INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 14, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Retreat at Lancaster County PA was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.1 (3) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(3) Comply with applicable Federal, State and local laws and ordinances.
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Observations
Based on a physical plant inspection completed on January 14, 2021, the facility failed to comply with Federal, State, and local laws and ordinances. client in wheelchair and walkers cannot open doors on their own, there are no push button door openers to get in and out of the building. These finding were reviewed with facility staff during the complaint investigation.
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Plan of Correction
Retreat will be ensuring that each floor has a door that will have a push button to open for patients with physical challenges. Facility Operations Director will oversee the installation of such doors. Chief Clinical Officer, this writer, will ensure this project is completed.
Corrective action will be implemented on 3/2/2021. |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection completed on January 14, 2021, the facility failed to maintain all equipment on the grounds of the site as to be free from danger to health and safety. The wooden bench behind the level 3 area and the Gym sign were cracked and had several splinters.
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Plan of Correction
The noted wooden bench has been removed from the campus. Facilities staff member removed the bench on 2/24/2021 and the CCO ensured this was complete.
Moving forward, all benches, along with all other equipment on the grounds, will be inspected during the monthly safety walkthroughs. These walkthroughs are completed by a facilities staff member. Facilities staff member will remove/replace any equipment right away that poses any danger to the health and safety of the patients or staff. CCO will monitor this by attending each monthly safety committee meeting, where we review monthly safety walkthroughs.
Corrective action will be implemented on 3/2/2021.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection completed on January 14, 2021, the facility failed to maintain sanitary and in good repair of the washers and dryers for client use. The washer on the second floor was unplugged because it was not working. There was a washer and dryer identify and reported not working on the third floor.
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Plan of Correction
the Corporate Supply Manager has submitted to this writer a work order for all new washers and dryers. They will be installed by the supply company under the oversight of the facilities manager. The CCO will ensure this is complete.
Corrective action will be implemented on 3/2/2021. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection, and client interviews completed on January 14, 2021, the facility failed to limit smoking to a designated area. The facility is allowing clients to smoke in non-smoking areas of the facility. These finding were reviewed with facility staff during the complaint investigation.
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Plan of Correction
This writer, CCO, has discussed the matter with the nursing, CA and Clinical department heads. The matter at hand was discussed and they were informed that staff must direct patients to smoke at the proper designated smoking areas. The CCO will ensure compliance via weekly walk-thru of the campus.
Corrective action will be implemented on 3/2/2021. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the unusual incident report dated 10/4/20, the facility failed to document follow-up of the incident as noted in their policy and procedures. The only action identified on the form is refer to safety committee.
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Plan of Correction
The follow through was completed during a discussion at the safety meeting, where all incidents are reviewed and an action plan is written in the meeting notes of the meeting. Moving forward, this writer, CCO, will attend the monthly safety meetings to ensure this practice is continued to maintain compliance. Meeting minutes will be reviewed during each meeting to ensure that all follow-up documentation is being completed thoroughly.
Corrective action will be implemented on 3/2/2021. |