|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | page 4, continued.
Individual #1's record contains health care plans that instruct direct support staff how they are to care for the individual and his specific needs. All plans in his record included: Seizure Disorder, Psoriasis, Prevention of pressure sores, Diastat Rectal Gel, use of hearing aid, Prevention and treatment of Osteoporosis, Chronic Constipation, Hyponatremia, Myringotomy w/placement of Tympanostomy tubes, oral hygiene, fall prevention/ambulatory, and Keppra allergy. There is no evidence that any staff working with Individual #1 received training in person by a medical professional, or someone proficient in caring for his specific medical needs. Improperly trained, or lack of adequately trained staff, puts a medically fragile individual who is totally dependent of caregivers, at risk of not receiving the specific care medically required and needed and is potentially harmful. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Please see pages 1 - 3 for information on the Plan of Correction. |
03/03/2020
| Implemented |
| 6400.16 | Individual #1's record, as referenced throughout this report and described in detail below, containes multiple instances where they agency's decisions and lack of follow through with the individual's physician's orders put the medically fragile individual at serious health and safety risks throughout the year.
The individual is diagnosed with Seizure Disorder -- Intractable Epilepsy. Per the home supervisor and agency administrator, Staff #2, the individual's Seizure disorder is delicate and requires constant and consistent monitoring by the agency and the individual's neurologist. His neurologist prescribes Depakote for his seizures. His most recent, 3/27/19 neurology appointment form complete by his neurologist states, "caregivers reports about 1-4 seizures per month which is a drastic reduction in seizure frequency over the past year" and that staff are to "get help right away if {the individual's} seizure doesn't stop after 5 mins, you have more than one seizure in a row and you do not have enough time between the seizures to feel better, a seizure makes it harder to breathe, a seizure is different from other seizures you have had, a seizure makes you unable to speak or use part of your body, and you do not wake up right after a seizure."
· The individual's record contained a Plan of Approach for the individual's seizures. This plan is created and signed off yearly by an agency nurse. This plan states that if his seizure last longer than 5 minutes or if he exhibits extreme pallor or has a bluish tint to the skin especially around the mouth, staff are to call the waiver nurse immediately. The neurologist's plan to "get help right away" if the individual is experiencing breathing difficulties, seizure abnormalities, or loss of consciousness, does not coincide with the agency created plan to "call the agency waiver nurse" should the individual experience said issues. The delay in obtaining treatment by calling the agency nurse instead of contacting 911 immediately, puts the individual at risk of further injury.
page 1, continued. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | A Certified Investigation (Attachment 41 - 58) with a corresponding EIM report # 8606520 was completed on 10-17-19 with a finding of neglect. The Health Services Supervisor, the Waiver LPN, and the House Manager were retrained by the Director of Nursing on the proper timing of implementing new physician orders and new medications in a timely manner. In addition, the procedure of contacting the ordering physician if an order or medication needs to be held for an order to do this (Attachment 59). |
03/03/2020
| Implemented |
| 6400.16 | page 2, continued.
· Staff #6 documented on 5/30/19, "Over the last 6 months we have seen a significant downward trend, although his performance can vary from day to day, and possibly at different times of the day. We have continued to work with {the individual} 2x/week to encourage ambulation. We have experimented with different varieties of assistive devices including platform walkers, gait trainers and "up and go" walkers. He now requires maximum support of 2 people and on some days is not able to advance to his feet. He had been able to transfer to the toilet with assistance of one, but he now requires 2 people and is not always able to move his feet. At times he is unstable sitting on the toilet and we will be adding a tray for postural support. When he is able to walk, he is very tremulous and unsteady. We are instituting use of an "easy stander" standing device to help maintain his weight bearing ability."
- The team meeting held on 5/23/19 with agency program and medical staff, Staff #1, #2, #6-#10, present documents, "{the individual's physical therapist noted that {the individual's} program staff have been expressing concerns on a weekly basis about {the individual's} ability to stand and walk safely. Team members commended that {the individual} is getting older and the decline in {the individual's} ambulation ability may be part of the aging process. In addition the team members noted that {the individual's} intractable epilepsy, and his seizure activity has a definite impact on his ability to stand and walk at times. The neurologist also commented (at 3/27/19 neurology appointment) that {the individual} has periods of shakiness that impede his ability to walk at times, and if this condition worsens, the neurologist may consider a slight reduction in his Depakote. A few team members suggested that {the individual's} neurologists should be consulted regarding the increased difficulty that {the individual} has recently had with standing/walking."
