There are  34 surveys for this facility. Please select a date to view the survey results.

Merakey Allegheny Valley School Blakiston (MAVSB) 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. MAVSB has submitted this Plan of Correction in order 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 MAVSB may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
C1
The Governing Body will exercise general policy, budget and operating direction over the facility. All maintenance and cleanliness issues will be evaluated by the Senior Executive Director and Associate Executive Director on or before April 14, 2023. Where applicable, items identified will be repaired and/or replaced (see specific items below).
On March 20, 2023, the Community Director began retraining the facility staff on shift responsibilities for cleaning and maintaining the site. The training included the chore list and daily responsibilities for each shift. The training was documented on a Staff Attendance Sheet (SA) and will be maintained at the site. A copy of the SA sheet will be sent to the Associate Executive Director to verify completion.
Beginning in April 2023, the House Manager will complete a weekly walk through of the home to ensure shift cleaning routines are completed. The House Manager will submit a Weekly Update form to the Associate Executive Director or designee to include when maintenance reports are filed and status of existing maintenance reports. These Weekly Update forms will be completed by the House Manager once a week for three consecutive months and forwarded to the Community Director to verity completion. Thereafter the House Manager will complete electronic maintenance work order whenever maintenance repairs and or concern occur and maintain copies of all work order forms in a binder which will be kept at the site.
C2
On or before April 14, 2023, the Associate Executive Director or designee will retrain the facility House Managers on Maintenance Repair/Skyline work order procedures. The training will emphasize the responsibility of the House Manager to tour the entire site weekly and place any electronic submission of repairs in the Skyline system. This training will be documented on a Staff Attendance Sheet (SA) and will be maintained in the Staff Development Office. A copy of the SA sheet will be sent to the Senior Executive Director to verify completion.


C3
The House Manager completes a tour of the entire facility at least once a week to ensure the cleanliness of the site and to address any needed repairs. Staff on each shift are responsible for completing a household chores list and initialing off once all task has been completed. If there are any issues or concerns with the completion of a task, the House Manager will address the concerns with staff through retraining and or corrective action. The House Manager will enter all Maintenance repairs into Skyline system which produces a work order. Whenever repairs are needed at the site, the House Manager will notify the Maintenance Supervisor, the Community Director, and the Associate Executive Director. The Maintenance Supervisor will determine the need for the repair(s) and if an outside vendor is required it will be sourced out. Any Maintenance issues that are Health and or Safety related concerns, the House Manager will notify via phone the Assistance Maintenance Supervisor. The House Manager will print out all Skyline work order forms and place it in a binder. This process will be monitored by the House Manager through completion, and if any discrepancies occur with required repairs and this information will be disseminated to the CD and the AED.
C4
On or before April 10, 2023, the Associate Executive Director or designee will complete by-weekly random walk through of the home to ensure cleanliness and repairs issues are addressed. This bi-weekly walk through will be conducted for two consecutive months. Any issues or concerns will be addressed immediately through retraining and or corrective actions. The Maintenance report binder will be reviewed, and any outstanding issues will be addressed with the Maintenance Supervisor for resolution.
The Associate Executive Director will provide summary of all audit outcomes to the Senior Executive Director at the monthly executive meeting regarding home/facility maintenance/cleaning issues.
C5
The Senior Executive Director will address any outstanding issues/concerns with the Director of Facilities and/or Fiscal Department immediately upon receipt.
Dining Room:
An approximate 18 by 22-inch discolored area on the ceiling had cracks and missing pieces of plasters, Repaired ceiling area and repainted on 3/30/23. Placed taupe on roof to address leakage. Will be obtaining 3 estimates of roof repairs and or replacement by 6/30/23
Kitchen:
Between the back of sink and the wall, the caulking was blacked. Remove/Clean and recalk wall on 3/30/23.
Between the sink and stove, there was no caulking between the back splash and the countertop; a gap of ¼ to 3/8 inch which was turning back. Remove/clean area turning black, Caulked behind back splash between sink and stove on 3/31/23.
There are 6 circular areas of missing Formica countertop near stove the size of circles varied in size of approximately a dime to approximately a quarter. Replace Formica countertop on or by 6/30/23.
Back TV Room:
Thick layers of dust on baseboards to the left as entered the room. Baseboards dusted/cleaned on 3/20/23.
Behind the TV there were multiple pieces of paper of various sizes from scraps to full sheets of paper and lick layer of dust on the floor heater vent. Paper thrown away, heater vent dusted, and area swept on 3/20/23
White circular area, on the tan wall representing a patched area of wall. Area smoothed out and repainted on 4/30/23.
A white circle on a tan wall which was approximately 12 to 14 inches hole was observed. Sealed, patched, and repainted by 4/30/23.
Where a repair of drywall had been completed. This repair had not been completed. Repair, repaint drywall area by 4/30/23.

