INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on June 28, 2011 and July 8, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Malvern Institute were substantiated. Malvern Institute 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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705.9 (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 a review of the facility's pest control policy and procedure, client interviews, interviews with the medical staff and a discussion with the executive assistant and a physical plant inspection conducted during a complaint investigation on June 28, 2011, the facility failed to be free of rodent and insect infestation. The facility failed to follow the policy and procedures relating to bed bugs, and failed to include procedures to help prevent the infestation of bed bugs.
The findings include:
A complaint investigation was conducted on June 28, 2011. The facility's policy and procedure for pest control was requested and presented for review. The policy presented for review was dated as being issued 7/93 and revised 10/04, 1/06 and 3/11.
This policy states: Malvern Institute will have a contract with a commercial pest control organization to ensure a pest free environment. The procedure is as follows:
"1. The contract will specify that the Pest Control Organization will come to spray at the facility, including outpatient location, on a regular, monthly scheduled basis .
2. Director of Plant Operations will coordinate with the Pest Control Organization to ensure a pest free environment.
3. If staff members notice pests,[sic] shall notify Director of Plant Operations or designee immediately.
4. Director of Plant Operations or designee shall coordinate with Pest Control Organization regarding pests and locations.
5. Director of Plant Operations or designee can schedule more visits other than monthly visits if warranted.
6. "Right to Know" information is obtained through Pest Control Organization and is available to any employee through Director of Plant Operations.
7. In the case of bed bugs, protocol will follow attachment, "How to Move and Leave Bed Bugs Behind." Monthly follow-ups will occur until facility is clear of bed bugs for two months."
The attachment titled "How to Move and Leave Bed Bugs Behind" states: Once bed bugs have been confirmed in the living area of an individual or family, there may be good reason to move them to a different area or apartment while the infested one is treated. However bed bugs may be transferred with personal belongings, causing more trouble in the new living space. Some suggestions for moving to a new location without bringing bed bugs are as follows:
Place all belongings in clear plastic bags that are sealed tightly. Sort items by type (clothes, towels, sheets and blankets) and keep things that are known to be infested away from clean items.
Have each individual shower and change into clean clothing and shoes and bag up the current (possibly infested) clothes for laundering.
Provide vinyl or bed bug proof covered mattresses.
A new policy issued 6/2011 with the subject heading: Bed Bugs, under the procedures stated the following:
"Reporting
1. As soon as a patient suspects the presence of bed bugs they should contact nursing staff. If a staff member learns of a potential bed bug problem, the Facility Manager should be contacted immediately.
2. The Facility Manager will inspect the area suspected and if the site shows the potential of bed bugs he will contact an exterminator as soon as possible. The exterminator will be dispatched to the location to perform a thorough inspection of the room and provide treatment as needed.
Patient Room Changes
2. Any patient in a room that is treated for bed bugs will be required to bag their clothing. The clothing will be laundered and dryed [sic] by a staff member and returned to the patient. Upon doing this the patient should shower and put on clean clothes."
Room #102, a room identified as having evidence of bed bugs had shoes under the bed that had not been bagged. While there was a plastic cover on the box springs, it had a tear in it thus negating the ability to encase any bed bugs. As of 12:00 PM, the room had not yet been treated.
Neither policy addressed the prevention of bringing bed bugs into the facility.
Eight patients/clients were interviewed at random. Eight of those patient/clients reported a current bed bug infestation in one bedroom, #102.
Six of the eight patients/clients in total (#1, 2, 4, 6, 7 and 8) stated they were aware that there had been a bed bug infestation the previous week as well.
One of the eight patients/clients (#4) stated he had been bitten during the previous week's infestation.
Two of the eight patient/clients (#6 and 8) stated they had been bitten the night prior to the complaint investigation. They provided evidence of bites on their arms, finger and back of the neck.
Four staff were also interviewed on June 28, 2011. All four staff interviewed stated they were aware of a current bed bug infestation.
Two of the four staff interviewed (#3 and 4) stated this has been a problem for the last two to three months. Both staff (#3 and 4) stated they don't believe the facility is addressing the problem quickly enough or taking it seriously.
During a discussion with the executive assistant, she acknowledged that there was a current bed bug infestation in bedroom #102. The executive assistant also acknowledged that the previous week client bedrooms #101 and #102 had been found to have bed bugs and were treated. She stated they have been having some issues with bed bugs, but they always act quickly and are doing everything they know to treat the problem and help prevent further problems.
A physical plant inspection was conducted on June 28, 2011 at approximately 12:00 PM. Evidence of bed bugs was found in bedroom #102. There were bed bug dropping marks on the wooden headboard of one of the three client beds in this bedroom. It was noted that the clients residing in this bedroom had reported being bitten overnight to nursing first thing in the morning on June 28, 2011.
This is a repeat citation.
The facility was cited on May 18, 2011 and April 21, 2011 for noncompliance with this standard.
