of case file, if information is to be noted missing or inconsistent, it will be the responsibility of the point person to reach out immediately to the assigned Certified Investigator to discuss and Administrator or designee to discuss appropriate follow-up. This will be required to be received within one week of request. Re-training will also review the need to have all information received from the Certified Investigator kept within the investigative packet. Re-training will be documented on a Staff Attendance Sheet (SA).
In order to monitor that the training was effective, the Sr. Regional Director or designee will review investigative files involving abuse and neglect for a period of six months (October, November, December 2023 and January, February, March 2024) and as needed thereafter to ensure all required information has been collected, documented and are presented in total consistently. Any concerns noted during the review will be addressed immediately and further corrective action taken where deemed appropriate. Review and findings follow-up will be documented within the investigative file.
483.420(d)(3) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must prevent further potential abuse while the investigation is in progress.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to ensure abuse was prevented during an investigation. This was noted for one of the two incidents of neglect in the past year (Individual #3). The findings included:
Investigations from the past year were reviewed on September 5-6, 2023. This review revealed the following:
A) An incident of possible neglect for Individual #3 occurred on May 1, 2023, at 7:30 PM. This individual was being transferred via mechanical Hoyer lift from her wheelchair to her bed. During this transfer, Individual #3 fell out of the Hoyer sling and onto the floor. Further review of the investigation packet revealed there was only one staff on duty at the time of the incident. This staff continued to work alone for the remainder of the shift.
B) The facility administrator was interviewed on September 5, 2023, at 1:15 PM. The administrator confirmed that the target staff was not immediately removed from client care after the incident and continued to work for the remainder of the shift.
Plan of Correction:Merakey Allegheny Valley School, 880 Poplar Street 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, 880 Poplar Street 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, 880 Poplar Street may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
W155
Merakey Allegheny Valley School, 880 Poplar Street will ensure that the facility prevents further potential abuse while the investigation is in progress.
The Administrator or designee will conduct re-training for all site level Certified Investigators, Point Persons and House Managers October 6th,2023 at which point the importance of preventing further potential abuse and protecting the individuals while an investigation is in progress will be reviewed. Re-training will include specific emphasis on the need for House Managers to immediately remove alleged targets from the floor once an allegation of abuse or neglect is made. Once removed from the floor, House Managers will not only be required to report the incident to the Administrator or designee but also confirm with the Administrator or designee that the alleged target has been removed from the floor. Re-training will be documented on a Merakey Staff Attendance Sheet (SA).
In order to monitor that the training was effective, the Sr. Executive Director will confirm with Administrator or designee at time of report that target is removed during investigative process to prevent further potential harm. This will be recorded on timeline within the Investigative file. Any concerns with timeliness of removal of target will be addressed via the standard disciplinary process. The Sr Executive Director will review all EIM submissions of incidents involving abuse and neglect for a period of six months (October, November, December 2023 and January, February, March 2024) and as needed thereafter to ensure that alleged targets are removed from the floor once an allegation of abuse or neglect is made.
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