INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 8-9, 2016 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.
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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 in a physical plant inspection conducted on December 9, 2016, the facility failed to keep the grounds of the facility in good repair.The following issues were observed during the physical plant inspection:4th floor: room 38 - cracked floor tiles room 33 - cracked floor tiles room 35 -cracked floor tiles restroom - cracked floor tiles room 46 - cracked floor tiles restroom - cracked floor tiles hallway - rubber strips pulling away from the wood (boarder)3rd floor: room 21 - torn carpet room 23 - torn and stained carpet room 22 - torn carpet restroom - crack tiles/missing tiles, broken window panel, chip paint room 29 - chipped wood on the radiator cover in the kids room. restroom - chipped tiles room 34 - water damage and chip paint by the wall next to the window2nd floor: worn tile issues in the hallway1st floor: Kitchen - chipped floor tiles Kitchen - emergency light unattached to the light fixture exposing wiresThe findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The loss of our building maintenance person added to the lapse in building repairs.
The 4th floor tiles will be replaced in all identified areas rooms # 33, 35, 46, restroom identified tiles will be replaced by 03/30/17. In addition all torn and stained carpet will be repaired/replaced by 04/30/17. In the meantime of being repaired, all areas where carpet is torn will be taped down to prevent individuals from tripping. All identified cracks tiles broken window panes will be repaired
by 05/30/17. Room #29 chipped wood will be covered until radiator can be
replaced.
We are actively seeking a maintenance person to replace the loss of the previous building maintenance person. In the interim we will be hiring a temporary maintenance person to complete the necessary repairs and maintain the up keep of the facility.
We have purchased a new facility that we anticipate moving into by the beginning of summer.
Person (s) responsible: All staff; Residential Director |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection which included inspection of mattresses throughout the facility as part of the onsite licensing inspection December 8-9, 2016 the facility failed to ensure that all mattresses were in good condition.Mattresses were randomly spot checked for cleanliness and good repair during the physical plant inspection conducted on December 9, 2016. The mattresses were generally in worn conditions. Tears were noted on the mattress covers in rooms 20, 30, 29 and 48. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Rooms 20, 30, 29, and 48 will all be replaced by 1/20/17.
Afterwards, all other mattresses will be checked in each bedroom (both sides) by RES staff. Staff will report the number of mattresses that are ripped/torn to Lead RES. Lead RES and Residential Director will meet to review these mattresses and begin replacing worst with new mattresses (which are already on site in storage) first. This portion will be completed by 02/28/16. Once all new mattresses that have already been purchased are used, if additional mattresses are needed, they will be purchased by 03/30/17. RES staff will begin checking mattresses for rips and tares during random monthly room checks.
Person's Responsible: RES Staff, Lead RES, Residential Director |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection conducted on December 9, 2016, the facility failed to provide slip resistant surfaces in one tub in the bathroom on the 4th floor. Additionally, the second tub in the bathroom located on the 4th floor had slip resistant strips that were worn and peeling away from the bottom of the tub.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Slip resistant strips will be purchased. The Lead RES will go around to all bathtubs and replace worn or missing slip resistant strips. During monthly building inspection, Residential Director will check to ensure all showers have slip resistant strips and replace as needed.
Person(s) responsible: Lead RES, Residential Director |
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 the physical plant inspection conducted on December 9, 2016, the facility failed to maintain each bathroom in a sanitary and clean manner.The following bathrooms had mold issues:4th floor - bathroom 2 along the tubs and a leaking faucet3rd floor - bathroom along the tubs The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All bathrooms are cleaned with bleach nightly. RES staff will work with patients to ensure they are cleaning all areas of the bathroom including grout. All areas of caulk that are not coming clean and appear to be mold will be removed and caulked by 02/03/17.
A plumber will be brought onsite to look at the leaks on the 3rd floor bath tubs. All leaks will be fixed no later than 02/28/17.
Staff and patients will report all future wear and tear of bathrooms by communicating via a work order with in 24 hours.