In response to the citation issued on May 18, 2011, the facility's plan of correction submitted on 6/8/2011 and approved on 6/24/2011, stated the following:
"Follow up extermination was complete on June 7 - no evidence of any bed bugs was found. Policy will be updated to prevent re-occurrence. Extermination will occur monthly for the next 6 months to ensure there is no re-occurrence. If a pt reports bed bugs, linens will be dried, clothes will be dried and pt will be moved to a new room. Also, all the wooden bed frames will be replaced by metal frames. The new bed frames will be set up by June 30. Precautionary procedures to be implemented on a daily routing admission are:
1) Patients are being limited to one clothing bag when admitted to facility. 2) Bags will be inspected and if considered questionable, will be washed and dryed [sic] prior to being given to the patient for use in the facility. 3)rooms are cleaned, vacuumed and sanitized every time a patient is assigned to the room. 4) New linens and bedding are dispensed every time a patient is assigned to a room. This process will be monitored by Exec Dir"
Based on an invoice provided by Malvern Institute via fax on July 7, 2011 and reviewed by the Department on July 8, 2011, the facility had not replaced all the wooden bed frames with metal bed frames. The information on the invoice indicates that 8 metal bed frames were purchased.
In response to the citation issued on April 21, 2011 the facility's plan of correction submitted on 4/25/2011 and approved on 5/9/2011, stated the following:
"Policy is updated to reflect pest control which includes actions to take specific to bed-bugs [sic] which is a very detailed plan of action that was provided by the PA DOH. Action to prevent future occurrence includes monthly exterminator checks and treatments. This will be monitored by Exec Dir.
In addition, the wooden bed frames were trhown [sic] out and replaced with metal frames. Exterminator sprayed entire facility and will follow up in 3 weeks. All laundry, sheets and pillows were washed and dried. All patient clothes were dried. There is no evidence of any bed bug activity at this time."
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Plan of Correction
To date, all bedbug infestation has been contained within the rooms in the west wing of the institute, commonly referred to as the 'first floor'. Considerable effort to eradicate the infestation has met with limited success, and has prevented cross-contamination from this area to the main building. Technologies that have been implemented include heat treatment, bedbug sniffing dogs, freezing treatments, 'active guards' (box spring covers that actively kill as well as contain bed bugs), mattress encasements, and 'moats' (captures bed bugs leaving and/or coming into a bed). There have been three separate companies hired to provide treatments and expertise. The first of these three has been retired due to poor response time. The third of these three provides bed bug sniffing dogs. Exterminators in our employ now have better response time and utilize the most advanced methods of detection and elimination. In addition, all wooden bed frames have been removed from rooms where bedbugs have been found or where suspicion exists, new metal bed frames and box springs have been purchased and installed in these rooms (a total to date of 18 beds. Our prior statement about bed replacement was poorly worded. The intention was that all beds in rooms that were treated would be replaced by metal beds). Active guards and moats have also been implemented in these rooms.
The room mentioned in this citation (Room #102) has been treated in this manner; the shoes that were found have been bagged and treated. The in-service training for staff outlined in Part Two, Item (3) has been conducted and was provided by a professional extermination company. Both existing and new staff will be oriented on the following policy.
Following is our updated policy regarding this issue.
Purpose: the purpose of this policy is to specifically address the resolution and prevention of bed bug infestation in the facility. The policy has three parts: Part one addresses the erection of a firewall meant to prevent the introduction of bedbugs into the facility. Part two addresses preventative actions meant to insure early detection and continued absence of bed bugs within the facility. Part three deals with the means to deal with an infestation if one were to occur.
Part One: In order to prevent the introduction of bedbugs into the facility the following policy will take effect as of July 27, 2011:
1. This policy applies to any patient entering the facility or re-entering the facility from leave of absence.
2. Only one item of luggage is permitted for each patient entering the facility. All clothing brought in luggage must be clean clothing only. Patients and visitors may only bring necessary items into the facility. Clothes, blankets, pillows, luggage, bags and other possessions that are not essential during a patient's stay should not be brought into the facility.
3. All clothing brought into the facility will be subjected to hot air at a temperature to exceed 122 Degrees Farenheit for a period of 45 minutes. This includes clothing dropped off for a client at a later date.
4. Items that cannot be subjected to heat treatment will be inspected carefully. Any item found to be contaminated or suspected of contamination will provide cause for all remaining items to be bagged, sealed, and stored.
5. All incoming emptied luggage and non-essential items will be placed within a heavy duty plastic bag, sealed, and kept in an isolated, designated area in the storage building, to be returned to the patient upon discharge.
6. No emptied luggage or stored items will be allowed to enter the building at discharge. Rather, the discharged patient will be given storage bags to enable transport of their clothing and personal items to their vehicle, and reunited with their stored items at that time, and outside of the facility buildings.
