INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 27-28, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Place 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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705.6 (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
A physical plant inspection was conducted on July 28, 2016, at approximately 1:00 pm. It was noted that hot water temperatures in resident bathrooms exceeded 120 degrees Fahrenheit. The findings were noted for bathrooms in the following resident bedrooms:
Bathroom in room # 9 registered a hot water temperature of approximately 136 degrees Fahrenheit.
Bathrooms in room #'s 4 and 5 registered a hot water temperature of approximately 137-138 degrees Fahrenheit.
Bathrooms in room #'s 6 and 8 registered a hot water temperature of approximately 140 degrees Fahrenheit.
Bathroom in room # 15 registered a hot water temperature of approximately 126 degrees Fahrenheit.
Bathrooms in room #'s 6, 14, 18, and 23 registered a hot water temperature of approximately 125 degrees Fahrenheit.
Bathrooms in room #'s 19, 20, 21, and 24 registered a hot water temperature of approximately 124 degrees Fahrenheit.
Bathroom for suite # 229 (rooms A & B) registered a hot water temperature of approximately 131 degrees Fahrenheit.
Bathroom in room # 217 registered a hot water temperature of approximately 134 degrees Fahrenheit.
Bathroom in room # 201 registered a hot water temperature of approximately 130 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation for the facility, as the facility was cited for non-compliance of this standard during the previous licensing renewal inspection on June 4, 2015.
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Plan of Correction
The hot water heaters were turned down on 7/28/16. Maintenance Supervisor tested the bathrooms #9, 4, 5, 6, 8, 15, 14, 18, 23, 19, 20, 21, 24, 229, 217, and 201 on 7/29/16. The temperatures were well below the 120 degree Fahrenheit mark. Maintenance Supervisor adjusted the water heaters to the setting between hot and warm on 7/29/16 to get the water temps to be more consistently between 115-120 degrees Fahrenheit. All of these rooms were retested on 8/2/16 by the Maintenance Supervisor and they are between 114-120 degrees Fahrenheit. Maintenance Supervisor will monitor the temperatures on the water heaters on a monthly basis and document in a log what the water temperatures are reading and adjust accordingly. |
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
A physical plant inspection was conducted on July 28, 2016.
Exhaust fans in the bathrooms for bedroom #'s 5, 9, and 10 were observed to be without covers. Additionally, a build-up of dust and lint was observed on the same exhaust fans.
Black mold was observed in the bathroom showers for bedroom #'s 5, 8, 10, 14, and 201. Additionally, a build-up of black mold and grime was observed on installed handicap seating in the bathroom showers of bedroom suite 229 (rooms A & B) and bedroom # 217.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Covers were replaced in the bedroom bathrooms fro room #'s 5,9,and 10, as well as the lint and dust buildup removed on 7/29/16. This was completed by the Facility Maintenance Supervisor. Facility Maintenance Supervisor and Facility Director will inspect all rooms on a monthly basis to make sure these fans are cleaned and have the appropriate covers.
The bathroom showers in bedroom #'s 5, 8, 10, and 201 were cleaned/scrubbed thoroughly on 7/30/16, and were inspected on 7/30/16 for any issues. The Facility Director and Maintenance Supervisor will inspect the bathrooms on a monthly basis to ensure no mold in showers.
The build-up of grime and mold that was located on the handicap seats in showers 229 and 217 were removed from the walls on 7/29/16, so that there was better access to the installation areas. The seats will be cleaned, and if not sufficient will be replaced by Maintenance Supervisor. The showers were cleaned on 7/30/16, and were inspected by Maintenance Supervisor and Facility Director. Maintenance Supervisor and Facility Director will inspect showers and seats on a monthly basis.
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709.28 (c) 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.
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Observations
Fourteen client records were reviewed on July 27-28, 2016. The facility failed to obtain an informed and voluntary consent where consent was applicable in client record # 14.
Client # 14 was admitted into treatment on 4/11/16 and was discharged on 5/20/16. The client's record documented that the facility sent a fax to a county public defender's office on 4/12/16, with a letter confirming the client's admission into treatment. A consent to release information to the public defender's office was not documented in the client's record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility clinical director will retrain all clinical staff on the appropriate completion and utilization of informed and voluntary client consent to release information forms at the weekly clinical staff meeting on 8/11/16 to ensure their understanding.
Facility clinical director will monitor weekly during regular client chart reviews beginning on 8/15/16 to ensure ongoing compliance.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Fourteen client records were reviewed on July 27-28, 2016. A review of client record # 6 found that the facility failed to report an event at the facility that required the presence of ambulance personnel.
Client # 6 was admitted into treatment on 3/8/16 and was discharged on 3/27/16. A nurse progress note documented in the client's record, dated 3/28/16, indicated that an ambulance transported the client to the emergency department on 3/27/16, due to a medical event. The record documented that the facility sent an incident report to the treatment funding source on 3/28/16, indicating that the client was transported to the emergency department by ambulance after 911 was called. The facility confirmed that the incident was not reported to the Department.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will retrain all facility staff on the appropriate completion of Department unusual incident report forms at the 8/17/16 Staff Meeting to ensure their understanding. The expectation is that an Unusual Incident report needs to be completed for any incident that requires the presence of police, fire, or ambulance personnel. Clinical staff will be responsible for the completion of this incident report if it is for their assigned client. Clinical staff will provide the incident report to Facility Director who will submit within 3 business days to DDAP. If it is a facility event, the Facility Director will complete the incident report and submit within the 3 business days to DDAP. Facility director will monitor ongoing compliance on a weekly basis beginning 8/17/16. Facility Director will also keep copies of the incident reports in a binder for easy access. |