INITIAL COMMENTS
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This report identifies the findings of an on-site complaint investigation conducted on November 30, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on January 12, 2007.
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Plan of Correction
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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
The facility lacks sufficient maintenance staff to keep up with the physical plant standards as evidenced by the following:
1. The carpeting in all of the client bedrooms, hallways and child daycare room was extremely dirty and presents a health concern for the residents and children residing in the program.
2. Client bedrooms had an unpleasant odor, were in disarray and unkempt. There were trash bags filled with clothing, toys and various objects all over the floors in client bedrooms.
3. Chairs in the dining room were torn, ripped and had holes in the upholstery which exposed the foam padding. The foam padding was missing in some of the chairs.
4. It was reported that the facility had two vacuum cleaners, but both of them ceased working and the facility had not fixed them or bought new ones at the time of the inspection.
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Plan of Correction
Work on a proposal for renovations has been underway since the first of November 2006. We received approval from the Dean last week to let the contract. This proposal was presented to the surveyor, and has been approved by the Director of MATER.
1, 3. As part of the renovations, carpeting will be removed, new dining room furniture is being purchased
Outside electrical contractors have completed work in enhancing the lighting within the facility.
(Completed)
2. ADL skills are part of the weekly curriculum. The Lead House Manager will re-enforce facility checks with the house managers to ensure all rooms meet daily inspection and do not present any health or safety hazards.
All room and facility checks will be documented and issue of non-compliance will be addressed clinically by the client's counselor; safety issues will be recorded on the Work Acquisition form and presented to the Residential Director for repairs.
Repairs that are outside the scope of the maintenance staff will be arranged with an outside contractor.
4. The goal is to eliminate carpeting, where feasible to reduce germs, dust, etc. Vacuum cleaners will be replaced. Vacuum cleaners are repaired/replaced frequently.
Person(s) responsible:
Director, Program Director, Lead House Manager, Maintenance Staff, and the
Residential Operations Director
Timeframe: Immediate
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705.8 (1) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(1) Shall have a heating and cooling ventilation system that is adequate to maintain an indoor temperature of at least 65F in the winter. When indoor temperatures exceed 90F, mechanical ventilation such as fans or air conditioning shall be used.
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Observations
The heating and cooling ventilation system was not adequate in maintaining the temperature within the facility. The licensing specialist worked in a room where both the radiator heat and window air conditioning unit were on to regulate the temperature. It was reported that both the heating and cooling systems are kept on during the day in an attempt to regulate the temperature within the facility. There were several areas within the facility that were uncomfortably hot during the day. It was reported that three to four client bedrooms are very cold at night.
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Plan of Correction
MSP is housed in a very old building, 4 story building. As such, the zone boxes (thermostats) do not always coincide with the floor on which it is located. Numerous and on-going efforts have been made to ensure that the rooms are comfortable for the clients, their children, and the staff. Unfortunately, when the patients and their children come first, some of the staff offices become very hot. Pipes have been covered in these offices and each office has an air conditioner. Some offices have two windows which allow for outside ventilation.
Each patient has a fan for her room. A/C is available in the common rooms and in staff offices, PCC, medication rooms.
The four bedrooms will be rechecked to ensure the radiators have been properly drained. If there is a hot water gravitation problem, the clients will be relocated until the plumber can repair the radiator.
Person(s) responsible:
Lead House Manager, Maintenance Staff, and the
Residential Operations Director
Timeframe for complete: Immediate |
705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Cleaning supplies were in two client bedrooms and were not secured in a locked area. These cleaning supplies were adjacent to children's drinks as shown in the attached photographs. A container of bleach and other cleaning supplies were beside baby formula in a client bathroom. Children had easy access to these cleaning supplies as they were not secured in locked containers as required.
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Plan of Correction
The Lead House Manager will instruct all House Managers and clients that cleaning products are to be labeled and stored in the House Manager's office on the 2nd floor. Clients will need to sign out and return their cleaning products to the House Manager's office upon completion of the weekly cleaning chores.
The Nurse will do a presentation with the clients to review the possible hazards associated with cleaning products, and why it is critical to have these products secured at all times.
Person(s) responsible:
Lead House Manager, Nurse and the
Residential Operations Director
Timeframe for completion: Immediate
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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
The full name of a client was written on a white board announcing the birth of her baby.
During the inspection, an employee made an announcement over the intercom system using a client's full name.
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Plan of Correction
The Residential Operations Director will review the existing written procedure regarding confidentiality with all staff. The training will be documented and placed in the staff's training chart.
A community meeting will be held by the Residential Operation Director to address confidentiality issues with the clients so that any announcements recorded by the clients on their "Information" board will not breach any
confidentiality issues.
Person(s) responsible:
Residential Operations Director
Timeframe for completion: Immediate
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711.54(a)(2) LICENSURE Receiving/storing/preserving
711.54. Project management services.
(a) When food is prepared at the project site and preparation is not directly supervised by the parent health care facility, then the drug and alcohol project shall have written policies and procedures for its dietetic services which includes, but is not limited to:
(2) Receiving, storing and preserving of food stuff.
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Observations
It was reported that the facility receives donated food items, such as milk, which is out of date, but is still received and stored by the facility for client use.
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Plan of Correction
This issue is under investigation since all outdated products are discarded upon expiration.
The Parent Child Coordinator will devise a more intensive tracking system of distribution. Also, room checks will include the House Managers inspecting any formula bottles in the client's rooms. Random inspection of diaper bags will be required to ensure formula which was distributed before expiration has not be stored by the clients.
The Chef will conduct checks of clients kitchen cabinets, checks to ensure the expired formula is not being stored in the cabinets beyond its effective date.
Person(s) responsible:
Residential Operations Director, Parent Child Coordinator, Lead House Manager, and Chef
Timeframe for completion: Immediate
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