INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19 - 20, 2015 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 (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, the facility failed to keep the grounds clean, safe, and sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. The findings include:A physical plant inspection was conducted on November 20, 2015. The facility failed to keep the grounds in good repair at all times. The rim around the foyer door knob was observed loose and detached from the door knob.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Immediate correction: a new door knob has been ordered. Upon arrival the door knob will be replaced.
To ensure this does not occur again, a physical plant walk through will occur on a weekly basis by the Building Super. The Building Super is required to notify the Residential Director immediately of any supplies needed. The Residential Director will do random building walk through's to ensure all repairs are being completed. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill log, the facility failed to prepare alternate exit routes during fire drills and set off a fire alarm or smoke detector during each fire drill.The findings include:The facility's fire drill log was reviewed on November 19, 2015, covering the period of December 2014 through October 2015. The facility failed to prepare or document alternate exit routes during fire drills conducted during the month of December 2014 and February 2015. In addition, the facility failed to set off a fire alarm or smoke detector during the fire drill for the month of December 2014.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Immediate Correction by 12/11/15: Staff members who incorrectly completed the form will be addressed in supervision.
To ensure this does not occur again, at the next mandatory House Managers Meeting on January 21, 2016 all House Managers will receive a training on properly filling out the form, the importance to the form being complete, and proper procedures for conducting fire drills. Additionally, all completed forms will be forwarded to Lead House Manager prior to being filed to ensure it is completed. The Lead House Manager will sign off on all forms and immediately identify any missing information. The Residential Director will ensure each fire drill is activated by the fire alarm or smoke detector and review all forms to ensure all fire drills are executed correctly and documented properly. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection, the facility failed to maintain protective caps over each electrical outlet.The findings include:A physical plant inspection was conducted on November 20, 2015.The facility failed to maintain protective caps over each electrical outlet throughout the facility. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All residents in the program will attend an information session lead by the Program Director regarding the safety of caps being on electrical outlets when not in use. All residents will be provided safety caps for the outlets in their rooms.
During room inspections (which are completed every morning) House Managers will ensure all safety caps are in all open outlets and provide safety caps to residents when needed. |
711.53(c)(1)(i) LICENSURE Client Confidentiality
711.53. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but is not limited to:
(i) Confidentiality of client identity and records.
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Observations
Based on a physical plant inspection, the facility failed to secure client records within locked storage containers and maintain the confidentiality of client identiy and records.The findings include:A physical plant inspection was conducted on November 20, 2015. Unsecured boxes of client's clinical documents and medical records were observed in the basement. Random client's documents were dumped in boxes, at least 4 boxes. The documents included clinical documents, client medication administration records, and prescriptions. During the client record review of discharged clients the Licensing Specialist did not observe medication administration sheets of patients that received medication. The Licensing Specialist inquired about the missing medication administration sheets of the discharged clients, at which time the nurse stated that discharged clients medication administration sheets are stored in the basement and are not maintained in the client record.
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Plan of Correction
Beginning immediately (12/14/15) all medication administration logs will be maintained in the closed charts of individuals who are not longer at My Sister's Place. The nurse will ensure all documents are filed in the medical charts before closed charts are transferred to Family Center to be stored. The Residential Director will check all closed charts to ensure documents are being filed properly.
Additionally, beginning 12/14/15 the population check-list forms will be filed in date order and stored in a locked file cabinet until the date of which they can be destroyed. No additional documents will be stored in the basement. The Residential Director will conduct random checks of the basement (at minimum every other month) to ensure documents are not being improperly stored.
Additional shredders will be purchased to have on-site to allow staff to shred documents immediately that do not pertain the the client's chart. This is for daily forms that include client information such as trip logs or counselor assignment lists. These shredders will be purchased and will be on site no later than 2/12/16. The Residential Director will be responsible for ensuring the corrective action plan is implemented. |