Initial Comments:
A focused fundamental survey visit was completed on April 13 and 14, 2023. The purpose of this visit was to evaluate compliance with the Requirements of 42 CFR, Part 483, Subpart I Regulations for Intermediate Care Facilities for Individuals with Intellectual Disabilities. The census at the time of the visit was four, and the sample consisted of two individuals.
Plan of Correction:
483.460(c)(4) STANDARD
NURSING SERVICES
Name - Component - 00
Nursing services must include other nursing care as prescribed by the physician or as identified by client needs.
Observations:
Based on record review and interview with facility nursing and administrative staff,
the facility failed to provide nursing care as prescribed by the physician for one of two sample Individuals with identified health needs. This practice is specific to Individual #1.
Findings include:
A review of Individual #1's record completed on 04/14/2023 from approximately 8:45 AM to 11:15 AM, revealed the following:
A review of a document titled, IPP Update, dated 12/20/2022 revealed the following information:
-"[Individual #1] was see by the PT (physical therapist) to instruct House Manager and one of his staff members on a relaxation program that is to be carried out at home after bathing, or when in bed, 3 X, preferably Mondays, Wednesdays and Fridays. Staff are to carry out the relaxation/stretching program to [Individual #1's] trunk and lower extremities to promote greater ranges in [Individual #1's] hips."
A review of a document titled, Progress and Order Record, revealed a verbal order received from the primary care physician 12/23/2022, and subsequently signed on 12/27/2022:
"After being bathed, when being changed on the bed, 3 X weekly, preferably Mondays, Wednesdays and Fridays; staff are to carry out relaxation /stretching program to
[Individual #1's] trunk and lower extremities to promote greater ranges in [Individual #1's] hips."
In further record review, there was no documented evidence that the above mentioned
Physical therapy recommendations and Physician's order was implemented.
Interview with Eastern Residential Social Services Director on 04/14/2023 at approximately 10:20 AM, confirmed that there is no documented evidence that Individual #1's PT recommendations and Physician's orders to address the relaxation /stretching program to trunk and lower extremities to promote greater ranges in hips has been implemented,
Plan of Correction:MMerakey Allegheny Valley School Byberry (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 May 12, 2023, the Physical Therapist (PT) will reevaluate the relaxation program for Individual #1 and develop an activity plan that will address the scope of the plan for relaxation/stretching program. The activity plan will focus on Individual #1's trunk and lower extremities to promote greater range in hips. The Primary Care Physician (PCP) will review and approve the activity plan before implementation. On or before May 17, 2023, the Physical Therapist (PT) and or designee will retrain the facility staff on the relaxation/stretching program for Individual #1. The training will be documented on a Staff Attendance (SA) Sheet and will be maintained at the site. The House Manager will provide training to all new staff on Individual #1's Activity Plan. A copy of the SA sheet will be forwarded to the Associate Executive Director to verify completion.
C2
On or before May 15, 2023, the Health Service Supervisor (HSS)/or designee will audit the last 90-day physician's orders to ensure all individuals are receiving nursing care as prescribed by physician, document findings on an audit form, and send to the Eastern Region Social Service Supervisor (ERSSS) and the Associate Executive Director (AED) for review. Any anomalies will be addressed within 7 days by the HSS and/or the ERSSS.
On or before May 18, 2023, the Eastern Region Social Service Supervisor or designee will audit all the facility Individuals documents from Dec 2022 to present to ensure that medical treatment programs are implemented as ordered by the physician, and document findings on an audit form. The completed audits will be sent to IDT (Interdisciplinary Team) members to review and verify the recommendations. Any anomalies will be addressed within 7 days by the QIDP and the appropriate team members.
On or before May 22, 2023, the Qualified Intellectual Disabled Professional will conduct IDT meetings to review all the facility Individuals IPP Updates to include Physicians orders written/verbal recommendation from Allied Health Professional-Physical Therapist (PT), Occupational Therapist (OT) to address nursing care or identified by the client needs. A copy of the mini-IDTs outlining follow-up action, recommendation(s) and resolution to the recommendations will be forwarded to the Eastern Region Social Services Supervisor (ERSSS) and to the Associate Executive Director (AED) within 7 days to verify completion.
C3
When recommendations requiring a physician's order are made by the Allied Health Services Professions (Physical Therapy (PT), Occupational Therapy (OT) and or Speech), it is sent to the Nursing Department within 24/48 hours for review. The Nurse then places the recommendation in a file for the Primary Care Physician (PCP) to review and approve within 7 days.
The Allied Health Service Professional will contact the Facility Nurse immediately if the situation is emergent the recommendations will be 12/24 hours. The Facility Nurse will notify the Primary Care Physician (PCP) via phone call and receive verbal approval.
