D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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MY SISTER'S PLACE THOMAS JEFFERSON UNIVERSITY
1239 SPRING GARDEN STREET
PHILADELPHIA, PA 19123

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Survey conducted on 01/08/2010

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on January 7-8, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, My Sister's Place Thomas Jefferson University was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on February 10, 2010.	Plan of Correction
705.10 (d) (5) LICENSURE Fire safety. 705.10. Fire safety. (d) Fire drills. The residential facility shall: (5) Conduct a fire drill during sleeping hours at least every 6 months.
Observations Based on a review of the facility ' s fire drill log, the facility failed to document a fire drill during sleeping hours at least every six months. The findings include:The facility ' s fire drill log was reviewed, and an interview with the facility director was conducted on January 8, 2010. The facility did not document unannounced fire drills during sleeping hours at least every six months. The facility ' s last documented unannounced fire drills during sleeping hours were on August 27, 2009, July 9, 2009 and October 10, 2008. The facility director confirmed that fire drills were not completed at least once every six months during sleeping hours.	Plan of Correction Based on the fragile population of babies, small children, and the high-risk pregnant clients, the facility will reinstitute the second fire drill for the Spring during the sleeping hours. This will then complete the requirement for two fire drills during sleeping hours. Person(s) responsible: Associate Director and Lead House Manager Timeframe for completion: Immediate
711.58(a)(1) LICENSURE Administration of Medication 711.58. Medication control. When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients, which shall include, but not be limited to: (1) Administration of medication.
Observations Based on the review of client medication administration records, the facility failed to document missed medication dosages in two of six client records. The findings include:Six client medication administration records were reviewed on January 7-8, 2010. All six records required documentation of complete medication administration records. The medication administration records in client records # 2 and 3 lacked documentation as to why medications were not administered on the dates as detailed below. Client # 2 was prescribed Docusate 100mg 1 capsule twice daily. During the month of December 2009, the facility did not document the reason(s) why this medication was missed in the evening on dates 12/3, 12/9, 12/10, 12/11, 12/12, 12/13, 12/15, 12/16, 12/17, 12/18, 12/20, 12/21, 12/22, 12/23, 12/26, 12/27, 12/28, 12/30 and 12/31.Client # 2 was prescribed Prenatal Plus 1 tablet at bedtime. During the month of December 2009, the facility did not document the reason(s) why this medication was missed on dates 12/10, 12/12, 12/13, 12/16, 12/17, 12/18, 12/21, 12/22, 12/23, 12/27, 12/30 and 12/31.Client # 2 was prescribed Ranitidine 150mg 1 tablet by mouth twice daily. During the month of December 2009, the facility did not document the reason(s) why this medication was missed in the morning on dates 12/5, 12/19, 12/20 and 12/21, and in the evening on dates 12/5, 12/6, 12/9, 12/10, 12/11, 12/12, 12/13, 12/16, 12/17, 12/18, 12/21, 12/22, 12/23, 12/27, 12/30 and 12/31.Client # 3 was prescribed Docusate 100mg 1 capsule twice daily. During the month of December 2009, the facility did not document the reason(s) why this medication was missed in the evening on dates 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, 12/9, 12/10, 12/11, 12/12, 12/13, 12/14, 12/15, 12/16, 12/17, 12/18, 12/19, 12/20, 12/21, 12/22, 12/23, 12/24, 12/25, 12/26, 12/27, 12/29, 12/30 and 12/31.Client # 3 was prescribed Prenatal Plus 1 tablet daily. During the month of December 2009, the facility did not document the reason(s) why this medication was missed on dates 12/5, 12/6, 12/12, 12/13, 12/16, 12/19, 12/20, 12/21, 12/26, 12/27, 12/29, 12/30 and 12/31.An interview with the facility director and the nurse was conducted on December 8, 2009. The facility director and nurse confirmed that the medication administration records for client records # 2 and 3 were incomplete. The nurse stated that a medication refusal form should have been completed if the clients refused the medications, but medication refusal forms had not been documented.	Plan of Correction The nurse will monitor the medication administration records on a daily basis to ensure that any deviation from the prescribed medication protocol is properly recorded on the "Refusal to Take Medication" form. The nurse will be responsible to complete an incident report and submit same to the Director and Associate Director noting the deviation and an action plan. Also, the nurse will be responsible to train all staff on the proper protocols when clients refuse their prescribed medications. Person(s) responsible: Nurse Timeframe for completion: Immediate