Initial Comments:
A focused fundamental survey was conducted June 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 core sample consisted of two individuals.
Plan of Correction:
483.460(k)(1) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.
Observations:
Based on observations, a review of physician's orders and medication administration record, and interview, it was determined that the facility failed to ensure that all medications were administered in accordance with physician's orders. This applied to one (#3) of three individuals observed during the morning medication administration.
Observations of the morning medication pass for three individuals were completed on June 5, 2023, from 7:03 AM until 7:47 AM. During the pour for Individual #3, the house manager assistant (HMA) administering the medication recognized that the label for one of the medications did not match the medication administration record (MAR). The label for the medication read, "Vitamin D Tab 50 mcg take 1 tablet by mouth daily" while the MAR read, "Vitamin D3 Tabs 2000 IU take 1 tablet by mouth daily." The HMA then contacted the health services supervisor, who advised the HMA to hold that medication for the morning medication pass and that a physician would be contacted to change the physician's order. A review of the June MAR indicated that this medication had been administered by direct care staff on June 2-4, 2023, as written on the medication label and MAR. A review of current physician's orders for these dates read, "Vitamin D3 Tabs 2000 IU take 1 tablet by mouth daily."
An interview was conducted with the assistant health services supervisor (AHSS) on June 5, 2023, at 9:48 AM. The AHSS confirmed that the physician's orders and the label of the medication administered from June 2-4, 2023, did not match. The AHSS further confirmed that this medication should not have been administered to Individual #3 on the above mentioned dates without first notifying a nurse of the discrepancy. The AHSS confirmed that the medication was administered in error.
Plan of Correction:TAG 0368 – DRUG ADMINISTRATION
Merakey/Allegheny Valley School (AVS), 107 Coleman Dr, makes its best efforts to operate in full compliance with both Federal and State law. Nothing included in this Plan of Correction is an admission otherwise. AVS, 107 Coleman Dr, has submitted this Plan of Correction 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 AVS, 107 Coleman Dr, may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
A Physician's Order was obtained for Vitamin D on 6/5/23 for individual #3. The staff person involved in the medication administration error involving individual #3, June 2-4, 2023, will receive retraining on Medication Error Retraining- Wrong Technique. With specific emphasis placed on the label and Medication Administration Record match. This will be completed by 6/6/10/23. All Staff Attendance Sheets will be completed and maintained with the Administrator.
On 6/8/23, the Health Services Supervisor (HSS), audited all individuals in the Allegheny/Beaver County that receive the medication Vitamin D for correct Physician's Orders.
During the month of June 2023, the Administrator and/or designee will conduct a House Manager's meeting for all managers in the Allegheny/Beaver/Butler/Mercer area. The Health Service Supervisor will provide training to all House Managers regarding making all Physician's Orders and labels match.
For monitoring of the concern outlined, two additional observations will be conducted by the Health Services Supervisor, Assistant Health Services Supervisor or her designee for the staff person who committed the error in the next 30-day period. These observations will be completed by 7/7/23 and results will be relayed to the Administrator. Copies of these observations will be sent to the Administrator and maintained with Administrator.
Ongoing monitoring via Practicum Observer Protocol will occur every 6 months thereafter. Any concerns will be relayed to the Health Services Supervisor, Assistant Health Services Supervisor or her designee and the Administrator for follow up.
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