· At the time of the annual inspection on 10/1/19, the agency never had the individual return to his neurologist at their clinic due to the decline in ambulation and problems discussed by all team members as requested by the individual's neurologist. The neurologist not only instructed to individual to return to the neurologist clinic if symptoms/concerns arose, she also instructed the individual on 3/27/19 to return to the clinic for a follow up appointment within 6 months, regardless of symptoms. He should have returned by 9/27/19. However, at the time of the inspection on 10/1/19, he had not returned and the agency did not have, nor attempted to have, a neurologist appointment scheduled for the near future.
· The agency program and medical staff documented and suggested on 5/23/19 that the individual's neurologist should be consulted regarding the increased difficulty in the individual's standing/walking ability. There is no evidence that the individual's neurologist was ever consulted or contacted until 7/11/19.
continued. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | The team gathered and identified specifics on seizure activity. Once his characteristics were defined, they were sent to the PCP for have orders match our protocol for seizure activity. Once the physician's orders were received, the information was sent to the Supports Coordinator to add to Brian¿s ISP. Then the waiver nurse or Admin/HM will do medical training in person on the ISP noting the proper protocol.
All training will be documented on a staff attendance sheet (SA) and are to be completed by February 28, 2020. The completed trainings related to this deficiency will then be submitted to Staff Development Facilitator who will ensure all the above noted parties are trained. The Staff Development Facilitator's signature and date of her review will be documented at the bottom of the above noted SA sheet with her signature serving as acknowledgement all staff were trained accordingly and the training was completed by February 28, 2020.
Chart Audits will be done to ensure the Individuals Plan of approach matches the Physicians plan, the ISP, and does not cause a delay in treatment. These initial chart audits will be completed by March 31, 2020. Any Plans of Approach that do not match the Physicians orders or ISP and/or will result in the delay of treatment will be brought to the physician's attention. They will either be asked to complete the information, or we will provide them with the information that they can review, modify if needed and then sign. If at any time it is found that the physical exam is brought back to the Waiver nurse that is not complete, the issue will be immediately addressed with the staff person (s). The responsible staff will be immediately counseled and retrained. Disciplinary action will be taken if necessary. After the initial Chart audits have been completed, audits will then be conducted every 6 months to ensure each area on the physical exam is completed.
Due to training and Plan of Approach being a possible issue of neglect a certified investigation with the accompanying EIM report will be completed by March 3, 2020. |
03/03/2020
| Implemented |
| 6400.16 | page 3, continued.
On 7/11/19, the individual's neurologist ordered a change in administration of the individual's Depakote medication that is used to control his seizures and also may have some relationship to his recent, steading decline in ambulation levels as documented. They ordered, "decrease Depakote to 500mg in the morning and 625mg in the evening, continue Lamotrigine and Vimpat. Repeat labs in 1 month." According to the individual's July 2019 Medication Administration Record (MAR), the medication was not administered as ordered until the evening of 7/26/19, 15 days after the doctor's order to do so. Per discussion with the house manager and agency administrator, Staff #2, on 10/2/19, she reported that direct support staff working at the home were instructed by the agency to not administer the medication to Individual #1 as ordered until Staff #2 returned from vacation. Staff #2 also confirmed that the individual's prescribing physician was never consulted about the agency's decision to not administer the Depakote as ordered for an additional 15 days and how this could negatively affect the individual's health and safety.