1st Floor Bathroom:
Wall mounted handrail next to the toilet of this bathroom. This rail is covered with round form pipe insulation. The foam covering is split along the top ) about 14 inches) down the side of the rail( approximately 5 to 6 inches) that attaches to the floor exposing the metal pipe of the railing. Replacing form insulation by 4/30/23
Upstairs Bathroom:
Three square tiles(approximately 2-3 inches square), one row back from where the floor meets the front end of the tub, were missing. The adhesive underneath the tiles was cracked and it could not be determined how deep the crack went. Will repair cracks under tiles on floor and replace tiles by 4/30/23.
A clear bathmat had a very dark color underneath the mat. The tub was cleaned 3/20/23 and replaced bathmat 3/31/23.
Paint was peeling from the ceiling in the far corner of the ceiling near the shower head. The area was 8-9 inches in diameter. Scape/smooth and repaint ceiling near shower area by 4/30/23.
White caulking underneath the faucet was observed to be reddish brown in color. Remove/clean area turning reddish brown, Recalk by 4/30/23.
Individual #4's Bedroom:
The full size head board for a bed was covered with vinyl material. Located in the middle of the head board, the vinyl is peeling showing the underlying cloth material. The top coat of the vinyl was peeled off in a rough oblong shaped pattern approximately 20-24 inches wide and 24 to 27 inches high. Repair head board by 4/4/23 Replace bed by 4/30/23.
The bed pillow was flat with no pillow case. The pillow it self was ecru in color with brown circles all over the top of the pillow. Replace pillows by 4/3/23.

Merakey Allegheny Valley School Blakiston (MAVSB) 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. MAVSB has submitted this Plan of Correction in order 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 MAVSB may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
C1
On March 21, 2023, Individual # 1, 2,and 4 self- administration maintenance plans were placed on hold until each Individuals are reassessed by Nursing. Thereafter, Individual # 1, 2, and 4 were reassessed by Nursing using the Self-Administration Assessment form. A new self-administration maintenance plan was created for Individual #1, 2, and 4.
On or before April 5, 2023, the Certified Med Administration staff completing the med pass on 3/20/23 will receive retraining and corrective action for not following the DPW OMR medication administration process and not completing the self- medication maintenance plans for Individual # 1, 2, and 4.
On or before April 10, 2023, the Facility Nurse will complete a medication training overview for all facility staff. The Facility Nurse will provide an overview to the facility staff of the 6 R's of medication administration. The Right Individual, Right medication Right dose, Right time, Right Method/Technique and Right route. All newly hired staff will undergo initial and refresher training during the course of their employment. The training will be documented on a staff attendance sheet. A copy of this training will be kept on file with the Associate Executive Director and the Staff Development Department.

