INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 3 - 5, 2018 of St. Joseph Institute by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, St. Joseph Institute 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 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
1. One of the three trash dumpsters, located to the right of the administrative building, was not covered. The dumpster itself was missing one of the four lids.
2. One of the three dumpsters, located to the right of the administrative building, had a large gap of approximately six inches between the two front lids. This gap would permit animals from entering the dumpster.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The trash removal company was contacted by the Maintenance Supervisor the week of inspection. On 12/21/18, the company replaced one dumpster and replaced the defective lids on the other 2 dumpsters. The Maintenance Supervisor will inspect weekly all dumpsters at the facility to ensure compliance. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure that every bathroom had hot and cold water under pressure and that hot water at all locations did not exceed 120 degrees Fahrenheit as evidenced by the following:
1. In the administrative building men and women's bathrooms, there was no hot water. On December 3, 2018 at 1pm, the water temperature in both bathrooms was recorded at 63 degrees with no differential temperature change between the hot and cold water.
2. In the wellness center bathrooms, the hot water temperature read above the allotted 120 degrees. On December 3, 2018 at 2pm, the women's bathroom registered at 129.3. The men's bathroom registered at 132.8.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
For the Administration building, a new On Demand hot water heater was purchased and installed on 12/14/2018 by the Maintenance Supervisor. It is factory pre-set for 110 degrees.
For the Wellness Center building, a new mixing valve was installed on 1/10/2019 on the hot water heater by an external HVAC company. It is set for 115 degrees.
The Maintenance Supervisor will test the water temperatures in all buildings weekly to ensure compliance.
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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.
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Observations
A review of the October 2017 through October 2018 fire drill logs was conducted during the onsite inspection. The facility failed to conduct any drills during sleeping hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/7/2019 at 1:00am, a fire drill was conducted. This occurred during sleeping hours at the facility. Another fire drill will be conducted during sleeping hours within 6 months. The Maintenance Supervisor and the Quality Improvement/Risk Manager will monitor and track the implementation of the monthly fire drills to ensure compliance. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of 14 client records, the facility's handbook, where the client's rights are listed, the facility failed to include documentation of all the required client rights, including creed, ethnicity, color, national origin and marital status. This documentation was missing from all 14 client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client rights were updated on 1/30/2019 by the Quality Improvement/Risk Manager to include all required documentation. All postings of the client rights will be updated by 2/8/2019; this includes the copies that are posted at the facility, the policy and procedure manual and the client handbook. The Quality Improvement/Risk Manager will monitor compliance with this documentation. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of 14 client records, the facility's handbook, where the client's rights are listed, the facility failed failed to include documentation of all the required client rights including all parts of 709.30(3).
This documentation was missing from all 14 client records.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The client rights were updated on 1/30/2019 by the Quality Improvement/Risk Manager to include all required documentation. All postings of the client rights will be updated by 2/8/2019; this includes the copies that are posted at the facility, the policy and procedure manual and the client handbook. The Quality Improvement/Risk Manager will monitor compliance with this documentation. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of 14 client records, the facility's handbook, where the client's rights are listed, the facility failed to include documentation of all the required client rights including the client's right to submit rebuttal data or memoranda to their own records.
This documentation was missing from all 14 client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client rights were updated on 1/30/2019 by the Quality Improvement/Risk Manager to include all required documentation. All postings of the client rights will be updated by 2/8/2019; this includes the copies that are posted at the facility, the policy and procedure manual and the client handbook. The Quality Improvement/Risk Manager will monitor compliance with this documentation. |