7. Upon admission, patients will be received into a changing area, where they will disrobe. The clothing they had been wearing will be placed into a heavy duty plastic bag, sealed, laundered and dried at high heat. Patients will be supplied with clean clothing and accompanied to their room, required to shower, and subsequently be provided with their clean and heat-treated clothing. The clothing they had been wearing in transit to their room, belonging to Malvern Institute, will be placed into a heavy duty plastic bag, sealed, laundered and dried at high heat.
Part Two: In order to enable early detection and prevention, Malvern Institute will follow an integrated pest management approach. The following policy will take effect 7/27/11:
1. All affected beds on the first floor will be equipped with moats, metal bed frames, and encasements. At time of this writing, all beds in all rooms identified as having had bed bugs have had these modifications. All beds on the first floor will be equipped with moats, metal bed frames and encasements by August 30, 2011. Any deviation from or delay of this plan will be communicated to DOH as a request. Any additional rooms identified in the future as having infestation will be similarly modified as part of the extermination process.
2. A pest management service has been contracted to provide monthly thorough inspections of the facility. This will include visual inspection and bed bug sniffing dogs when deemed appropriate by the pest management service. This service will continue until no evidence of infestation has been found for a period of six months.
a. The Facility Manager may schedule additional inspections if warranted.
3. In-service training of staff will be conducted so that staff and patients can recognize early signs of infestation, and are familiar with procedures that must be followed in such a case. The date of training and sign-off sheet must be provided and go in personnel record with regular training.
a. Patients will be trained by facility staff on identification of bed bugs within first week of admission. Current clients will be trained by August 5, 2011.
4. Staff responsible for cleaning rooms and changing bed linens will be trained on the identification of bed bug infestation and directed to perform a visual inspection of bedding and of the moats at each change of linen. This training will be completed by August 5, 2011. Responsible party will be Executive director or designee. Any staff missing due to illness or other will be trained immediately upon returning to work and prior to starting work.
Part Three: In order to provide prompt and thorough treatment in the event of an infestation, the following policy will take effect:
1. Reporting
a. All reports of bed bugs or suspicion of bed bugs will be taken seriously and follow this policy.
b. As soon as a patient suspects the presence of bed bugs they should contact nursing staff. If a staff member learns of a potential bed bug problem the Facility Manager should be contacted immediately.
i. Nursing staff will examine the affected patient for signs of adverse clinical reactions and communicate any findings to the Facility manager.
ii. Nursing staff will document results of the examination in the Patient's file.
c. The Facility manager will inspect the area suspected and if the site shows the evidence of bed bugs he will contact an exterminator as soon as possible. The exterminator will be dispatched to the location to perform a thorough inspection of the room and provide treatment as needed. If the exterminator concludes that signs of bed bugs are present in the room:
i. For an incident involving a single room, that room and any adjacent room (on any side or above or below), bed bug checks will be done two times on night shift (once in early night, once before dawn) until the exterminator designates the room is free of infestation.
ii. If a second room is found to have evidence of bed bugs, that room will be treated the same as (i), above.
iii. If a third room is found to have evidence of bed bugs, the procedure will be that all rooms in the building will be checked as in (i).
iv. A separate bed bug log book will be kept and documentation of all bed bug bites or reports of signs of bedbugs, and actual bedbug sightings along with facility actions will be documented in this log.
d. Any report of a possible bed bug infestation must be investigated and documented.
i. The facility Manager will document when the suspected infestation was reported, the room number, if and where bugs were observed, and any adverse clinical reaction (e.g. bites).
2. Exterminator Findings
a. Only the exterminator can confirm the presence of bed bugs.
b. If the exterminator finds there are no signs of bed bugs present in the inspected area then no further action will be taken. The patient will be asked to continue monitoring their living space and to notify nursing immediately if there are any further concerns.
c. If the exterminator concludes that signs of bed bugs are present in the room the room will be treated by the exterminator and the Facility manager will provide the affected patients with detailed instruction for the removal and laundering of their personal items.
d. If the exterminator concludes that signs of bed bugs are present in the room, adjacent rooms will be examined by the exterminator.
i. Adjacent rooms will be treated if such treatment is found necessary by the exterminator.
e. If the presence of bed bugs is confirmed by the exterminator, it will be reported to the Pa Department of Health, Division of Drug and Alcohol Program Licensing as an 'Unusual Incident' by telephone or fax within 24 hours of the discovery, followed by an Unusual Incident Report Form (Form #HD1062F) within 72 hours of the incident.
i. If the presence of bed bugs is confirmed, the facility will follow the procedure outlined in Licensing Alert 5-97.
ii. Responsible party is Executive Director or designee.
f. Rooms found to be affected will be:
i. Stripped of wooden beds if so equipped, prior to treatment.
1. Wooden bed to be disposed of properly and immediately.
ii. Stripped of box springs if not contained within an encasement, prior to treatment.
1. Mattresses to be disposed of properly and immediately.
iii. Re- equipped with moats, metal bed frames, mattress and encasements after treatment by the exterminator.
