INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on July 24, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Clem Mar House Inc. 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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705.5 (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 the facility failed to maintain mattresses in good condition in each client bedroom.
The findings include:
Mattresses and pillows in ten client rooms were inspected during the complaint investigation of July 24, 2012. Mattresses and pillows in five of ten rooms were stained.
Room # 2- One lower bunk bed had visible yellow stains and blood stains on the mattress and pillow.
Room # 4 - One lower bunk bed had visible blood stains on the mattress and pillow.
Room # 5- One single bed had evidence of bed bug infestation with dead bed bugs/casings observed on the side of the mattress. Visible blood staining was noted on the mattress and pillow.
Room # 6- One lower bunk bed had visible blood stains on the mattress and pillow. Blood stains and dead bed bugs/casings were observed on the mattress.
Room # 7 - One lower bunk bed had visible yellow and blood stains on the mattress at the time of inspection.
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Plan of Correction
All client pillows were replaced on 8/8/12, and the mattresses on the client beds listed were replaced on 8/10/12. In addition, water- and pest-proof airtight vinyl mattress coverings were purchased from pest management specialist, and installed on 8/17/2012 when received, and maintenance technician coated all under-bed support areas with vinyl paint to cover pores in wood which may house pests.
To prevent recurrence, resident managers will do a daily check of rooms to ensure beds and bedding is in good repair. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on the physical plant inspection, the results of client interviews and documentation presented to Division staff at the time of the inspection , the facility failed to ensure that it was free of rodent and insect infestation at all times.
The findings include:
Four clients were randomly selected for interviews during the onsite complaint investigation of July 24, 2012. Invoices from a pest control contractor were reviewed and a physical plant inspection which included an inspection of all mattresses and pillows in the facility was completed also on that date.
Client interviews verified that there were observations of mice in and around the facility. A rodent dropping was noted in a corner in Room 2. One client reported that mice had been caught in his room. Invoices from the pest control contractor verified the presence of bed bugs on 1/3/12, 2/2/12, 6/14/12 and 6/18/12. Blood stains were observed on mattresses in rooms 2, 3, 5 and 6. Dead bed bugs were observed on mattresses in rooms 5 and 6.
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Plan of Correction
Durable plastic bed covers were ordered from pest control specialist on July 25, 2012 for each bed in the facility and rec'd on 8/17/12. These encase all beds in an airtight seal to prevent propagation of bedbugs. In addition, the surfaces on which client mattresses are placed were all treated with pore-preventing vinyl paint to prevent the ability for pests to burrow into the wood.
In addition, to prevent recurrence, upon any client report of bedbug or rodent sighting, the pest control specialist is on-call to immediately address concerns. To prevent recurrence the resident managers on duty will inspect rooms daily to ensure that clients are not storing/eating/housing food in the bedding area, which encourages rodent presence.
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705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a physical plan inspection , the facility failed to ensure that there were two exits from each floor including the basement and the attic. The basement has only one exit.
The findings include;
The physical plant was inspected as part of an onsite complaint investigation on July 24,2012. The basement was inspected as part of this process. Division staff had been led to believe in the past that the basement was used only when maintenance was necessary and that only a small portion of the basement just inside the entrance door was accessed. During this inspection Division staff gained access to a large section of the basement adjacent to the entrance which is obviously used to a great extent for storage of client possessions and seasonal decorations. The basement has only one exit.
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Plan of Correction
Prior to the site visit on July 24, 2012, the storage area in the basement for client supplies was moved from the basement to a room in the 2nd Story of the facility to prevent clients from entering the basement for any reason, though the space for storage was still evident.
On August 22, 2012, the maintenance technician moved all other supplies from the basement to external storage area to prevent confusion with storage spaces. To prevent recurrence, all RM Staff was re-trained on 8/22/12 regarding client access to the basement area, and the area will be remain locked with only access by The Clinical Director and/or Senior RM in the event of emergency. |
709.28 (c)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(c) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records the facility failed to document an informed consent for each release of information in one of one client records reviewed.
The findings include:
One client record was reviewed during the onsite complaint investigation of July 24,2012.
The record contained a Photo release consent form which did not specify who information (photos) would be released to or for what purpose. Consequently it did not meet the requirements for an informed consent to release information.
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Plan of Correction
Beginning on August 13, 2012, the photo release forms were removed from the client charts. These release forms were previously part the chart for photos that may have been taken for community events, but because CMH values client privacy, no photos from any client events are shared outside of the facility. To prevent recurrence, if a client participates in a community activity in which they will be identified as a CMH client, they will fill out an individualized release form specific to the incident in question.
To ensure compliance, the clinical director will review all client releases before enabling any client to be photographed. In addition, he will check all charts for compliance on a bi-weekly basis. |