Staff #6 documents multiple physical therapy notes to include his need for the assistance of 2 staff for standing, walking, and hygiene. On 3/21/19 she documents, "{the individual} is being walked with the assistance of 2 people supporting him under the arms. On 4/4/19, "{the individual} has been having difficulty standing and walking recently. This is occurring at home and at program. Continue to use 2 people for bathroom transfers when {the individual} is having difficulty. It is important to continue to do pivot transfers in hope of maintain his skills. It is fine to support him as the second person takes care of his clothing." On 5/2/19, "He is generally requiring the support of 2 people recently. When 2 people are walking him, he does not need a gait belt. This applies at home, program or in PT. If he is able to walk with one person, a gait belt is required." On 5/30/19, "He had been able to transfer to the toilet with assistance of one but he now requires 2 people and is not always able to move his feet." On 9/5/19 she describes how he required 2 staff to complete bathroom hygiene. An agency occupational therapist created a 7/22/19 Occupational Therapy Assessment for the individual that stated, "{Individual #1} can completed stand-pivot transfers between level surfaces (i.e. wheelchair to/from toilet) and ambulate short distances with handheld assistance x 2 (two staff)." For 6 months, the individual's therapists have documented his need for two staff's assistance for standing, walking, transferring, and hygiene care. However, Staff #2 reported during the 10/1/19 inspection, that Individual #1 is still only staffed with one staff in his residential facility and that they still attempt to do pivot transfers with him with one staff.
continued. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | The following part of the citation involving Individual #1's ambulation was to be removed. The section referring to Physical therapist and Individual # 1's walking and transferring abilities. It looks like it is paragraph 5, 6, and 8. I am sending documentation that shows Individual 1's shaking, and difficulty walking has been an ongoing issue dating back to his arrival at AVS in 2011 (Attachment 1, 2, and 3), The weekly concerns by the day program staff that were addressed at the team meeting on 5/23/19 (Attachment 4) had not been brought to the team's attention prior to this. The mechanical devices listed in the citation other than the gait belt are solely for use at the day program (Attachment 5 ,81, and 82). The house and day program staff were not directed to not do stand pivots with Individual #1. The Physical Therapist did assess the day program staff doing a stand pivot (Attachment 6). A stand pivot is completed using 1 staff to complete the transfer (Attachment 7). The second person in the (Attachment 6) was pulling down clothing not assisting in the stand pivot. Staff were able to continue to use stand pivots depending on Individual #1 ability that day (Attachment #8). Approximately 2 years ago, a grab bar had been placed by the toilet to assist Individual # 1 while toileting. In addition, the toilet has side bars and a pelvic belt. In the event Individual #1 is unable to complete a stand pivot transfer, the group home has several other options available including using a 2nd person, 2 person top bottom lift, and the use of a Hoyer lift (Attachment 9). All of these methods have been utilized depending on Individual # 1's abilities at the time.
I have attached the documentation referenced above (Attachment 1-9 and 81-81) as well as the email (Attachment 60) where the citation was to be removed. |
03/03/2020
| Implemented |
| 6400.68(c) | The home's coliform water test was completed on 5/2/19 and not again until 8/22/19. More than 3 months have elapsed between water tests. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | Merakey Allegheny Valley School acknowledges the coliform water test at was completed on 5/2/19 and not again until 8/22/19, with more than 3 months elapsing between tests.
The Administrator immediately contacted Pure Test Laboratory on 10-1-19 to correct the water testing issue (Attachment 38). The testing will now be conducted every other month to prevent a reoccurrence of this issue. Water testing was conducted on 10-14-19 (Attachment 39) and again on 12-17-19 (Attachment 40). Documentation of the water analysis will be kept in the House Fire Book when completed. The Maintenance Supervisor will monitor the testing for compliance. |
12/17/2019
| Implemented |
| 6400.71 | The telephone number to the nearest hospital was not located on or near the telephone in the kitchen. The telephone number to the hospital was on a sticker on the back of the phone and the sticker was rubbing off; rendering the telephone number the hospital illegible. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Merakey Allegheny Valley School acknowledges the sticker on the telephone at did not have a legible hospital telephone number.
New emergency numbers were placed on the telephone (Attachment 37) on 10/8/2019. To prevent a future reoccurrence of this issue, an envelope with additional labels to replace a peeling label were placed in an envelope by the telephone. The House Manager will conduct weekly checks that the emergency numbers are intact and legible. |
10/08/2019
| Implemented |
| 6400.141(c)(12) | Individual #1's 5/29/19 physical examination form did not include all of his physical limitations or need for adaptive equipment and assistance during ambulation. The doctor recorded on the form, "gait disturbance/ambulatory dysfunction." The physical form does not include that there are occasional days where the individual can ambulate with assistance of staff (1 or 2 depending on the circumstances), a Hoyer lift, and can occasionally perform a stand-pivot transfer. | The physical examination shall include: Physical limitations of the individual. | Merakey Allegheny Valley School will ensure the physical examination shall include: Physical limitations of the individual.