3. Patient Room Changes
a. Room changes will not be granted to patients until the exterminator has completed the inspection of the area and appropriate action has been taken. This is crucial so we can prevent the spread of bed bugs from one room to another.
i. In the event the exterminator cannot respond in a timely fashion, the Facility Manager and/or Director of Nursing may grant a room change.
b. Any patient in a room that is treated for bed bugs will be processed in a manner identical to that described in Part One of this Policy.
i. Responsible party is the Facility Manager or designee.
c. The room will then be closed to entry by any individual not involved in the treatment of the room until deemed appropriate by the exterminator.
i. Responsible party is the Facility manager or designee.
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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 upon a supervisory review of incident reports previously filed by the facility, complaints lodged against the facility regarding bedbug infestations, correspondence from the county health department to the facility regarding bedbugs, and documentation from an exterminator to the facility, the facility failed to file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
The findings include:
On July 8, 2011, a review of incident reports filed by the facility from March 1, 2011 through July 8, 2011 with the Department was conducted. That review confirmed that the facility failed to file any incident reports informing the Department of bedbug infestation at the facility during that time period.
On March 22, 2011, a complaint was filed with the Pennsylvania Department of Health regarding a former patient/client at the facility who had been bitten by bed bugs and treated at a hospital.
The facility did not forward an incident report regarding this matter within the required 48 hours following the incident. As of the review occurring on July 8, 2011, the facility had not filed any written incident report regarding the bed bug infestation or patient.
On April 21, 2011, an investigation regarding the above-mentioned complaint was conducted. During that investigation, the executive director confirmed that the facility had a problem with bed bugs and that the county health department became involved as a result of the client reporting to the hospital for treatment of bites and sores on his body.
A letter dated March 9, 2011 from the county health department, revealed that the county received a complaint regarding bed bugs in rooms # 114 and 115. In addition, the letter revealed that the executive director stated that the facility had an exterminator on site on March 6 and 7, 2011 and rooms # 108, 114 and 116 were found to have bed bug activity. The letter indicated that the rooms were treated and that the exterminator was scheduled for a follow-up inspection in approximately three weeks.
As of the review occurring on July 8, 2011, the facility had not filed any written incident report regarding the bed bug infestation noted in the March 9, 2011 letter.
At the time of the licensing inspection conducted May 16-18, 2011, a staff interview with the nurse on duty in the medication station indicated that bed bug bites were reported on May 16, 2011 by a patient/client. The nursing notes and doctors notes for this patient/client were reviewed and it indicated that the patient/client had bed bug bites. Staff interviews with the project director and nursing staff were conducted at 2:50 PM. The staff indicated that the facility did not have a policy and practice in place for clients entering the facility to help prevent the infestation of bed bugs.
As of the review occurring on July 8, 2011, the facility had not filed any written incident report regarding the bed bug infestation and bites.
During a discussion with the executive assistant, she acknowledged that there was a current bed bug infestation in bedroom #102. The executive assistant stated that the previous week client bedrooms #101 and #102 had been found to have bed bugs and were treated.
As of the review occurring on July 8, 2011, the facility had not filed any written incident report regarding the bed bug infestation in rooms # 101 and # 102.
On July 8, 2011, a review of an invoice dated May 17, 2011 for extermination services, identified that the Driscol Lounge and rooms # 2, 3, 4, 8, 9, 10, 99, 101, 103, 112, 113, 114, 115, 116 and 117 were treated for bed bugs.
As of the review occurring on July 8, 2011, the facility had not filed any written incident report regarding the bed bug infestation at the facility.
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Plan of Correction
Hereafter, any incident falling under the umbra of Licensing Alert 5-97 will be responded to within the time frames outlined in Licensing Alert 5-97, using the DOH Unusual Incident Report. Responsible party will be Executive Director or designee. As this applies to bed bugs, this has been added to company policy on Bed Bug issues in Part (3), (2) (e): " If the presence of bed bugs is confirmed by the exterminator, it will be reported to the Pa Department of Health, Division of Drug and Alcohol Program Licensing as an 'Unusual Incident' by telephone or fax within 24 hours of the discovery, followed by an Unusual Incident Report Form (Form #HD1062F) within 72 hours of the incident. If the presence of bed bugs is confirmed, the facility will follow the procedure outlined in Licensing Alert 5-97."
This portion of general policy shall be put into effect as of 7/27/11 |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this complaint investigation that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On June 28, 2011, the facility was again found to be out of compliance with the following standards:
1. 705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
This area of noncompliance was also identified during the April 22, 2011 complaint investigation (plan of correction submitted on 4/25/2011 and approved on 5/9/2011) and the May 18, 2011 licensure inspection (plan of correction submitted on 6/8/2011 and approved on 6/24/2011).
