INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on March 14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Marworth were partially substantiated. A plan of correction must be submitted by April 14, 2011.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of staff training records, the facility failed to document individual training plans on each staff member.
The findings included:
During the onsite inspection of March 14, 2011, five staff records were reviewed. Four of the records were of maintenance personnel. Four of four training records of maintenance personnel failed to include documentation of an annual training plan for the current training year (2010-11).
Employee # 2 became an employee of Marworth as the result of the Geisinger system acquiring the hospital he previously worked at. He was hired at that hospital in 2005 and transferred to Marworth on February 15, 2009. No training plan was documented for this employee for the 2010-11 training year as of March 14, 2011.
Employee # 3 was hired at Marworth on 9/4/07. No individual training plan was documented for the 2010-11 training year as of March 14, 2011.
Employee # 4 was hired on May 23,1994. No individual training plan was documented for the 2010-2011 training year as of March 14, 2011.
Employee # 5 was hired on January 5, 2009. No individual training plan was documented for the 2010-11 training year as of March 14, 2011.
The QI Director and Maintenance Supervisor were presented with these findings and did not dispute them.
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Plan of Correction
Individual training plans were completed on employees #2, #3, and #4 on March 15, 2011 by the Maintenence Supervisor and placed in their personnel records. Employee #5 had been out on medical leave and resigned from Marworth on April 5, 2011 before we could initiate a training plan. Maintenance personnel records will be monitored by Human Resources to ensure continuing compliance with the training plan standards. |
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 the physical plant inspection conducted on 3/14/11, the facility failed to ensure that the building was safe, sanitary and in good repair at all times .
The findings included:
A physical plant inspection was conducted onsite on March 14, 2011. The sub- basement below the room designated as the AA room was inspected. When the stairway to the area was opened a strong odor of sewage was noted. The odor was particularly strong in the stairwell leading to the sub-basement. The cast iron pipes in this section of the facility were noted to be badly corroded. It was noted that much of the system was in place to circulate water and heat for an indoor swimming pool which is no longer functional. Many of the corroded pipes were not in use.
In one corner of the basement there is a run of pipes devoted to handling sewage from the floors located above it. There is a badly corroded holding tank and pipes which pump the raw sewage to be processed elsewhere on the grounds. The pipes were observed to be leaking and a shallow puddle of liquid sewage was on the floor beneath the pipes.
The findings were reviewed with the QI Director and the Maintenance Supervisor who did not dispute them.
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Plan of Correction
Permanent solution: Maintenance supervisor for Geisinger has obtained a bid to replace the "sewage lift station" in the sub-basement of the AA room. The vendor for the project is Koberlein Company. The cost of the project,due to age of plant and location of station, is $47,000. The project will take approximately 90 days to complete.
Short term solution: Until the project is completed , Absorbant "socks" and pads will be applied to the pipe and floor area by maintenance personnel to contain the liquid sewage. Absorbant pads are replaced every two days and fresh water is applied to the floor area to help drain left over leakage to the drain pipe. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on interviews and a physical plant inspection conducted on site during the March 14, 2011 unannounced complaint investigation, the facility failed to ensure that each bathroom was maintained in a clean, functional and sanitary manner at all times.
The findings included:
A physical plant inspection was conducted on March 14, 2011 at approximately 1 P.M. During the course of the inspection a considerable amount of dirt was observed in bathroom vents in rooms # 216 and 220. A maintenance technician accompanying Facility and Division staff on the inspection was asked to remove the vent covers so that the insides of the vents in these rooms could be examined. Dirt was caked on the insides of the vents.
At 1:40 P.M. an interview was conducted with the housekeeping group leader. The group leader indicated that bathroom vents were cleaned monthly at the beginning of each month. Because the inspection was occurring in the middle of the month, and it did not appear that the vents had been cleaned in the two rooms mentioned, the group leader was queried about whether this was a fair representation of the condition of the vents in the other rooms. The housekeeping group leader commented that the condition of the rooms would not be different than those observed in the two rooms inspected.
Maintenance staff were interviewed and all acknowledged the presence of mold on the drywall behind the showers when renovated. One shower that was in the process of being renovated had a small area of mold on the front of the drywall near the fixture. When maintenance staff present were interviewed they stated that the amount of mold in this shower was pretty typical of what they observed in those showers where mold was found during the renovations.
The QI Director and Maintenance Supervisor were present during this interview and did not dispute the findings.
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Plan of Correction
Maintenance personnel for Marworth will remove all (35) patient bathroom exhaust fans and vents to be thoroughly cleaned by hand by no later than April 30, 2011.
Additionally, housekeeping staff will clean/dust vents weekly as part of routine housekeeping duties. Vent cleaning will be monitored monthly by housekeeping supervisor on 50% of all patient bathrooms. Housekeeping will maintain a log of all inspections to monitor compliance with cleaning schedule.
The presence of mold on the drywall behind shower stalls has been noted as bathrooms have been renovated. Matworth maintenance personnel were trained on mold mitigation on March 21,2011 by the Industrial Hygiene Department of Geisinger. As bathrooms are renovated, the presence of mold will be mitigated according to training specifications. |