Initial Comments:
A focused fundamental survey was conducted October 11-12, 2023, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Requirements for Intermediate Care Facilities. The census during the survey was three and the sample consisted of two individuals. One deficiency was identified.
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 of the two individuals who received morning medications (Individual #1). The findings included:
A) Morning medication administration was observed on October 11, 2023, between 6:35 AM and 8:20 AM. Individual #1 received her medications, including but not limited to Synthroid 75 micrograms (mcgs) and Prilosec 20 milligrams (mgs) at 8:20 AM.
B) Physician's orders, dated October 4, 2023, were reviewed on October 11, 2023. This review revealed that Individual #1 was prescribed Synthroid 75 mcgs, one tablet daily at 6:00 AM, and Prilosec 20 mgs, one capsule daily at 6:00 AM.
C) The health services supervisor (HSS) was interviewed on October 11, 2023, at 12:56 PM. The HSS confirmed that Individual #1's Synthroid and Prilosec medications were administered late.
Plan of Correction:Tag 0369
Merakey Allegheny Valley School, 840 Middletown 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. 840 Middletown 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 840 Middletown 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 10/11/23 the surveyor informed the Health Services Supervisor that while observing the morning med pass for one individual in the home they noted the staff had not administered meds to 1 individual at the correct time.
A medication administration practicum for the staff person who was administering medications at the time of the observation was performed on 10/18/2023 without error. This included all individuals in the home.
The SFR nurses will train the covering house manager and house manager aid staff in the home concerning proper procedure for completing a medication pass which includes administering medications at the time they are prescribed as per Physician Orders by 10/28/23. 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 by 10/28/23.
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 are receiving all medications at the time they are prescribed 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 October 23, 2023.
If during this process, it has been identified that the staff observed are not administering medications as per policy, then 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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