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Plan of Correction
Plan of Correction:
Malvern Institute has been expending considerable effort, time and resources to bring this issue under control and prevent any further or future spread in the facility. We intend to adhere to plans of correction, correct items in accordance to the plans identified, bring the situation under control, and maintain vigilance and conformance to our policy on the matter. If our plans change, or an anticipated date cannot be met, we will apply to DOH in writing to request an extension. Responsibility will rest with the Chief Executive Officer. In order to monitor compliance to stated plans, Executive director will meet weekly with department heads to evaluate status. This action will be implemented by immediately.
The corrective action date for this item is 8/30/2011. What follows here is the policy that outlines the 'stated plans' mentioned above. Dates mentioned in the verbiage below may differ, but refer to other issues and are only stated here for reference purposes.
Purpose: the purpose of this policy is to specifically address the resolution and prevention of bed bug infestation in the facility. The policy has three parts: Part one addresses the erection of a firewall meant to prevent the introduction of bedbugs into the facility. Part two addresses preventative actions meant to insure early detection and continued absence of bed bugs within the facility. Part three deals with the means to deal with an infestation if one were to occur.
Part One: In order to prevent the introduction of bedbugs into the facility the following policy will take effect as of July 27, 2011:
1. This policy applies to any patient entering the facility or re-entering the facility from leave of absence.
2. Only one item of luggage is permitted for each patient entering the facility. All clothing brought in luggage must be clean clothing only. Patients and visitors may only bring necessary items into the facility. Clothes, blankets, pillows, luggage, bags and other possessions that are not essential during a patient's stay should not be brought into the facility.
3. All clothing brought into the facility will be subjected to hot air at a temperature to exceed 122 Degrees Farenheit for a period of 45 minutes. This includes clothing dropped off for a client at a later date.
4. Items that cannot be subjected to heat treatment will be inspected carefully. Any item found to be contaminated or suspected of contamination will provide cause for all remaining items to be bagged, sealed, and stored.
5. All incoming emptied luggage and non-essential items will be placed within a heavy duty plastic bag, sealed, and kept in an isolated, designated area in the storage building, to be returned to the patient upon discharge.
6. No emptied luggage or stored items will be allowed to enter the building at discharge. Rather, the discharged patient will be given storage bags to enable transport of their clothing and personal items to their vehicle, and reunited with their stored items at that time, and outside of the facility buildings.
7. Upon admission, patients will be received into a changing area, where they will disrobe. The clothing they had been wearing will be placed into a heavy duty plastic bag, sealed, laundered and dried at high heat. Patients will be supplied with clean clothing and accompanied to their room, required to shower, and subsequently be provided with their clean and heat-treated clothing. The clothing they had been wearing in transit to their room, belonging to Malvern Institute, will be placed into a heavy duty plastic bag, sealed, laundered and dried at high heat.
Part Two: In order to enable early detection and prevention, Malvern Institute will follow an integrated pest management approach. The following policy will take effect 7/27/11:
1. All affected beds on the first floor will be equipped with moats, metal bed frames, and encasements. At time of this writing, all beds in all rooms identified as having had bed bugs have had these modifications. All beds on the first floor will be equipped with moats, metal bed frames and encasements by August 30, 2011. Any deviation from or delay of this plan will be communicated to DOH as a request. Any additional rooms identified in the future as having infestation will be similarly modified as part of the extermination process.
2. A pest management service has been contracted to provide monthly thorough inspections of the facility. This will include visual inspection and bed bug sniffing dogs when deemed appropriate by the pest management service. This service will continue until no evidence of infestation has been found for a period of six months.
a. The Facility Manager may schedule additional inspections if warranted.
3. In-service training of staff will be conducted so that staff and patients can recognize early signs of infestation, and are familiar with procedures that must be followed in such a case. The date of training and sign-off sheet must be provided and go in personnel record with regular training.
a. Patients will be trained by facility staff on identification of bed bugs within first week of admission. Current clients will be trained by August 5, 2011.
4. Staff responsible for cleaning rooms and changing bed linens will be trained on the identification of bed bug infestation and directed to perform a visual inspection of bedding and of the moats at each change of linen. This training will be completed by August 5, 2011. Responsible party will be Executive director or designee. Any staff missing due to illness or other will be trained immediately upon returning to work and prior to starting work.
Part Three: In order to provide prompt and thorough treatment in the event of an infestation, the following policy will take effect:
1. Reporting
a. All reports of bed bugs or suspicion of bed bugs will be taken seriously and follow this policy.
b. As soon as a patient suspects the presence of bed bugs they should contact nursing staff. If a staff member learns of a potential bed bug problem the Facility Manager should be contacted immediately.
i. Nursing staff will examine the affected patient for signs of adverse clinical reactions and communicate any findings to the Facility manager.
ii. Nursing staff will document results of the examination in the Patient's file.