On or before April 17, 2023, the Facility Nurse will retrain the House Manager and the facility staff on the importance of encouraging Individual # 1, 2 and 4 and indeed all of the facility Individuals to participate in the self-medication process as per their assessments. The training will include the importance of allowing the Individuals to actively engage in the administration of their medication as per their optimal levels. This training will emphasize the proper procedure for implementing the steps in the self-medication maintenance plan to maintain the medication administration skills for Individual #1, 2 and 4. The training will be documented on an SA sheet and maintained on the site. The House Manager will train any newly hired staff and maintain the training at the site. A copy of the training will be sent to the Associate Executive Director to verify completion.
C2
On April 24, 2023, the House Manager, the Facility Nurse and the Qualified Intellectual Disabilities Professional (QIDP) will complete Medication Administration Audits and review of the Self-Administration Maintenance Plan for Individual # 1, 2, and 4 on a weekly basis for one month. The audits should be varied i.e., mornings, evenings, and weekends. This will be done to capture a greater number of staff and at varying times during the day. All medication pass audits, and review of the self-administration maintenance plan will be sent to the Associate Executive Director to verify completion. The House Manager, the Facility Nurse and the Qualified Intellectual Disabilities Professional (QIDP) will complete Medication Administration Audits and review of the Self-Administration Maintenance Plan for Individual # 1, 2, and 4 for a month. The House Manager will complete one Medication Administration Audit and review of the Self-Administration Maintenance Plan for 2 consecutive months. All audits will be completed on the Medication Pass Audit and/or Mealtime Audit forms and sent to the Associate Executive Director to verify completion.
C3
The Certified Med Administration staff follow the guidelines outlined by PA DPW OMR, to administer medication. The Certified Med Administration Staff must follow the procedure of medication administration, the Right Individual, Right medication Right dose, Right time, Right Method/Technique and Right route. The Certified Med Administration Staff will follow the Individual Self-Administration Goal Plan and or the Self-Administration Maintenance plan. Prior to starting the Medication Administration process, the Certified Med Administration Staff will review the self-administration goal plan or self-administration maintenance plan for the Individual and follow the written instructions and procedures for the plan to completion. Once the self-administration goal plan or self-administration maintenance plan is completed the Certified Med Administration Staff will document the result onto the plan.
C4
The Qualified Intellectual Disabilities Professional (QIDP/PS) will complete quarterly observations for all the individuals at the facility. The observations will include the monitoring of self-administration maintenance plan. The documented observations will be forwarded to the Eastern Region Social Service Supervisor and/or designee and to the Associate Executive Director.
C5
The Associate Executive Director will be responsible for monitoring the process and reporting any continuing concerns to the Senior Executive Director at the monthly Director's meetings.

Merakey Allegheny Valley School Blakiston (MAVSB) 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. MAVSB has submitted this Plan of Correction in order 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 MAVSB may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
The facility will maintain all drugs and biologicals locked, except when being prepared for administration.
C1
On March 20, 2023, the Community Director retrained the facility staff on ensuring that all drugs and biologicals are locked when passing medications to Individual #2 and 4. The training emphasized the importance of keeping drugs and biological locked when medications are not being prepared for administration. On or before April 5, 2023, the staff passing the medication on 3/20/23 will be receiving corrective actions for not following the medication administration process on Locking Medication Cabinet and double checking the lock to ensure it is secured. The training will be documented on a Staff Attendance Sheet (SA), maintained on the site. A copy of the training will be forwarded to the Associate Executive Director to verify completion.
C2
On or before April 24, 2023, the Facility Nurse and the House Manager will conduct medication pass audits for staff administering medication weekly for six(6) weeks primarily focusing on the drugs and biologicals being locked when medication are not being prepared for administration. Beginning June 2023 the Facility Nurse and the House Manager will complete random medication pass audit for staff administering medication (alternating medication passes at 6a-8a-4p-8p) primarily focusing on the drugs and biologicals being locked when medication are not being prepared for administration.
C3
As outlined by PA DPW OMR, the House Manager will complete quarterly MAR reviews for each staff certified to administer medication. This process must include securing and locking all medication cabinets after medication has been administered. Staff must ensure this process is completed. All new employees will be trained in the Medication Administration Training (PA DPW OMR) prior to administration of medication. Monitoring of the medication administration process for new and existing staff will be completed in accordance with the process outlined by the medication training developed by the Pennsylvania Department of Public Welfare and OMR and by the audit procedures outlined herein.
C4
The House Manager will complete random Med Pass Audits for staff administrating medications 2 consecutive months (alternating medication passes at 6a-8a-4p-8p) primarily focusing on the drugs and biologicals being locked when medication are not being prepared for administration. Any concerns will be addressed through further training or a progressive discipline process. The Med Pass Audits will be forwarded to the Associate Executive Director to verify completion. Any concerns will be addressed through further training or a progressive discipline process. Any trends will be forwarded to the QI Department for recommendations.
C5
The Associate Executive Director will be responsible for monitoring the process and reporting any continuing concerns to the Senior Executive Director at the monthly Director's meetings.