Once a recommendation is reviewed and approved by the PCP, the Nursing Administrative Assistance will send the recommendations (within 7 days of PCP's approval) via email to Qualified Intellectual Disabilities Professional (QIDP) and the QIDP will forward recommendation (s) to the appropriate IDT members. The Allied Health Services Professional will develop an Activity Plan to address the recommendation and initiate a Staff Attendance sheet that identifies the recommendations and instructions for implementation (within 5 business days). The Activity Plan and the Staff Attendance sheet (SA) will be sent to the PCP for final approval. The Nursing Administrative Assistance will forward the approved program to the Qualified Intellectual Disabilities Professional (QIDP) for review and signature. The QIDP will forward the Activity Plan to the House Manager (HM) who then will place it in the program book for implementation. The QIDP is then responsible for tracking the completion of the training and activity plan.
The House Manager will generate the Activity Plan and review/monitor the Activity plan at the residence twice a week. The Facility Nurse will review/monitor the Activity Plan at the residence once a month. The QIDP will complete monthly residential observations monitoring of activity plans at the residence.
Any noted concerns throughout the process will be addressed, via retraining and or other corrective actions at the time of discovery, by the responsible department head.
C4
On or before May 24, 2023, the House Manager (HM) and the Facility Nurse will each audit the Activity Plan once a week, to ensure completion for one month. The HM and the Facility Nurse will initial and date the time of their separate reviews on the bottom of the form. Any noted concerns discovered by the HM will be addressed at the time of discovery, via retraining and/or disciplinary actions. Any noted concerns discovered by the Facility Nurse will be reported via email to the HM within 24 hours, for review and address via retraining or disciplinary action. Thereafter the HM and Facility Nurse will follow scheduled reviews and monitoring. Any disciplinary actions will be forwarded to the AED for review.
The QIDP will complete residential observation for all the facility Individuals every other week for 3 consecutive months. Thereafter, the QIDP will complete monthly residential observations for all four individuals at the facility. Observations will include monitoring goal plans and activity plan implementation, and documentation. Any issues noted during the observations will be immediately corrected by the QIDP. Copies of the observations will be forwarded to the ERSSS for review and then sent to the AED to verify completion.
C5
The Associate Executive Director, the Eastern Regional Social Service Supervisor and or designee will be responsible for monitoring the process and reporting any discrepancies and corrective actions taken to the Senior Executive Director at the monthly Director's meetings. All corrective actions will be monitored by the positions identified in the above sections which are incorporated herein by reference.
483.460(l)(2) STANDARD
DRUG STORAGE AND RECORDKEEPING
Name - Component - 00
The facility must keep all drugs and biologicals locked except when being prepared for administration.
Observations:
Based on observation and interview with administrative staff, the facility failed to ensure that all drugs and biologicals are locked except when being prepared for administration for two of two sample Individuals. This practice is specific to Individuals #1 and #2.
Findings include:
Observations completed on 04/13/2023 from approximately 7:20 AM until 7:30 AM and from 2:00 PM to 2:15 PM revealed that when the surveyors entered Individual #1 and #2's bedroom at the times noted, it was observed there were topical medication items sitting on each the chest of drawers in each Individual's bedroom. These included the following :
Individual #1:
1. Both morning and afternoon observations of Individual #1's bedroom revealed the following topical items were left on top of this individual's dresser:
-Minerin Cream
-Nystatin powder
All of these items were marked with a pharmacy label listing Individual #1's name.
A review of Individual #1's record revealed a 90 day physician's order dated 03/20/2023 through 06/17/2023, for the following topical medication items:
-Minerin Cream- Apply to damp skin after bathing as directed
-Nystatin powder- Apply between all toes twice daily (6A, 8P) after cleaning and patting dry
Individual #2:
1. During both observation periods listed above, the following biologicals were left on top of the individual's chest of drawers in his bedroom :
-Chlorhexidine Gluconate Solution, 0.12% (Peridex mouth rinse)
-Two cans of Athlete Foot Relief spray powder
-An empty tube of triple antibiotic ointment- a jar of petroleum jelly.
All of these items were marked with a pharmacy label listing Individual #2's name.
2. A review of Individual #2's record revealed a 90 day physician's order dated 03/24/2023 through 06/24/2023, for the following topical medication items:
-Chlorhexidine Gluconate Solution, 0.12% (Peridex mouth rinse)- Brush teeth/gums twice daily.
-Tolnaftate spray powder 1%: Spray to toes webs and toes twice daily
-Triple antibiotic ointment (Neosporin)
-Petroleum Gel Jelly: Apply to both feet after bathing and rubbing off any dry skin
Interview with the home manager on 04/13/2023 at approximately 2:15 PM, revealed this interviewee was unaware prescibed topical medications should be kept locked except when administering these items at prescribed times.
Plan of Correction:Merakey Allegheny Valley School Byberry (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 May 10, 2023, the House Manager retrained the facility staff on ensuring that all drugs and biologicals are locked when passing medications to Individual's #1, 2 and all the facility Individuals. The training emphasized the importance of keeping drugs and biological locked when medications are not being prepared for administration. 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 May 12, 2023, the Facility Nurse, Qualified Intellectual Disability Professional (QIDP) and the House Manager will conduct medication administration pass audits for staff administering medication weekly for six (6) weeks primarily focusing on the drugs and biologicals being locked when medication is not being prepared for administration. The Med Administration Pass Audits will be documented on a Community Home Med Pass Audit form which non-medication certified persons can complete. Beginning July 2023, the Facility Nurse and the House Manager will complete random medication administration 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 for the next two months. These Med Administration Pass Audits will be documented on a Community Home Med Pass Audit form.
