Initial Comments:
A focused fundamental survey was conducted December 6-7, 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 five and the sample consisted of three individuals.
Plan of Correction:
483.430(e)(2) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
For employees who work with clients, training must focus on skills and competencies directed toward clients' health needs.
Observations:
Based on record review, observations, and interviews, it was determined that the facility failed to ensure that staff demonstrated the necessary skills and competencies directed towards the dietary needs of the individuals. This applied to one (#3) of three individuals in the core sample. Findings included:
Observations at the residence were completed on December 6, 2023, from 3:00 PM to 6:30 PM. During this time, the dinner meal was observed. At 4:37 PM, Individual #3 was observed to receive their dinner, which consisted of baked chicken, green beans, and mashed potatoes. Individual #3 was observed to consume all of the food on their plate. At 4:50 PM, Individual #3 was observed to receive a second portion of the chicken, mashed potatoes, and green beans and then consume all of these portions as well.
A record review was completed for Individual #3 on December 7, 2023. This review revealed a physician's order dated September 26, 2023, which indicated that Individual #3 is to receive a 1500-calorie diet with "no seconds except vegetables/salads." Review of Individual #3's facility provided "CWS Vital Signs Report" revealed a 15-pound weight gain since January 2023. Additionally, this review revealed the following nurses notes:
-November 3, 2023, "Family Contact: Spoke with [guardian] about concerns for weight gain. Reports [Individual #3] has stated he was fat and not comfortable with stomach."
-November 6, 2023, "Per nutritionist on calorie restricted diet no recommended changes at this time."
-November 8, 2023, "Family Contact: Remains concerned with weight gain stating 15 lbs over last year. November weight not obtained yet and will be reviewed with [guardian] when done. Discuss nutritionist review."
-November 29, 2023, "Family Contact: Concerns related to weight expressed by [guardian]. Review current weight, dietician previous advice and avatar documentation."
An interview was conducted with the administrator on December 7, 2023, at 12:57 PM. The administrator confirmed that Individual #3 should not receive seconds of their meals, except for vegetables and salads, and that Individual #3 had an undesirable weight gain of 15 pounds within the last year. The administrator further confirmed that the staff training had failed in providing the appropriate ordered diet for Individual #3.
Plan of Correction:Allegheny Valley School Pine Hollow I SFR makes its best effort to operate in full compliance with both Federal and State regulations. Nothing included in the Plan of Correction is an admission otherwise.
AVS Pine Hollow I SFR has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections contained herein. Please note that AVS Pine Hollow I SFR may contest the merits and/or form of any deficiency or finding alleged below and take responsible steps to appeal them.
On 12/7/23, all staff members working at 908 Pine Hollow SFR received retraining from the Administrator on Individual #3's feeding profile and current diet order. In addition, staff also received retraining on all feeding profiles and diet orders for all individuals residing at the 908 Pine Hollow SFR. Training focused on diet orders and appropriate food textures for all individuals, with specific focus placed on individuals receiving second portions and methods to effectively promote appropriate dietary habits.
In order to monitor the effectiveness of this training, the facility will complete three Mealtime Audits, from December 2023 to February 2024. Personnel completing the audits will include the QIDP, House Manager and Administrator. Mealtime Audit will include monitoring for appropriate diet orders followed and ensure that appropriate food textures are offered. Any issues noted during the audit process will be addressed immediately and reported to the Administrator. Any concerns requiring further evaluation will be referred to the OT. The completed audit documentation will be sent to and maintained by the Administrator.
Ongoing monitoring of mealtimes at the 908 Pine Hollow Rd SFR will be completed by the QIDP on a quarterly basis. Any issues noted during the audit will be addressed immediately and reported to the Administrator. A summary of the observation will be sent to the Administrator for review.
On 12/14/23, at Individual #3's Annual IDT, his monthly weights were reviewed with his guardians, including weight for the months of November and December. Individual #3's guardians were satisfied with the slight weight loss noted over the past two months and the team agreed to ongoing monitoring of monthly weights by nursing staff. Any issues with weight gain will be referred to the dietician as needed.