The Waiver Nurse will train each house manager on what is needed to complete a physical exam. This includes paperwork that needs to accompany the physical as well as all areas that must be completed by the physician during the physical exam. Staff must review the physical exam and make sure all areas are completed prior to leaving the physicians office. If any areas are found that are not complete, the staff must ask the physician to complete those before they can leave the office. When the completed physical is received by the Wavier nurse, they must immediately review the paperwork to ensure all areas are completed on the form. If there are areas that are not completed by the physician, the HM will be asked to return to the clinic to have the paperwork completed.
All training will be documented on a staff attendance sheet (SA) and are to be completed by February 28, 2020. The completed trainings related to this deficiency will then be submitted to Staff Development Facilitator who will ensure all the above noted parties are trained. The Staff Development Facilitator's signature and date of her review will be documented at the bottom of the above noted SA sheet with her signature serving as acknowledgement all staff were trained accordingly and the training was completed by February 28, 2020.
Chart Audits will be done to ensure the physical examination is completed and includes: Physical limitations of the individual. These initial chart audits will be completed by March 31, 2020. Any documentation found to be missing will be brought to the physician's attention. They will either be asked to complete the information, or we will provide them with the information that they can review and sign. If at any time it is found that the physical exam is brought back to the Waiver nurse that is not complete, the issue will be immediately addressed with the staff person (s). The responsible staff will be immediately counseled and retrained. Disciplinary action will be taken if necessary. After the initial Chart audits have been completed, audits will then be conducted every 6 months to ensure each area on the physical exam is completed. |
03/31/2020
| Implemented |
| 6400.144 | Throughout the previous year, there are multiple occasions, some of which are documented below, where Individual #1's medical team have made recommendations and orders for the agency to implement. However, none of the examples below were implemented to address the individual's health and safety needs.
Individual #1's physician recorded on 7/11/19 that the individual was to, "decrease Depakote to 500mg in the morning and 625mg in the evening, continue Lamotrigine and Vimpat. Repeat labs in 1 month."
Additional recommendations recorded on the same 7/11/19 document in the individual's record included, "consult neurology about {the individual's} decrease in ability to stand/walk, assess {the Individual} for toilet tray, person responsible: PT/nursing." Staff #1, the individual's program specialist, signed the form on 5/30/19. There is no evidence that the individual's neurologist was consulted to discuss the individual's health decline after the recommendation. The last appointment where he was assessed by his neurologist occurred on 3/27/19, prior to the documented significant decline in his ability to walk.
During Individual #1's 3/27/19 neurology appointment, his neurologist documented, "return to clinic in 6 months or sooner if problems arise." Agency staff have documented in the individual's record, a significant decline in the individual's ability to walk immediate after this appointment. During one team meeting held on 5/23/19 for Individual #1, with agency nurses, program specialist, house manager, direct support staff, and his physical therapist, it was documented that, "{Individual #1} Physical Therapist noted that {the individual} program staff have been expressing concerns on a weekly basis about {the individual's} ability to stand and walk safely." The program specialist created a report in the individual's record on 4/24/19, based off of the neurologist's 3/27/19 appointment summary and recommendation. The program specialist reported that a follow up neurologist appointment is needed for Individual #1 but not scheduled yet. After all the documentation of the individual's decline in ability to walk, and the neurologist's recommendations to return if there were any concerns, at the time of the inspection on 10/1/19, the individual was never seen by their neurologist after 3/27/19. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Merakey Allegheny Valley School will ensure all Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
The Waiver Nursing/HM will receive training on reviewing all referrals that are completed at an appointment and document/track any follow up recommendations made. When applicable, follow up appointments should be made prior to leaving the doctor's office. In addition, the nurse will receive training on documenting all conversations with physicians and/or physician's office staff regarding individual concerns and attempts made to schedule any follow ups based on recommendations.
