Observations
Based on observation on October 5, 2011, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients and employees and visitors.
The findings include:
A physical plant inspection was conducted on October 5, 2011. During the inspection, it was observed at approximately 9:51 A.M., that the door for residential bedroom # 3 on the second floor had areas that had scratches, stains, and peeling paint. Also, the door for residential bedroom # 3 on the second floor had areas that needed to be repainted.
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Plan of Correction
The door to bedroom #3 was sanded and repainted on 10/8/11.
Additionally all walls and doors on the 2nd and 3rd floor will be repainted over then ext 2 months.
Quarterly the Maintenance Manager will conduct physical plan inspctions of the entire facility to ensure all painted surfaces are properly maintained. |
Observations
Based on observations on October 5, 2011, photos taken at the facility, and a review of the facility's pest control policies and procedures, the facility failed to follow their policy and procedures relating to bed bugs.
The findings include:
The facility's policy titled: "Bed Bug Policy," states:
"In order to prevent the introduction of bedbugs into the facility the following policy will take effect:
1. This policy applies to any patient entering the facility or re-entering the facility 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 drop-offs to patients will comply with this policy.
4. 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.
5. Items that can not be subject to heat treatment will e 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.
6. All incoming emptied luggage and non-essential items will be placed within a heave duty plastic bag, sealed, signed by patient, and kept in an isolated, designated area in the storage building, to be returned to the patient upon discharge.
7. 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.
8. 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."
A physical plant inspection was conducted on October 5, 2011. On October 5, 2011, 4 detox bedrooms and 3 residential bedrooms were inspected for evidence of bed bugs and to determine if the facility was following their policy and procedures relating to bed bugs. The facility failed to follow their policy and procedures relating to bed bugs at the following locations and times:
1. At approximately 8:49 A.M., detox bedroom # 102 had non-essential clothing stored in an unsealed plastic bag on the floor instead of being stored in a sealed bag in the designated storage building.
2. At approximately 9:15 A.M., detox bedroom # 112 had non-essential clothing stored in an unsealed plastic bag on the floor instead of being stored in a sealed bag in the designated storage building.
3. At approximately 9:23 A.M., detox bedroom # 114 had non-essential clothing stored in an unsealed plastic bag on one of the beds instead of being stored in a sealed bag in the designated storage building.
4. At approximately 9:51 A.M., residential bedroom # 3 had non-essential clothing stored in an unsealed plastic bag on the floor instead of being stored in a sealed bag in the designated storage building.
5. At approximately 9:59 A.M., residential bedroom # 5 had non-essential clothing stored in an unsealed plastic bag on one of the beds, in an unsealed plastic bag on the floor, and in a suitcase underneath one of the beds instead of being stored in a sealed bag in the designated storage building.
This is a repeat citation. The facility was cited on July 8, 2011; May 18, 2011; and April 21, 2011 for noncompliance with this standard.
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Plan of Correction
On October 6, 2011 all rooms were inspected and all luggage and plastic bags found in patient bedrooms were removed.
On November 4, 2011 the Quality/Risk/Regulatory Compliance Manager conducted a follow-up inspection of all bedrooms at the facility to ensure no luggage or plastic bags were in any patient bedrooms.
Starting December 5, 2011 staff began conducting daily room inspections of all patient bedrooms. Staff are inspecting the bedrooms for the following items:
- Beds are made
- Clothes are folded and put away (no plastic bags present in rooms)
- No luggage/duffle bags in room
- Room looks neat and organized
Each day following room inspection the patients are informed of the inspection results. Those patients whose rooms did not pass inspection are being asked to return to their rooms to clean up their rooms in order to pass room inspection.
Starting December 9, 2011 the Quality/Risk/Regulatory Compliance Manger will conduct weekly random room inspections to ensure the daily room inspection process is being followed. |