For other potentially affected individuals, training will be completed for all Allegheny and Beaver County ICF homes regarding feeding profiles and dietary orders with specific focus placed on individuals receiving second portions and appropriate food textures. This training was completed at the House Managers meeting on 12/19/23 and the House Managers will be responsible for training their subordinate staff. Additionally, one Mealtime Audit will be completed by the House Manager of each home in the month of January 2024. Any issues noted during the audit process will be addressed immediately. Any concerns requiring further evaluation will be referred to the OT. This training will be completed by 1/19/24. All training sheets and Mealtime Audit sheets will be sent to and maintained by the Administrator.
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, review of physician's orders, and interviews, it was determined that the facility failed to ensure that medications were administered without error. This applied to one (#2) of three individuals observed during the morning medication administration. Findings included:
Morning observations were completed at the residence on December 6, 2023, from 5:55 AM to 8:15 AM. Individual #2's medication administration was observed from 6:12 AM to 6:15 AM. Individual #2 was observed to be administered levothyroxin, oyster shell d, vitamin d3, and fish oil. The medication label for Individual #2's oyster shell d indicated that the medication was to be administered "1 tablet by mouth twice daily with meals." Individual #2 was observed to take their medication with water. Indvidual #2 was not observed to consume a meal during morning observations at the residence.
An interview was conducted with the house manager (HM) on December 6, 2023, at 8:10 AM. The surveyor questioned the HM regarding Individual #2's morning routine and described their observation. The HM stated that Individual #2 has become more reclusive over the past few months, and has not wanted to consume their meals when other individuals are present. The HM further stated that it is typical for Individual #2 to consume their meals after 8:00 AM on most mornings.
A review of physician's orders for medication administration reconciliation was completed for Individual #2 on December 6, 2023. Individual #2's current physician's orders, dated September 26, 2023, indicated that they are ordered to receive their oyster shell d "1 tablet by mouth twice daily with meals."
An interview with the administrator was conducted on December 6, 2023, at 10:00 AM. The administrator confirmed that Individual #2 should have received their oyster shell d with a meal, and further confirmed that this medication was administered in error.
Plan of Correction:Allegheny Valley School Pine Hollow I SFR makes its best effort to operate in full compliance with both Federal and State regulations. Nothing included in the Plan of Correction is an admission otherwise.
AVS Pine Hollow I SFR has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections contained herein. Please note that AVS Pine Hollow I SFR may contest the merits and/or form of any deficiency or finding alleged below and take responsible steps to appeal them.
The staff person involved in the medication administration error on 12/6/23 involving individual #2 was addressed via the standard disciplinary process on 12/7/23. This staff person received retraining on 12/7/23 for the Administration of Medication Protocol including the "Five Rights of Medication Administration". Specific emphasis was placed on "Right Technique", ensuring that all medication is administered according to physician order, including special instructions such as medication to be taken with food.
To monitor the effectiveness of this training, two additional observations will be conducted by a Certified Practicum Observer for the staff person who committed the error in the next 30-day period. These observations will be completed by 1/21/24. The results of these extra observations will be relayed to the Administrator and the Health Services Supervisor. The Administrator will retain copies of these extra observations.
In order to protect all other potentially affected individuals, all med trained staff working at the Pine Hollow SFR received training regarding the Five Rights of Medication Administration on 12/6/23. Specific emphasis was placed on "Right Technique", ensuring that all medication is given according to physician order, with specific emphasis placed on thorough and complete medication administration and ensuring that all medications that are ordered are administered accordingly. This training also outlined that medication orders that state "take with meal" or "take with food", should be administered as such. If the consumer refuses to eat a complete meal at the time of medication administration, staff must offer food such as applesauce, pudding, cereal bar, etc. The signed staff training sheet was sent to the Administrator and will be maintained by the Administrator.
