INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22-23, 2013 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.
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Plan of Correction
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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 observation during a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents.The findings include:A physical plant inspection was conducted on January 23, 2013 at approximately 1:30 PM. Bedroom # 44 located on the fourth floor was observed with two large stained/water damaged ceiling tiles which appeared to be wet .The Facility Director confirmed that bedroom # 44 had stained/water damaged ceiling tiles. She stated that roof repairs were recently done.
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Plan of Correction
1 - The patient's room was changed immediately
2 - Daily room checks will include observation of ceilings, in addition to all other safety checks
2- We are tenants of the Diocese of Philadelphia and would not be assuming this responsibility. However, the church has been soliticing roofing bids and will be replacing entire roof, rather than the on-going temporary patching repairs. A meeting was held on 2/14/13 between the church and administration of MSP/TJU to discuss the roofing and pointing issues. The church will be repairing the roof.
Person(s) Responsible: Program Director and Lead House Manager
Timeframe for completion: #1 & #2 immediate; #3 expected start date (dependent on weather conditions) with an expected completion date of 4/30/13 |
711.53(a)(8) LICENSURE Work as Therapy
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(8) Verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to verify that any work done by the client is an integral part of the treatment and rehabilitation plan.The findings include:On January 22-23, 2013, eight client records requiring documentation of work therapy as an integral part of treatment were reviewed. The facility failed to document work therapy on the individual treatment plan or treatment plan updates in eight of eight records reviewed, client records # 1, 2, 3, 4, 6, 7, 8 and 9. An interview with the Facility Director and clinical supervisor confirmed that clients participate in work outside of cleaning their personal space and that work as therapy was not documented on the treatment plans.
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Plan of Correction
#1 - Recovery/Treatment Plans (RTP)will include "work therapy" under ADL treatment goals.
#2 - Clinical Supervisor will provide a staff training on how to include the required "work therapy" within the RTP's under ADL.
#3 - All Comprehensive and Update RTP's will be reviewed by the Clinical Supervisor for compliance.
Person(s) Responsible: Clinical Supervisor, Primary Counselors
Timeframe for completion:
#1 & #3- immediately for all due RTP's; all other RTP's within in the next required time period for the comprehensive or updated RTP's
#2 - Documented training addressing the incusion of work therapy within the RTP's will be completed by 2/22/13 for all clinical staff. |