Merakey Allegheny Valley School Blakiston (MAVSB) 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. MAVSB has submitted this Plan of Correction in order 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 MAVSB may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
C1
On or before April 5, 2023, the House Manager will retrain all the facility staff on the COVID 19 Screening and Visitors Procedures. The training will instruct the staff that the process of performing the Covid 19 Screening for anyone entering the facility must be followed. The training emphasized the following: temperature check, answering screening questions, washing hands or use of hand sanitizer upon arrival and prior to taking temperature. Temperature checks shall be documented on the identified Temperature Screening Sheet kept in a binder. The House Manager will monitor this process by checking the Temperature Log twice a week and initialing off at the bottom of page to identify completed check. The staff on 3/20/23 who violated this procedure will receive retraining and corrective action. The training will be documented on a Staff Attendance sheet and kept on file at the site. A copy of the training will be forwarded to the Associate Executive Director to verify completion.
C2
On or before April 14, 2023, the Associate Executive Director or designee will retrain all the facility House Manager on COVID 19 Screening and Visitors Procedures. The training will instruct the House Manager to reinforce this process to staff to perform the Covid 19 Screening for anyone entering the facility. The training will emphasize the following: temperature check, answering screening questions, washing hands or using hand sanitizer upon arrival and prior to taking temperature. Temperature checks shall be documented on the identified Temperature Screening Sheet kept in a binder. The House Manager will also be trained in Checking Visitor Log and Temperature Log sheets twice a week. The Trainings will be documented on a Staff Attendance Sheet and kept on file at the site. A copy of the SA sheet will be forwarded to the Associate Executive Director to verify completion.
C3
All Staff and Visitor who enter a Merakey facility shall have his/her temperature checked and shall answer screening questions. All staff /visitors shall wash hands or use hand sanitizer upon arrival and prior to taking temperature. Temperature checks shall be documented on the identified Temperature Screening Sheet kept in a binder. Person presenting with symptoms or fever of 100.0 or higher must remain in the screening area, separate from others, and report information to his/her supervisor. Any Merakey visitor with an elevated temperature of 100.0 or any visitor who answers "yes" to the screening questions will be asked to leave the facility. Any Merakey staff refusing the temperature check and/or screening will be educated on the reason for this precaution and retrained on the process. Further refusal will result in the employee being sent home. Any visitor refusing the temperature check and/or screening will be asked to leave the facility.
C 4
Beginning on April 2023, the House Manager will submit audits of the Covid 19 Screening Sheets, for the next four consecutive weeks to confirm that all employees and visitors have had their temperatures taken and have completed the questionnaire to address possible COVID exposure. Thereafter the House Manager will complete random audits of the Covid 19 Screening Sheets for the next 4 months. The completed audit forms will be forwarded to the Associate Executive Director to verify completion. Any issues or concerns identified through the audit process will be addressed through further training and or corrective action.
C5
The Associate Executive Director will be responsible for monitoring the process and report any continuing concerns to the Senior Executive Director at the monthly Director's meetings

