INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 12, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel files on August 12, 2021, the facility failed to ensure that all counselors and counselor assistants were trained in HIV/AIDS and TB/STD within the first year of employment.Staff #4 was hired on April 21, 2020 as a Counselor. Staff #4 never received their four hours of mandatory TB/STD training. Staff #5 was hired on August 5, 2019 as a Counselor. Staff #5 never received their four hours of mandatory TB/STD training. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor shall ensure that all new hires have received all required trainings (HIV/AIDS, TB/STD, first Aid, etc.). Any newly hired staff members who have not received the required trainings will be scheduled for needed trainings within 2 weeks of the date of hire. Starting 30 September 2021 or the next new hire, whichever comes first, all mandatory trainings will be documented in employee intake packages. The clinical supervisor functions as the facility training officer and monitors all scheduled staff trainings to ensure regulation compliance. Regarding staff members #4 and #5, they have been in contact with DDAP training office and were notified that there will be a TB/STD on 19 November 2021. Because DDAP policy is that individuals must wait until 6 weeks prior to the scheduled training date to register, these staff members will register on 8 October 2021. In addition, the training officer is aware of this issue and will ensure that staff members #4 and #5 register on that date. All information pertaining to this issue will be documented in each employees' 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.
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Observations
Based on a physical site inspection on August 12, 2021, 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. Woman's staff bathroom countertop had a sharp edge where it had been broken off.2. Apt #2 had cracked tiles on the countertop in the kitchen. 3. Apt #2 Room #4 had a hole in the wall behind the door.4. Apt #8 had a broken kitchen countertop with a sharp edge. 5. Apt #8 Room #1 had cracked tiles with sharp edges on the floor. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director is responsible for ensuring that the facility physical plant is kept in a safe, sanitary condition and in good repair. Through weekly inspections conducted by the project director and/or the head building manager, any items found to be dirty, unsafe, or broken are noted and documented in the facility maintenance log, which is located in the main business office. When repairs are completed the writeups are signed off by the project director or the head building manager following verification of completion of the corrective action.
Write-ups #1, #3, #4, and #5 were repaired by the facility maintenance staff within the first week following the annual inspection. they were entered in the facility maintenance log on 13 August 2021 and were signed off as completed by the project director on 19 August 2021.
Concerning write-up #2 regarding the cracked countertop in Apt. #2, repairs on this deficiency are awaiting parts and will be completed no later than 30 September 2021. This write-up has been entered in the facility maintenance log with a note that it is awaiting parts. The project director will monitor the progress and ensure that the repairs are completed in a timely manner. |
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 site inspection on August 12, 2021, the facility failed to ensure that hot water temperatures did not exceed 120 degrees Fahrenheit. The water temperature in the women and men's staff bathrooms read 138 degrees Fahrenheit. The water temperature in Apt #3, Apt #7 and Apt #8 bathrooms read 130 degrees Fahrenheit. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director is responsible for ensuring that the facility physical plant is kept in a safe, and sanitary condition and in good repair. The hot water heaters for apartment #3, #7, and #8 as well as the water heaters for the men's and women's first floor staff bathrooms were immediately adjusted by the facility maintenance staff to below 120 F degrees. These writeups were entered in the facility maintenance log and signed off by the project director on 12 August 2021.
It is facility policy that all physical plant water temperatures are checked on a monthly basis and results as well as any adjustments are entered in the facility water temperature log located in the main business office.
We will continue to check and document all building water temperatures on a monthly basis and to promptly adjust any as needed.
Starting in September 2021 all water temperatures will be tested with an electronic water temperature testing device.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical site inspection on August 12,2021 the facility failed to ensure restrooms were ventilated by either an exhaust fan or window. In Apt #5 the bathroom's exhaust fan was not in working order and the bathroom did not have a window. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director is responsible for ensuring that the facility physical plant is kept in a safe, sanitary condition and in good repair. The exhaust fan in Apartment #5's bathroom will be replaced by the facility maintenance staff no later than 30 September 2021.
This write-up has been entered in the facility maintenance log.
Following the replacement of the bathroom exhaust fan the project director will perform an operational check and the repairs as well as the operational check will be documented in the facility maintenance log. The project director will continue to monitor any progress and will ensure that this issue is corrected in a timely manner. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records on August 12, 2021, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven client records reviewed. Client #2 was admitted on May 11, 2021 and was still active at the time of the inspection. A treatment plan update was completed on July 9, 2021 and the next update was due no later than August 8, 2021; however, was not completed until August 11, 2021.Client #3 was admitted on May 11, 2021 and was still active at the time of the inspection. A treatment plan update was completed on July 9, 2021, and the next update was due no later than August 8, 2021; however, the next update not completed until July 11, 2021. Client #4 was admitted on May 13, 2021 and was still active at the time of the inspection. A treatment plan update was completed on June 11, 2021, and the next update was due no later than July 10, 2021; however, the next update was not completed until July 13, 2021. Client #5 was admitted on May 21, 2021 and was discharged July 27, 2021. A treatment plan update was completed on June 18, 2021 and the next update was due no later than July 17, 2021; however, the next update was not completed until July 21, 2021These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor and quality assurance staff are responsible for ensuring that all required clinical documentation meets regulations. At the weekly staff meeting on 19 August 2021, the clinical staff was counseled on the importance of proper documentation and the need to complete all treatment plan reviews within the required timeframes. This will be repeated during subsequent staff meetings to ensure familiarization and conformity.
Quality assurance staff was directed to pay special attention to this area and to immediately report any deficiencies to the clinical supervisor. Any counselors that are having difficulties with timely completions of treatment plan reviews will be identified by quality assurance and will receive individual instruction by the clinical supervisor. |