Person(s) Responsible: all staff and clients are responsible to report any concerns. RES staff will report any suspected mold or leaks during their nightly chore checks; Lead RES; Residential Director |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection conducted on December 9, 2016, the facility failed to ensure the exits from the facility were unobstructed. At the time of the physical plant inspection, the exit located on the 1st floor in the kitchen was jammed and very hard to open. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Residential Director will bring in a maintenance person to complete the repairs to the kitchen exit door and secure the light fixture to the exit light by 02/28/17. The door jam appeared to stick from not being regularly opened due to the age of the building, therefore we will open this door weekly.
Person(s) responsible: Residential Director |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection on December 9, 2016, the facility failed to ensure that exits/stairs are lighted at all times.The second exit interior lights on the fourth floor and the fire tower escape exit stairwell on the same floor lights were off .The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
After the facility walk through, Residential Director went back to look at the lights and one had a loose light bulb that was screwed in and worked immediately. The other was a switch that needed to be turned to on so the motion sensor would work. Both were immediately fixed.
To ensure this does not occur again, Residential Director will do monthly building walk throughs and will check all lights to ensure working. Any lights found to not be working will be immediately replaced.
Person(s) responsible: Residential Director |
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records on December 8-9, 2016, the facility failed to document an informed and voluntary consent in client records, #2, 3, 4, 5 and 7.Client #2 was admitted on September 22, 2016. The consent to release dated September 29, 2016 to the client's probation officer did not included the purpose of the release.Client #3 was admitted on September 21, 2016. The consent to release dated September 22, 2016 to a government agency did not include the purpose of the release.Client #4 was admitted on August 25, 2016. The consent to release dated October 21, 2016 for the client's friend showed that the client signed the consent on October 21, 2017 and the witness signed the consent on October 21, 2016.Client #5 was admitted on September 1, 2016. The consent to release dated 10/31/12 for the client's family was not a valid consent since the client was admitted on September 1, 2016.Client #7 was admitted on April 22, 2016. The consent to release dated April 22, 2016 did not include the name of the agency/person and what was being released.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Information on properly completing a consent form will be provided to all staff. This mini-training will be conducted by the Clinical Supervisor and will consist of ensuring that all information is completed (purpose, what is being released, accepting/not accepting a copy). Additionally, after the client signs the date will be checked to ensure the client dated the correct date. Staff will also be reminded that all letters going out need to be directed to a person and not "to whom it may concern". During quarterly chart audits, counselors will ensure all consent forms are properly filed and not expired. Clinical Supervisor will also check during random quarterly audits.
Client #2 and #3 will have a new consent form completed with their Primary Counselor indicating the purpose immediately. This will be done and filed no later than 1/20/17.
Client #4 will sign a new consent form with her Primary Counselor. Primary counselor will ensure this is dated correctly. This will be done and filed no later than 1/20/17.
Client #5 will sign a new consent form with her Primary Counselor. Primary counselor will ensure this is dated correctly. This will be done and filed no later than 1/20/17.
Client #7 will sign a new consent form that is completely filled out including the name and agency along with what will be released. This will be done and filed no later than 1/20/17.
Persons responsible: Counselors and other clinical staff, Clinical Supervisor |
711.53(c)(3) LICENSURE Copy of Client Consent
711.53. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records on December 8-9, 2016, the facility failed to document that the client was offered a copy of the informed and voluntary consent in client records, #3, 4 and 5.Client #3 was admitted on September 21, 2016. Consent to release for the client's family dated September 22, 2016. Client #4 was admitted on August 25, 2016. Consent to release for the client's friend dated October 7, 2016. Client #5 was admitted on September 2016. Consent to release for the client's family dated October 31, 2012. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Information on properly completing a consent form will be provided to all staff. This mini-training will be conducted by the Clinical Supervisor and will consist of ensuring that all information is completed (purpose, what is being released, accepting/not accepting a copy). Additionally, after the client signs the date will be checked to ensure the client dated the correct date. Staff will also be reminded that all letters going out need to be directed to a person and not "to whom it may concern". During quarterly chart audits, counselors will ensure all consent forms are properly filed and not expired. Clinical Supervisor will also check during random quarterly audits.
Client #3, #4, and #5 will sign new consent forms and indicate if they want or do not want a copy. All new consent forms will be completed and filed by 1/20/17.
Persons responsible: Counselors and other clinical staff, Clinical Supervisor |