Merakey Allegheny Valley School Blakiston (MAVSB) 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. MAVSB has submitted this Plan of Correction in order 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 MAVSB may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
C1
On March 20, 2023, the Community Director retrained the facility staff on family style dining. The training emphasized the importance of placing food items in individualize serving bowls with lids on the table, the use serving spoons for Individual to scoop food onto plate, provide condiments appropriate for the food served, and to provide liquids appropriate for the meal. The training also informed the staff to encourage Individuals #1, 2, 3 and all the facility Individuals to be as independent as possible/and provide whenever prompting needed. The remaining facility staff were retrained in family style dining as they reported to their shifts. Any newly hired employee will be trained in family style dining by the House Manager. This training will be documented on a Staff Attendance Sheet. The training will be maintained at the site and a copy forwarded to the Associate Executive Director to verity completion.
On or before April 10, 2023, the House Manager will retrain all the facility staff on Normalizing the Mealtime Experience, Levels of Assistance for Eating, and Mealtime Guide. These trainings will provide a comprehensive overview of the dining experience, levels of supervision/techniques, and understanding of food textures and liquid consistency. The training will be documented on a Staff Attendance Sheet (SA), maintained on the site. A copy of the training will be forwarded to the Associate Executive Director to verify completion.
C2
On April 10, 2023, the House Manager, QIDP, and or Facility Nursing will conduct random Mealtime Audits varying in shifts and days of the week at breakfast, lunch, dinner, and weekends for eight consecutive weeks to ensure meals are served to the individuals in a manner consistent with family style dining, and to ensure that of Individual #1, 2, 3 and all of the facility Individuals are actively engaged in the process. These observations will be documented on the Mealtime Audit Form. Any discrepancy will be addressed at the time of discovery by the Supervisory Staff. Any other issues or concerns will be addressed through retraining and or disciplinary action. Thereafter, starting in June 2023, the House Manager, Nurse, and QIDP will complete random Mealtime Audits monthly varying in times of breakfast, lunch, dinner, and weekends for four consecutive months. The audits will be forwarded to the QIDP to review during monthly Case reviews or whenever a review is needed. A copy of the audits will be forwarded to the AED to verify completion.
C3
Individuals are assessed annually on mealtime skills to determine the extent to which individuals can participate in family style dining. Each assessment is reviewed by the QIDP for accuracy and approved. Upon assessment staff are to encourage each individual to participate during the meal to the best of their ability.
Individuals should be encouraged to participate in all aspects of the mealtime process, setting the table: placemats, utensils, and napkins prior to the food arriving at the table. The Staff are to place the prepared meals in serving containers with lids ( may also use plastic wrap, and or foil to cover the food) Each serving container must have a separate serving utensil. Liquids can be kept in its original container or put into pitchers with lids onto the table. Staff will assist Individuals during the serving process to address each Individuals need.
Condiments appropriate to the meal should be placed on the table.
Individuals are to be encouraged to be as independent as possible and staff will provide whatever assistance is needed.

C4
The House Manager will complete random Mealtimes Audits varying shifts and days of the week monthly and/or as needed to ensure meals are served to the individuals in a manner consistent with family style dining. The purpose of these audits is to ensure meals are served to the individuals in a manner consistent with family style dining. These audits will be documented on the Mealtime Audit form and will be completed across mealtimes to include breakfast, lunch, and dinner. Copies of the Mealtime Audit forms will be submitted to the Associate Executive Director to verify completion. The AED will initial the audits and maintain them in the plan of correction file.
The Qualified Intellectual Disabilities Professional (QIDP/PS) completes monthly observations and a random mealtime audit. The documented observations will be forwarded to the Eastern Region Social Service Supervisor and/or designee and to the Associate Executive Director.
C 5
The Associate Executive Director will be responsible for monitoring the process and reporting any continuing concerns to the Senior Executive Director at the monthly Director's meetings.