INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 24-25, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, James A. Casey House, LLC 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:
|
Plan of Correction
|
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on a review of personnel records on February 24-25, 2020, the facility failed to collect and document feedback forms for completed trainings in employee #1 ' s record. Employee #1 was hired on April 1, 2013 and was promoted to the position of Project Director on June 15, 2016. The facility ' s training year that was reviewed was from January 1, 2019 to December 31, 2019. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The clinical supervisor will schedule and conduct a mandatory training session covering staff training as well as applicable regulations including Chapter 704-staffing. All staff, including the project director, will attend this training. This training session will be scheduled no later than 5/30/20. If needed, a make-up session will be scheduled no later than one month following the initial session for staff members who miss the initial training session. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of personnel records and employee schedules on February 24-25, 2020, the facility failed to provide at least one person with CPR certification and first aid training during the project ' s hours of operations, which are 24 hours a day, seven days a week. There was not a staff person trained in these areas on duty between 7:00am - 8:00am on Thursdays and Fridays. Reviewed schedules from December 1, 2019 through February 22, 2020.The findings were reviewed with facility staff during the licensing process. This is a repeat citation from the January 9, 2019 licensing inspection.
|
Plan of Correction
Beginning immediately 2/26/20, the project director will ensure that the facility has at least one CPR certified member providing coverage 24 hours 7 days per week. To ensure the maximum availability of qualified staff, the clinical supervisor will schedule our next CPR certification training for all available staff no later than 5/20/20. In addition,the project director will be notified of any upcoming shift or staff changes by the head manager so that continued 24 hour 7 days per week coverage is maintained. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records on February 24-25, 2020, the facility failed to document the completion of 12 clock hours of annual training required for counselors in employee #1 ' s record. Employee #1 was hired on April 1, 2013 and was promoted to the position of Project Director on June 15, 2016. The facility ' s training year that was reviewed was from January 1, 2019 to December 31, 2019. Employee #1 ' s employee record only documented 1.5 hours of annual training for the training year reviewed.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The clinical supervisor will schedule and conduct a mandatory training session covering staff training as well as applicable regulations including 704-Staffing. All staff, including the project director, will attend this training. The training session will be scheduled no later than 5/30/20. If needed, a make-up session will be scheduled no later than one month following the initial session for staff members who miss the initial training session. This training session will be documented and placed in the staff members' training file. |
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.
|
Observations
Based on a physical site inspection on February 24, 2020, the facility failed to maintain the facility in a clean, safe, and in good repair for the safety and well-being of residents, employees and visitors as evidenced by the following:1)In Area 205, the rear fire exit window glass was broken. 2)Holes were observed in the walls and closet doors in Area 199, Apartments # ' s 2, 2-2, 2-3, 5-4 and 11-3.3)In Area 199, apartments # ' s 2-2 and 2-3, the radiator cover was raised up exposing the heating element underneath. The radiator cover itself was a hazard in addition to the heating source being exposed and accessible. 4)Broken ceiling tiles were observed in Area 199, apartment # ' s 5-4, 8-1 and 11-3.5)In Area 199, apartment #6 the side of the kitchen cupboard was broken and protruding out causing a hazard. In Area 199, apartment #8, kitchen cupboard knobs were missing. In Area 199, apartment #11-1, the dresser was missing knobs. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will direct the facility building maintenance crew A.) To repair or replace the rear fire exit door window in area 205. B.) To repair all holes found in apartment doors and walls in apartment #2's common area, and in bedrooms 2-2, 2-3, 5-4, and 11-3. C.) To repair the heater covers in bedrooms 2-2 and 2-3. D.) To repair or replace broken ceiling tiles in bedrooms 5-4, 8-1, and 11-3. E.) To repair the broken kitchen cupboard in apartment #6, to replace the kitchen cupboard knobs in apartment #8 and to repair the dresser in bedroom 11-1. |
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.
|
Observations
Based on a physical site inspection on February 24, 2020, the facility failed to ensure hot water temperatures do not exceed 120F. In Area 199, apartment two, the bathroom hot water temperature read 133.3F. In Area 199, apartment one ' s first floor bathroom, the hot water temperatures read 129.2. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director instructed the building maintenance crew on 2/25/20 to immediately adjust the water heaters in apartments #1 and #2 not to exceed 120F. The water temperatures in apartments #1 and #2 were rechecked on 2/26/20 and were found to be in compliance with temperatures of 118F and 119F, respectively. The building maintenance crew will check all apartment water temperatures the first week of every month to ensure they remain in compliance. These checks will be documented monthly and entered in the facility maintenance log located in the project director's office. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
|
Observations
Based on a physical site inspection on February 24, 2020, the facility failed to ensure restrooms were ventilated by either an exhaust fan or window. In Area 199, apartment one, the bathroom ' s exhaust fan was not in working order and the room did not have a window. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will instruct the building maintenance crew to repair or replace the exhaust fan in apartment #1's bathroom. This will be accomplished no later than 4/1/20. Upon completion, the project director will perform an operational check. The repairs and/or the replacement of the exhaust fan as well as the operational check will be documented in the facility maintenance log which is located in the project director's office. |
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.