c. The Facility manager will inspect the area suspected and if the site shows the evidence of bed bugs he will contact an exterminator as soon as possible. The exterminator will be dispatched to the location to perform a thorough inspection of the room and provide treatment as needed. If the exterminator concludes that signs of bed bugs are present in the room:
i. For an incident involving a single room, that room and any adjacent room (on any side or above or below), bed bug checks will be done two times on night shift (once in early night, once before dawn) until the exterminator designates the room is free of infestation.
ii. If a second room is found to have evidence of bed bugs, that room will be treated the same as (i), above.
iii. If a third room is found to have evidence of bed bugs, the procedure will be that all rooms in the building will be checked as in (i).
iv. A separate bed bug log book will be kept and documentation of all bed bug bites or reports of signs of bedbugs, and actual bedbug sightings along with facility actions will be documented in this log.
d. Any report of a possible bed bug infestation must be investigated and documented.
i. The facility Manager will document when the suspected infestation was reported, the room number, if and where bugs were observed, and any adverse clinical reaction (e.g. bites).
2. Exterminator Findings
a. Only the exterminator can confirm the presence of bed bugs.
b. If the exterminator finds there are no signs of bed bugs present in the inspected area then no further action will be taken. The patient will be asked to continue monitoring their living space and to notify nursing immediately if there are any further concerns.
c. If the exterminator concludes that signs of bed bugs are present in the room the room will be treated by the exterminator and the Facility manager will provide the affected patients with detailed instruction for the removal and laundering of their personal items.
d. If the exterminator concludes that signs of bed bugs are present in the room, adjacent rooms will be examined by the exterminator.
i. Adjacent rooms will be treated if such treatment is found necessary by the exterminator.
e. If the presence of bed bugs is confirmed by the exterminator, it will be reported to the Pa Department of Health, Division of Drug and Alcohol Program Licensing as an 'Unusual Incident' by telephone or fax within 24 hours of the discovery, followed by an Unusual Incident Report Form (Form #HD1062F) within 72 hours of the incident.
i. If the presence of bed bugs is confirmed, the facility will follow the procedure outlined in Licensing Alert 5-97.
ii. Responsible party is Executive Director or designee.
f. Rooms found to be affected will be:
i. Stripped of wooden beds if so equipped, prior to treatment.
1. Wooden bed to be disposed of properly and immediately.
ii. Stripped of box springs if not contained within an encasement, prior to treatment.
1. Mattresses to be disposed of properly and immediately.
iii. Re- equipped with moats, metal bed frames, mattress and encasements after treatment by the exterminator.
3. Patient Room Changes
a. Room changes will not be granted to patients until the exterminator has completed the inspection of the area and appropriate action has been taken. This is crucial so we can prevent the spread of bed bugs from one room to another.
i. In the event the exterminator cannot respond in a timely fashion, the Facility Manager and/or Director of Nursing may grant a room change.
b. Any patient in a room that is treated for bed bugs will be processed in a manner identical to that described in Part One of this Policy.
i. Responsible party is the Facility Manager or designee.
c. The room will then be closed to entry by any individual not involved in the treatment of the room until deemed appropriate by the exterminator.
i. Responsible party is the Facility manager or designee.
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709.17(a)(10) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
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Observations
Based on client interviews, interviews with the medical staff and a discussion with the executive assistant and a physical plant inspection conducted during a complaint investigation on June 28, 2011, the facility, by nature of its physical condition, is endangering the health and safety of the public.
The findings include:
A complaint investigation was conducted on June 28, 2011. Eight patients/clients were interviewed at random. Eight of those clients reported a current bed bug infestation in bedroom #102.
Six of the eight patients/clients in total (#1, 2, 4, 6, 7 and 8) stated they were aware that there had been a bed bug infestation the previous week as well. One of the eight patients/clients (#4) stated he had been bitten during the previous week's infestation.
Two patient/clients (#6 and 8) stated they had been bitten the night prior to the complaint investigation. They provided evidence of bites on their arms, finger and back of the neck.
Three of the eight patients/clients interviewed (#4, 6 and 8) stated they are unable to focus on their recovery because they are too worried about the bed bug issues at this facility.
Four staff were also interviewed on June 28, 2011. All four staff interviewed stated they were aware of a current bed bug infestation.
Two of the four staff interviewed (#3 and 4) stated this has been a problem for the last two to three months. Both staff (#3 and 4) stated they don't believe the facility is addressing the problem quickly enough or taking it seriously.
Staff #4 stated that while performing a bed check, they observed bed bugs crawling all over a patient in detox. That staff person also stated that several patients/clients have gone AWOL and left treatment at this facility because of the bed bug problem.
During a discussion with the executive assistant, she admitted that there was a current bed bug infestation in bedroom #102. She stated they were in the process of following the facility's protocol. She stated the clients had been vacated from the room until the exterminator could arrive and treat the room via a carbon dioxide freeze. She stated the clients' clothing had been bagged and would be taken off-site to be laundered. She also stated that all three wooden beds would be replaced with metal beds and the facility is going to gradually put metal beds in all of the bedrooms. The executive assistant also admitted that the previous week client bedrooms #101 and #102 had been found to have bed bugs and were treated. She stated they have been having some issues with bed bugs, but they always act quickly and are doing everything they know to treat the problem and help prevent further problems.