All training will be documented on a staff attendance sheet (SA) and are to be completed by February 28, 2020. The completed trainings related to this deficiency will then be submitted to Staff Development Facilitator who will ensure all the above noted parties are trained. The Staff Development Facilitator's signature and date of her review will be documented at the bottom of the above noted SA sheet with her signature serving as acknowledgement all staff were trained accordingly and the training was completed by February 28, 2020.
Chart Audits will be done to review all paperwork to ensure all Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. In addition, all nurses¿ notes will be reviewed to make sure all conversations have been documented. These initial chart audits will be completed by March 31, 2020. Any follow up not complete will be brought to the House Managers attention. They will be asked to contact the office and schedule the follow up immediately. If at any time it is found that a follow up has not been scheduled, the issue will be immediately addressed with the staff person (s). The responsible staff will be immediately counseled and retrained. Disciplinary action will be taken if necessary. After the initial Chart audits have been completed audits will then be conducted every 6 months to ensure each form in the chart is legible, dated and signed. |
03/31/2020
| Implemented |
| 6400.181(e)(3)(iv) | Individual #1's current, 10/23/18 assessment does not include his current level of performance in personal needs with or without assistance from others. The 10/23/18 assessment was never updated throughout the year to continue to include the changing, current level of assistance needed to perform personal, daily living skills. The current assessment states, "He is able to walk short distances with the assistance of 1-2 staff or with the use of a walker" and "{The Individual} requires the assistance of one staff to transfer from his wheelchair to the toilet and back." However, his record includes numerous amounts of documentation from staff, doctor's, and physical therapists regarding a significant decline his is ability to ambulate and the increased need of staff assistance because of this.
On 5/30/19, Individual #1's physical therapist stated in a letter in his record, "Over the last 6 months we have seen a significant downward trend, although his performance can vary from day to day, and possibly at different times of the day. We have continued to work with {the individual} 2x/week to encourage ambulation. We have experimented with different varieties of assistive devices including platform walkers, gait trainers and "up and go" walkers. He now requires maximum support of 2 people and on some days is not able to advance to his feet. He had been able to transfer to the toilet with assistance of one but he now requires 2 people and is not always able to move his feet. At times he is unstable sitting on the toilet and we will be adding a tray for postural support. When he is able to walk he is very tremulous and unsteady. We are instituting use of an "easy stander" standing device to help maintain his weight bearing ability." | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | Allegheny Valley School/Merakey acknowledges that the individual # 1's current level of performance and progress in the areas of personal needs with or without assistance from others was not updated in the assessment.
The Program Specialist(s) will be in-serviced by 2/10/2020 on including an individual's level of performance and progress in meeting own personal needs activities with or without assistance from others in an individual's assessment. Individual # 1's record will be updated to reflect specific needs of assistance by 2/14/2020. All other individuals residing at CLA will be reviewed by the program specialist (s) and updated as necessary by 2/21/2020. The Social Services Supervisor will sign/initial updates to assessments for 1 year as changes are necessary. This information will be maintained in the Social Service Supervisor's office. If concerns arise during the review, appropriate action will be taken. |
02/21/2020
| Implemented |
| 6400.212(b) | Individual #1's record contained a "health demographic form" that contained information written in pencil, then erased and other information in pencil written over it. There are also multiple dates and staff's names recorded on the form, then erased and additional information recorded over it. This form was to contain specific health information, diagnoses, and health needs of the individual. However, all the entries made did not contain permanent signatures and dates to determine the entry of the individual's specific health needs.
Individual #1's physician recorded on 7/11/19 that the individual was to, "decrease Depakote to 500mg in the morning and 625mg in the evening, continue Lamotrigine and Vimpat. Repeat labs in 1 month." Someone used a pen to cross off "repeat labs in 1 month" from the physician's faxed order. The entry does not include the name or date of person making the entry. There is no evidence that a physician was responsible for crossing off the laboratory blood work requirement. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| Merakey Allegheny Valley School will ensure all entries in an individual's record shall be legible, and all corrections made are dated and signed by the person making the entry.
The Waiver Nursing/HM/HMA staff will receive training that all changes made to a form, must be completed in pen to show a legible, dated and signed timeline of each change. In addition, training with the nurses/HM/HMA will also be done addressing any time a change is made by an outside entity (i.e. doctor or clinic visit), that is not legible, dated or signed by the outside entity that they must return the form and ask for it to be clarified, dated and signed. Paperwork received by the nurse that is found not to be legible, dated and signed by the outside entity, will be sent back to the outside entity to obtain clarification. Documentation of these attempts will be included in the individuals record.