C3
As outlined by PA DPW (Department of Public Welfare) OMR, the House Manager will complete quarterly MAR (Medication Administration Record) reviews for each staff certified to administer medication. This process must include securing and locking all medication cabinets after medication has been administered to include drugs and biologicals being locked when medication is not being prepared for administration. Staff must ensure this process is completed. All new employees will be trained in the Medication Administration Training (PA DPW OMR) before administering 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 Administration Pass Audits for staff administrating medications (alternating medication passes at 6a-8a-4p-8p) primarily focusing on the drugs and biologicals being locked when medication is not being prepared for administration. Any concerns will be addressed through further training or a progressive discipline process. The Community Home Med Administration 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.
483.470(l)(1) STANDARD
INFECTION CONTROL
Name - Component - 00
There must be an active program for the prevention, control, and investigation of infection and communicable diseases.
Observations:
Based on observation and staff interview, the facility failed to ensure that an active program for the prevention and control of a communicable disease was maintained. This practice is specific to the implementation of the facility's COVID-19 Infection Control Procedures.
Findings include:
Observations completed on 04/13/2023 from approximately 7:15 AM to 7:32 AM revealed that when the survey staff arrived at the residence front door at approximately 7:15 AM, the House Manager answered the door without a mask. Upon entering the home and walking into the dining room it was observed that two additional staff were assisting two Individuals with their breakfast, without a mask. This surveyor ask the staff if their agency changed their COVID - 19 policy requiring staff to wear mask when working with the Individuals. The staff answered "Yes". At approximately 7:32 AM the Home Manager, wearing a mask, walked into the dining area with KN 95 masks and handed each staff a mask. Staff proceeded to put on the mask.
Interview with the Associate Executive Director on 04/13/2023, at approximately 9:30 AM, confirmed that the agency policy regarding staff wearing mask has not changed. This interviewee acknowledged that the Home Manger and staff should have been wearing a mask when working with the Individuals.
Plan of Correction:Merakey Allegheny Valley School Byberry (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 April 13, 2023, the Community Director retrained the House Manager on the Infection Control Protocol- mask requirement. The training emphasized employees working in residential setting must wear KN95 mask while providing care and working directly with consumers. N95 mask are required with confirmed or suspected Covid-19 infection. The training was documented on a Staff Attendance Sheet and will be maintained at the site. On the same date, the House Manager retrained all facility staff on the Infection Control Protocol-mask requirement. A copy of the training was documented on the Staff Attendance sheet and forwarded to the Associate Executive Director to verify completion. On or before May 8, 2023, the staff who were observed not wearing mask will receive appropriate corrective action and retrained on the infection control protocol highlighting the mask requirement.
C2
On April 20, 2023, Merakey updated the Use Personal Protective Equipment (PPE) requirements for masks. The ICF/IDD division staff were trained in revisions. The training emphasized that surgical masks (or more protective mask if desired) must be worn by Merakey staff in all Merakey locations and care settings where consumers are present unless you are providing direct care to someone with confirmed or suspected Covid-19. KN95 masks are no longer to be used. N95 masks are required when providing care to someone with confirmed or suspected Covid 19, This training was documented on a Staff Attendance Sheet and will be maintained at the site. A copy of the training will be forwarded to the Associate Executive Director to verify completion.
C3
Merakey requires that all employees wear surgical masks (or more protective mask if desired) in all Merakey locations and care settings where consumers are present unless providing direct care to someone with confirmed or suspected COVID-19. N95 masks are required when providing care to someone with confirmed or suspected COVID-19. KN95 masks are no longer to be used in Merakey setting. Surgical mask must be worn while in the facility, unless eating or drinking.
C4
On or before May 8, 2023, the House Manager will complete daily observations, rotating shifts, for one week, to ensure that all staff are following the infection control protocol, which includes but is not limited to, wearing face mask while providing direct care to an individual. The House Manager will conduct monthly observations thereafter for all staff in the facility rotating shifts to confirm that all staff are adhering to policies. Any issues or concerns identified will be addressed via corrective actions, i.e., retraining and/or progressive discipline per policy. The completed observations will be forwarded to the Associate Executive Director to verify completion.
On or before May 15, 2023, and for two consecutive months, the Community Director/ or designee will review the infection control observations submitted by the House Manager to ensure adherence to the protocols/policies and appropriate follow up by the House Manager when a concern was noted. Any issues or concerns identified will be addressed via retraining and corrective actions as per progressive disciplinary policy.
C5
The Associate Executive Director will be responsible for monitoring the process and reporting any discrepancies and corrective actions taken to the Senior Executive Director at the monthly Director's meetings. All corrective actions will be monitored by the positions identified in the above sections which are incorporated herein by reference.
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