INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System 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 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a review of grounds, the facility failed to maintain all structures free of danger to health and safety.
The findings include:
An inspection of the facility grounds on July 21, 2011, upon inspection of the porch of the facility Administration Office, the carpet was pulled away from the porch, providing a hazard. Additionally, the top step leading into the porch area of another building had a step that was weak and loose.
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Plan of Correction
705.2. Building exterior and grounds. The residential facility shall: (1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
CFBHS will maintain building exteriors and grounds to be free of risk and/or danger and to provide for safety of staff and patients.
Cove maintenance staff replaced and repaired the carpet on the front porch of the Administration building on the same day that the problem was identified: 7/21/11.
Maintenance staff also repaired the top step of Knepp House on 7/21/11. Steve Bryan, Facility Director, assured that both repairs were completed.
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on review of administrative documentation provided during the inspection and staff interviews, the facility failed to submit documentation of unusual incidents to the Department as required.
The findings include:
A review of documentation provided to the Department upon a physical plant investigation on July 22, 2011, a professional extermination report from Ehrlich pest control, confirmed the facility had an infestation of bedbugs in two of the in-patient housing. The facility failed to inform the Department of any unusual incidents that could impede the treatment of the patients.
Ehrlich Pest Control provided service to this facility on 06/30/2011 and 07/11/2011. Live bedbugs were detected in Deibert Hall. Complaints of bedbugs were received from Knepp Hall residents.
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Plan of Correction
Unusual incidents:
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following: (1) Complaints of patient abuse (physical, verbal, sexual and emotional). (2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances. (3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence. (4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern. (5) Drug related hospitalization of a patient.
Unusual incidents that the Facility Director may feel causes community concern will be reported to the State.
An unusual report
will be completed by the Assistant. Administrator, Anita Stoudnour, and sent to the State on this date: 8/15/11.
Erlich's Pest Control provided eradication service on 6/9/11, 6/10/11, 6/30/11, and 7/11/11.
Protocol for the detection and prevention of bed bugs was written. Staff was trained on 6/29/11.
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