All training will be documented on a staff attendance sheet (SA) and are to be completed by February 28, 2020. The completed trainings related to this deficiency will then be submitted to Staff Development Facilitator who will ensure all the above noted parties are trained. The Staff Development Facilitator's signature and date of her review will be documented at the bottom of the above noted SA sheet with her signature serving as acknowledgement all staff were trained accordingly and the training was completed by February 28, 2020.
Chart Audits will be done to review all paperwork to ensure it is legible, dated and signed. These initial chart audits will be completed by March 31, 2020. Any documentation found not to be legible, dated and signed will be brought to the staff/entity's attention. They will be asked to provide clarification and to sign and date their correction. If applicable the nurse may obtain a verbal clarification, then send it to the entity for them to date and sign. If at any time it is found that documentation in the individual chart is not found to be legible, dated and signed, the issue will be immediately addressed with the staff person (s). The responsible staff will be immediately counseled and retrained. Disciplinary action will be taken if necessary. After the initial Chart audits have been completed audits will then be conducted every 6 months to ensure each form in the chart is legible, dated and signed. |
03/31/2020
| Implemented |
| 6400.163(a) | Individual #1's prescribed Alendronate medication did not include a medication label issued by a pharmacy. The sticker attached to the medication did not include the complete dosage instructions to include "take in the morning 30 minutes before food and drink or medications. Remain upright for 30 minutes after giving. Dx. Osteoporosis," the pharmacy who issued the medication, the doctor who ordered the medication, and a complete medication label. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Merakey Allegheny Valley School will ensure all prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.
The House Manager and the House Manager Aids will receive training on the Administration of Medication Protocol that states The contents of each prescription shall be kept in the original container bearing the original label, on which shall be written the individual's name, quantity of medication, name of physician, original order date, directions, date of filling of the prescription, and the initials of the pharmacist that filled the prescription, and generic comparable to (C.T.) or eq. (equivalent).
All training will be documented on a staff attendance sheet (SA) and are to be completed by February 28, 2020. The completed trainings related to this deficiency will then be submitted to Staff Development Facilitator who will ensure all the above noted parties are trained. The Staff Development Facilitator's signature and date of her review will be documented at the bottom of the above noted SA sheet with her signature serving as acknowledgement all staff were trained accordingly and the training was completed by February 28, 2020.
Medication Cabinet Audits which include a review of all medications in the home will be completed to make sure each medication is in the original container with the full prescription label. These initial medication cabinet audits will be completed by March 31, 2020. Any medication found not to be in their original container will be brought to the Waiver Nurses attention. These will be reviewed with pharmacy to determine how to return the medication to pharmacy to obtain the full label. If at any time it is found that staff administered a medication in which the medication was not in its original container, the issue will be immediately addressed with the staff person (s). The responsible staff will be immediately counseled and retrained on the Administration of Medication Protocol. Disciplinary action will be taken if necessary. After the initial Medication Cabinet audits have been completed audits will then be conducted every 6 months to ensure each medication is in the original container with the full prescription label. |
03/31/2020
| Implemented |
| 6400.166(a)(4) | Individual #1's October 2019 Medication Administration Record (MAR) listed a medication, "Guaifenesin-DM 100/10mg." However, the medication label attached to this medication listed the name of the medication to be, "Extra Action Syrup 100/10-5." The medication name on the medication label and the MAR did not match. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | I have attached a picture (Attachment A2) of the cough medicine for individual #1. The label on the bottle has both Extra Action Cough Syrup and Guaifenesin with Dextromethorphan HBr. |
03/31/2020
| Implemented |
| 6400.166(a)(12) | Individual #1's November 2018-September 2019 Medication Administration Records (MARs) did not record the time of administration for his medication Divalproex 125mg. The medication has been initialed as administer for the previous year. The time of administration slot on the MAR associated with administration of Divalproex 125mg, recorded a prepopulated "10PM." However, someone crossed off the 10PM with a pen and recorded 9PM next to it. There is no evidence for when this change was made, thus no evidence of when the medication was administered. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | Merakey Allegheny Valley School will ensure a medication record is kept for each individual for whom a prescription medication is administered. The MAR will include the correct way to document the date and time of each change made.