A physical plant inspection was conducted on June 28, 2011 at approximately 12:00 PM. Evidence of bed bugs was found in bedroom #102. There were bed bug dropping marks on the wooden headboard of one of the three client beds in this bedroom. It was noted that the clients residing in this bedroom had reported being bitten overnight to nursing first thing in the morning on June 28, 2011.
As of 12:00 PM, the room had not yet been treated. The bed linens had been stripped off the beds and the clients' clothing had been tied in plastic bags, but the door to the bedroom was left open and another random client was standing in the doorway looking in at the time of the inspection. The room had not been sealed off, nor had it been treated yet by an exterminator.
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Plan of Correction
The issues relating to the room #102 involved in the complaint investigation on June 28, 2011 have been resolved according to policy. Policy has been reviewed and a newer policy created addressing prevention, maintenance, oversight, and decontamination. As of this writing, no evidence of bedbugs is found. This action will be implemented by immediately. Responsible party is the Chief Executive Officer.
The corrective action date for this item is 8/30/2011.
To date, all bedbug infestation has been contained within the rooms in the west wing of the institute, commonly referred to as the 'first floor'. Considerable effort to eradicate the infestation has met with limited success, and has prevented cross-contamination from this area to the main building. Technologies that have been implemented include heat treatment, bedbug sniffing dogs, freezing treatments, 'active guards' (box spring covers that actively kill as well as contain bed bugs), mattress encasements, and 'moats' (captures bed bugs leaving and/or coming into a bed). There have been three separate companies hired to provide treatments and expertise. The first of these three has been retired due to poor response time. The third of these three provides bed bug sniffing dogs. Exterminators in our employ now have better response time and utilize the most advanced methods of detection and elimination. In addition, all wooden bed frames have been removed from rooms where bedbugs have been found or where suspicion exists, new metal bed frames and box springs have been purchased and installed in these rooms (a total to date of 18 beds. Our prior statement about bed replacement was poorly worded. The intention was that all beds in rooms that were treated would be replaced by metal beds). Active guards and moats have also been implemented in these rooms.
The room mentioned in this citation (Room #102) has been treated in this manner; the shoes that were found have been bagged and treated. The in-service training for staff outlined in Part Two, Item (3) has been conducted and was provided by a professional extermination company. Both existing and new staff will be oriented on the following policy.
Following is our updated policy regarding this issue.
Purpose: the purpose of this policy is to specifically address the resolution and prevention of bed bug infestation in the facility. The policy has three parts: Part one addresses the erection of a firewall meant to prevent the introduction of bedbugs into the facility. Part two addresses preventative actions meant to insure early detection and continued absence of bed bugs within the facility. Part three deals with the means to deal with an infestation if one were to occur.
Part One: In order to prevent the introduction of bedbugs into the facility the following policy will take effect as of July 27, 2011:
1. This policy applies to any patient entering the facility or re-entering the facility from leave of absence.
2. Only one item of luggage is permitted for each patient entering the facility. All clothing brought in luggage must be clean clothing only. Patients and visitors may only bring necessary items into the facility. Clothes, blankets, pillows, luggage, bags and other possessions that are not essential during a patient's stay should not be brought into the facility.
3. All clothing brought into the facility will be subjected to hot air at a temperature to exceed 122 Degrees Farenheit for a period of 45 minutes. This includes clothing dropped off for a client at a later date.
4. Items that cannot be subjected to heat treatment will be inspected carefully. Any item found to be contaminated or suspected of contamination will provide cause for all remaining items to be bagged, sealed, and stored.
5. All incoming emptied luggage and non-essential items will be placed within a heavy duty plastic bag, sealed, and kept in an isolated, designated area in the storage building, to be returned to the patient upon discharge.
6. No emptied luggage or stored items will be allowed to enter the building at discharge. Rather, the discharged patient will be given storage bags to enable transport of their clothing and personal items to their vehicle, and reunited with their stored items at that time, and outside of the facility buildings.
7. Upon admission, patients will be received into a changing area, where they will disrobe. The clothing they had been wearing will be placed into a heavy duty plastic bag, sealed, laundered and dried at high heat. Patients will be supplied with clean clothing and accompanied to their room, required to shower, and subsequently be provided with their clean and heat-treated clothing. The clothing they had been wearing in transit to their room, belonging to Malvern Institute, will be placed into a heavy duty plastic bag, sealed, laundered and dried at high heat.
Part Two: In order to enable early detection and prevention, Malvern Institute will follow an integrated pest management approach. The following policy will take effect 7/27/11:
1. All affected beds on the first floor will be equipped with moats, metal bed frames, and encasements. At time of this writing, all beds in all rooms identified as having had bed bugs have had these modifications. All beds on the first floor will be equipped with moats, metal bed frames and encasements by August 30, 2011. Any deviation from or delay of this plan will be communicated to DOH as a request. Any additional rooms identified in the future as having infestation will be similarly modified as part of the extermination process.