Ongoing monitoring via Practicum Observer protocol will occur every six months thereafter for all med trained staff. Any concerns will be relayed to the Health Services Supervisor or her designee, and the Administrator for appropriate follow-up.
To ensure that the Administration of Medication Protocol for complete medication pass without errors is followed, training will be completed for all Allegheny and Beaver County ICF homes regarding Medication Administration Protocol. This training was completed at the House Managers meeting on 12/19/23 and included specific emphasis on ensuring that all medications ordered by physician are administered without error, all special instructions are followed as ordered, and food is offered immediately if medications are ordered to be taken with meals. The House Managers will be responsible for training their subordinate staff. This training will be completed by 1/2/24. Completed training sheets will be sent to the Administrator and will be maintained by the Administrator.
483.470(l)(1) STANDARD
INFECTION CONTROL
Name - Component - 00
The facility must provide a sanitary environment to avoid sources and transmission of infections.
Observations:
Based on observations and interview, it was determined that the facility failed to provide a sanitary environment. This applied to all five individuals living at the residence. Findings included:
Observations were completed at the residence on December 6, 2023, from 3:00 PM to 6:30 PM. At 3:15 PM, during a tour of the facility, several electric razors were observed in a drawer in the first-floor bathroom. The razors were observed to be labeled with each individual's initials, commingled in the drawer without any sanitary covers. The surveyor questioned the house manager (HM) regarding the sanitary condition of the electric razors. The HM then placed the razors in individual zip-lock bags and stated that replacement heads would be obtained for each individual.
On December 7, 2023, at 12:48 PM, an interview was conducted with the administrator. At this time, the administrator confirmed that the electric razors were not being stored in a sanitary environment to ensure infection control.
Plan of Correction:Allegheny Valley School Pine Hollow I SFR makes its best effort to operate in full compliance with both Federal and State regulations. Nothing included in the Plan of Correction is an admission otherwise.
AVS Pine Hollow I SFR has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections contained herein. Please note that AVS Pine Hollow I SFR may contest the merits and/or form of any deficiency or finding alleged below and take responsible steps to appeal them.
On 12/7/23, all razors that were stored in the bathroom drawer were thoroughly cleaned and replacement heads with covers and labels were put on each individual razor. All razors were then placed in the personal hygiene basket for each individual.
All staff working at the 908 Pine Hollow SFR were trained on infection control protocol, with specific emphasis placed on all personal hygiene items being maintained in individual's personal hygiene baskets and not in communal drawers, bins or cabinets. This training was completed on 12/19/23 and the signed training sheet will be maintained by the Administrator.
In order to monitor the effectiveness of this training, random site observations will be conducted at 908 Pine Hollow Rd for three months, from December 2023 through February 2024. Site observations will be conducted by the QIDP, House Manager, and Administrator. Any infection control concerns will be addressed immediately and reported to the Administrator. Site observation papers will be sent to and retained by the Administrator.
Ongoing monitoring for infection control protocols regarding personal hygiene items at the 908 Pine Hollow Rd SFR will be completed by the QIDP on a quarterly basis. Any issues noted during the audit will be addressed immediately and reported to the Administrator. A summary of the observation will be sent to the Administrator for review.
For other potentially affected individuals, training will be completed for all Allegheny and Beaver County ICF homes regarding infection control protocol. This training will place specific emphasis on personal items not being stored in areas where they would comingle, and all personal care items such as razors should be stored in personal hygiene baskets for each individual client. This training was completed at the House Managers meeting on 12/19/23 and the House Managers will be responsible for training their subordinate staff. This training will be completed by 1/2/24. All training sheets and Mealtime Audit sheets will be sent to and maintained by the Administrator.
483.480(b)(2)(iii) STANDARD
MEAL SERVICES
Name - Component - 00
Food must be served in a form consistent with the developmental level of the client.