The House Manager and the House Manager Aids will receive training on the proper way to make changes on the MAR. This training will include the need to initial and date all changes made on the front of the MAR and then signing the back of the MAR. All training will be documented on a staff attendance sheet (SA) and are to be completed by February 28, 2020. The completed trainings related to this deficiency will then be submitted to Staff Development Facilitator who will ensure all the above noted parties are trained. The Staff Development Facilitator's signature and date of her review will be documented at the bottom of the above noted SA sheet with her signature serving as acknowledgement all staff were trained accordingly and the training was completed by February 28, 2020.
Medication Cabinet Audits which include Medication Administration Record (MAR) review will be completed for all individuals living to ensure any changes made to the MAR are clearly dated and initial and that the signature is on the back of the MAR. These initial chart audits will be completed by March 31, 2020. Any incorrect changes found on the individual's MAR will be brought to the Waiver Nurses attention. If at any time it is found that staff did not follow the facilities Protocol on properly documenting a change on the MAR, the issue will be immediately addressed with the staff person (s). The responsible staff will be immediately counseled and retrained on proper documentation procedures. Disciplinary action will be taken if necessary. After the initial Medication Cabinet audits have been completed audits will then be conducted every 6 months. |
03/31/2020
| Implemented |
| 6400.167(c) | All medication errors described under 6400.165(c), and the follow up action taken, was never reported as an incident to the Department as specified in 6400.18(b), relating to incident reporting and investigation. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | The facility will confirm that all medication errors are reported within 72 hours of discovery in accordance with state law through established procedures. The facility has several current protocols, i.e., Facility Medication Errors and the Internal Incident Report, as well as the Incident Management Bulletin to ensure that prompt reporting will take place. The medication error was entered into EIM on 10/09/2019.
The House Manager and the House Manager Aids will be trained on prompt reporting of medication errors. All training will be documented on a staff attendance sheet (SA) and are to be completed by February 28, 2020. The completed trainings related to this deficiency will then be submitted to Staff Development Facilitator who will ensure all the above noted parties are trained. The Staff Development Facilitator's signature and date of her review will be documented at the bottom of the above noted SA sheet with her signature serving as acknowledgement all staff were trained accordingly and the training was completed by February 28, 2020.
Medication Cabinet Audits which include Medication Administration Record (MAR) review will be completed for all individuals living to ensure all medications have been administered without error. These initial chart audits will be completed by March 31, 2020. Any errors found on the individual's MAR will be brought to the Waiver Nurses attention to determine if the error was reported within the 72 hours of discovery. If at any time it is found that staff did not follow the facilities Protocol on prompt reporting, the issue will be immediately addressed with the staff person (s). The responsible staff will be immediately counseled and retrained on proper reporting procedures. Disciplinary action will be taken if necessary. After the initial Medication Cabinet audits have been completed, audits will then be conducted every 6 months. |
03/31/2020
| Implemented |
| 6400.213(1)(i) | As required under 6400.213(1)(ii), the individual's record must contain their race and any identifying marks. Individual #1's record never defined his race. His record stated that his race was "Hispanic" but also included that his race was "White/Caucasian."
This individual's record stated that identifying marks were not applicable for him. However, this regulation is a requirement and identifying marks must be included in the individual's record. The individual had missing teeth that would fall under the requirement of an identifying mark that authorities or authorized personal could use to identify Individual #1. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Allegheny Valley School/Merakey acknowledges that the individual's record did not define race.
The individual's record was updated on 10/11/19 to include Caucasian as the individual's defined race (Attachment 35). The Program Specialist(s) was in-serviced on 1/27/2020 regarding providing required personal information and updating as needed on the general information sheet (Attachment 36). The remaining individuals records for those residing at CLA will be reviewed and updated as necessary to ensure the records contain required personal information; review will be completed by 2/14/2020. The Social Services Supervisor will review the updated personal information record and will sign/initial for 1 year as changes are necessary. This information will be maintained in the Social Service Supervisor's office. If concerns arise during the review, appropriate action will be taken. |
02/14/2020
| Implemented |
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