2. A pest management service has been contracted to provide monthly thorough inspections of the facility. This will include visual inspection and bed bug sniffing dogs when deemed appropriate by the pest management service. This service will continue until no evidence of infestation has been found for a period of six months.
a. The Facility Manager may schedule additional inspections if warranted.
3. In-service training of staff will be conducted so that staff and patients can recognize early signs of infestation, and are familiar with procedures that must be followed in such a case. The date of training and sign-off sheet must be provided and go in personnel record with regular training.
a. Patients will be trained by facility staff on identification of bed bugs within first week of admission. Current clients will be trained by August 5, 2011.
4. Staff responsible for cleaning rooms and changing bed linens will be trained on the identification of bed bug infestation and directed to perform a visual inspection of bedding and of the moats at each change of linen. This training will be completed by August 5, 2011. Responsible party will be Executive director or designee. Any staff missing due to illness or other will be trained immediately upon returning to work and prior to starting work.
Part Three: In order to provide prompt and thorough treatment in the event of an infestation, the following policy will take effect:
1. Reporting
a. All reports of bed bugs or suspicion of bed bugs will be taken seriously and follow this policy.
b. As soon as a patient suspects the presence of bed bugs they should contact nursing staff. If a staff member learns of a potential bed bug problem the Facility Manager should be contacted immediately.
i. Nursing staff will examine the affected patient for signs of adverse clinical reactions and communicate any findings to the Facility manager.
ii. Nursing staff will document results of the examination in the Patient's file.
c. The Facility manager will inspect the area suspected and if the site shows the evidence of bed bugs he will contact an exterminator as soon as possible. The exterminator will be dispatched to the location to perform a thorough inspection of the room and provide treatment as needed. If the exterminator concludes that signs of bed bugs are present in the room:
i. For an incident involving a single room, that room and any adjacent room (on any side or above or below), bed bug checks will be done two times on night shift (once in early night, once before dawn) until the exterminator designates the room is free of infestation.
ii. If a second room is found to have evidence of bed bugs, that room will be treated the same as (i), above.
iii. If a third room is found to have evidence of bed bugs, the procedure will be that all rooms in the building will be checked as in (i).
iv. A separate bed bug log book will be kept and documentation of all bed bug bites or reports of signs of bedbugs, and actual bedbug sightings along with facility actions will be documented in this log.
d. Any report of a possible bed bug infestation must be investigated and documented.
i. The facility Manager will document when the suspected infestation was reported, the room number, if and where bugs were observed, and any adverse clinical reaction (e.g. bites).
2. Exterminator Findings
a. Only the exterminator can confirm the presence of bed bugs.
b. If the exterminator finds there are no signs of bed bugs present in the inspected area then no further action will be taken. The patient will be asked to continue monitoring their living space and to notify nursing immediately if there are any further concerns.
c. If the exterminator concludes that signs of bed bugs are present in the room the room will be treated by the exterminator and the Facility manager will provide the affected patients with detailed instruction for the removal and laundering of their personal items.
d. If the exterminator concludes that signs of bed bugs are present in the room, adjacent rooms will be examined by the exterminator.
i. Adjacent rooms will be treated if such treatment is found necessary by the exterminator.
e. If the presence of bed bugs is confirmed by the exterminator, it will be reported to the Pa Department of Health, Division of Drug and Alcohol Program Licensing as an 'Unusual Incident' by telephone or fax within 24 hours of the discovery, followed by an Unusual Incident Report Form (Form #HD1062F) within 72 hours of the incident.
i. If the presence of bed bugs is confirmed, the facility will follow the procedure outlined in Licensing Alert 5-97.
ii. Responsible party is Executive Director or designee.
f. Rooms found to be affected will be:
i. Stripped of wooden beds if so equipped, prior to treatment.
1. Wooden bed to be disposed of properly and immediately.
ii. Stripped of box springs if not contained within an encasement, prior to treatment.
1. Mattresses to be disposed of properly and immediately.
iii. Re- equipped with moats, metal bed frames, mattress and encasements after treatment by the exterminator.
3. Patient Room Changes
a. Room changes will not be granted to patients until the exterminator has completed the inspection of the area and appropriate action has been taken. This is crucial so we can prevent the spread of bed bugs from one room to another.
i. In the event the exterminator cannot respond in a timely fashion, the Facility Manager and/or Director of Nursing may grant a room change.
b. Any patient in a room that is treated for bed bugs will be processed in a manner identical to that described in Part One of this Policy.
i. Responsible party is the Facility Manager or designee.
c. The room will then be closed to entry by any individual not involved in the treatment of the room until deemed appropriate by the exterminator.
i. Responsible party is the Facility manager or designee.
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