Observations:
Based on observations, record review, and interview, it was determined that the facility failed to ensure that all individuals received meals consistent with their identified needs. This applied to one (#3) of three individuals in the core sample. Findings included:
Observations were completed at the residence on December 6, 2023, from 3:00 PM to 6:30 PM. During this time, the dinner meal was observed. At 4:37 PM, Individual #3 was served his dinner, which consisted of green beans that appeared to be finely chopped, mashed potatoes, and baked chicken in pieces that appeared to be approximately 1 to 2 inches in size. At 4:45 PM, the surveyor asked to see the feeding profile for Individual #3, which indicated that their food should be cut into chopped into inch pieces, smaller than dime size. At this time, Individual #3 was observed receiving a second serving of food that consisted of regular whole green beans, mashed potatoes, and chicken in pieces that appeared to be 1 to 2 inches in size. The surveyor questioned the staff regarding the difference in texture between what was indicated on the feeding profile and the texture of the food that was served and eaten. The staff replied that they believed that the feeding profile was incorrect and that Individual #3 was able to tolerate the texture in which their meal was served. The surveyor further questioned the staff regarding the discrepancy between the texture indicated on the feeding profile and the texture of the food that Individual #3 was actively consuming. The staff then took Individual #3's plate to the kitchen and returned to the dining room with Individual #3's food cut into what appeared to be in approximately inch pieces. Individual #3 then proceeded to finish their meal.
A record review was completed for Individual #3 on December 7, 2023. This review revealed current physician's orders dated September 26, 2023, that indicated Individual #3's food should be "bite size (inch)."
An interview was conducted with the administrator on December 7, 2023, at 12:55 PM. The administrator confirmed that Individual #3's food texture should be in bite size, inch pieces. The administrator further confirmed that Individual #3's dinner meal had not been served in a form consistent with their identified need.
Plan of Correction:Allegheny Valley School Pine Hollow I SFR makes its best effort to operate in full compliance with both Federal and State regulations. Nothing included in the Plan of Correction is an admission otherwise.
AVS Pine Hollow I SFR has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections contained herein. Please note that AVS Pine Hollow I SFR may contest the merits and/or form of any deficiency or finding alleged below and take responsible steps to appeal them.
For the affected Individual #3, the staff person involved in the incident on the date of December 6, 2023, was immediately retrained on the feeding profile. This training was completed on 12/7/23 by the Administrator and the signed training sheet will be maintained by the Administrator.
For potentially affected individuals at 908 Pine Hollow Rd, all staff at the site were retrained by the Administrator on current feeding profiles for all individuals that reside at the site. This training was completed on 12/19/23 and signed training sheets will be maintained by the Administrator.
In order to monitor the effectiveness of this training, the facility will complete three Mealtime Audits, from December 2023 to February 2024. Personnel completing the audits will include the QIDP, House Manager and Administrator. Mealtime Audit will include monitoring for appropriate diet orders followed and ensure that appropriate food textures are offered. Any issues noted during the audit process will be addressed immediately. Any concerns requiring further evaluation will be referred to the OT. The completed audit documentation will be sent to and maintained by the Administrator.
Ongoing monitoring of mealtimes at the 908 Pine Hollow Rd SFR will be completed by the QIDP on a quarterly basis. Any issues noted during the audit will be addressed immediately and reported to the Administrator. A summary of the observation will be sent to the Administrator for review.
For other potentially affected individuals, training will be completed for all Allegheny and Beaver County ICF homes regarding Feeding Profiles and dietary orders with specific focus placed on individuals receiving second portions, and appropriate food textures. This training was completed at the House Managers meeting on 12/19/23 and the House Managers will be responsible for training their subordinate staff. Additionally, one Mealtime Audit will be completed by the House Manager of each home in the month of January 2024. Any issues noted during the audit process will be addressed immediately. Any concerns requiring further evaluation will be referred to the OT. This training will be completed by 1/2/24. Completed training sheets will be sent to the Administrator and will be maintained by the Administrator.
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