|
Observations
Based on a physical site inspection on February 24, 2020, the facility failed to maintain bathrooms in a functional, clean and sanitary manner. Grime and soap scum were observed in the showers in Area 199, apartments one, five, six, seven and nine. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 3/2/20 the project director and the head building manager addressed the entire manager staff and explained the need to focus on cleanliness in general and with apartment bathroom cleanliness in particular during their weekly apartment inspections and to ensure that the managers and clients understand the need to ensure that any unsanitary conditions must be addressed. Beginning 0n 3/9/20 the managers performing weekly inspections will be accompanied by the head manager, the project director, or both to ensure that the apartments are inspected properly. The head manager will ensure that any areas found to be unsanitary are promptly cleaned by clients and/or manager staff. All of these actions will be documented in the facility maintenance log which is located in the project director's office. |
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.
|
Observations
Based on a physical site inspection on February 24, 2020, the facility failed to ensure all exits from rooms are unobstructed. In the basement, the second exit door was blocked by a table. In addition, the door was locked from the outside preventing it from being used as a fire exit. The findings were reviewed with facility staff during the licensing process. This is a repeat citation from the January 9, 2019 annual inspection.
|
Plan of Correction
The project director directed the building maintenance crew to remove the table blocking the second exit door and to remove the lock on the outside of the door. This was accomplished on 2/25/20. The manager staff performs weekly facility inspections for cleanliness and damages and the head manager instructed them that as a part of these inspections they ensure all exits are unobstructed. Any issues or actions will be documented in the facility maintenance log located in the project director's office. |
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.
|
Observations
Based on a physical site inspection on February 24, 2020, the facility failed to light interior exits and stairs at all times. In Area 205, the front fire escape hall and the second-floor hallway were not lit as lightbulbs had blown out. The findings were reviewed with facility staff during the licensing process. This is a repeat citation from the January 9, 2019 annual inspection and a September 4, 2019 complaint investigation.
|
Plan of Correction
The project director will ensure that the building maintenance staff replaces all burned out light bulbs in area 205. This was accomplished on 2/25/20 and an operational check, by the head manager, was good. The manager staff were instructed by the head manager to check all lighting during their weekly inspections and to report any burned out light bulbs to the building maintenance staff for replacement or repairs. All lighting issues will be documented in the apartment inspection log by the managers. All repairs or replacements will be documented in the building maintenance log by the building maintenance staff. |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
|
Observations
Based on a physical site inspection on February 24, 2020, the facility failed to ensure all fire extinguishers were mounted to the wall. The fire extinguishers in Area 199, apartments three and ten were not mounted on the wall. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will ensure that the fire extinguisher provider (Cintas) is contacted as soon as possible to schedule a visit in order to mount the existing fire extinguishers in the kitchen areas of apartments #3 and #10. The project director will inspect these areas to ensure that the fire extinguishers are properly mounted before Cintas leaves the facility. These actions will be documented in the facility maintenance log located in the project director's office.
Update: Cintas visited on Friday 3/6/20 and mounted the fire extinguishers, the project director ensured that they were mounted properly before Cintas left the facility. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on a physical site inspection on February 24, 2020, the facility failed to ensure all fire extinguishers are annually inspected by the local fire department or fire extinguisher company. The fire extinguisher located outside the staff bathrooms was last inspection in December 2018. The fire extinguisher in Area 205, apartment 4-A did not have a tag; therefore, inspection of the extinguisher could not be verified. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will ensure that the fire extinguisher provider (Cintas) is contacted as soon as possible to schedule a visit to inspect the fire extinguisher outside the first floor staff restrooms as well as the fire extinguisher in apartment #4A in area 205 and ensure that they are properly tagged. The project director will ensure that these actions are completed before Cintas leaves the facility. These actions will be documented in the facility maintenance log located in the project director's office.
Update: Cintas visited the facility on Friday 3/6/20 and inspected and tagged both fire extinguishers that were missing tags. The project director ensured that these actions were accomplished before Cintas left the facility. |
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.
|
Observations
A review of the January 2019 through January 2020 fire drill logs was conducted during the onsite inspection on February 24-25, 2020. The facility failed to conduct unannounced drills during sleeping hours every six months. Overnight sleeping drills were conducted on January 10, 2019 and then again on October 11, 2019. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will ensure that fire drills are conducted in accordance with Chapter 705.10(d) and will ensure that we abide by all regulations pertaining to fire drills, this includes making sure that fire drills are conducted during sleeping hours at least every 6 months. All fire drills are documented and kept in the fire drill log located in the project director's office. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
|
Observations
Based on a physical site inspection on February 24, 2020, the facility failed to maintain an area for drugs requiring special conditions. In the medication room refrigerator, coffee creamer was being stored for staff usage. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will ensure that the medication room refrigerator is used solely for medications and that no food or drinks are stored in the refrigerator. The project director notified all staff members who work in the medication room that the medication room refrigerator is for medications, only. Signs were posted in the medication room including on the front of the refrigerator stating "Medication only, no food or drink items are to be stored in this refrigerator." the project director will ensure compliance by randomly inspecting the refrigerator at least every month. |