INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on December 28-29, 2020 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Salvation Army Harbor Light Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection on December 28, 2020, the facility failed to keep the building in good repair.
Room # 202 - had 8 lightbulbs missing from ceiling lights
Room #239 - had a ceiling light burnt out
Room # 241 - had one ceiling light burnt and one ceiling light missing a cover
The findings were reviewed with facility staff.
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Plan of Correction
Light bulbs for room 202, 239, and 241 have been replaced and extra bulbs have been ordered from provider.
Plastic ceiling light cover for room 241 has been ordered but is custom-made. Light in that room has been replaced with a bulb containing a bulb shield for safety.
Monthly facility checks with checklist including lights and light fixtures will be completed by the Lead Recovery Support Specialist on the first of every month. Recovery Support Specialist complete building checks on each shift (4 times per day) and during the overnight shift. When deficiencies are noted during these checks, the Director will immediately be notified of missing or burned out bulbs/covers and will be replaced by the Lead RSS immediately.
When deficiencies/wear/tear are noted on the monthly checks, the Lead RSS will immediately inform the Program Director who will order replacement bulbs or authorize the immediate purchase of bulbs and light covers.
This will be implemented immediately beginning 1/5/2021. |
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection on December 28, 2020, the facility failed to maintain counseling area furnishings in good repair.
Office # 121A - office chair was torn and had masking tape over it.
The findings were discussed with facility staff.
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Plan of Correction
Office 121A is not used as a counseling space and only houses a bed bug baker for processing new clothing of intakes. There are no clients in this room and no services take place in this space. The chair in question has been thrown out.
All therapy sessions take place in the therapist offices or in the designated treatment room 121B which contains a new leather sofa, end table, and new leather chair.
The Lead Recovery Support Specialist has been put in charge of purging old and damaged furniture throughout the building and cleaning up areas where clutter appear. This check is done on a monthly basis (or as needed as issues arise) and recorded on an inventory form. Any items which are to be thrown away are then reviewed wiht the bookkeeper as items are not able to be thrown out without checking with Divisional Headquarters first and audited as waste. Once this is complete and the Book Keeper gives the Lead RSS the ok, the items will then either be disposed of in the dumpster, or a junk removal company will be contacted.
The Director has also met with the clinical team and informed them that at no time are sessions to be conducted for any reason in any rooms other than identified treatment rooms. All staff have been notified by the Director via email that the room in question is to be used as a room for the bed bug tent baker only and at no time is it to be used for any other reason than to drop off clothing or other items to be baked.
This has been implemented immediately beginning 1/5/2021. |
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 on December 28, 2020, the facility failed to maintain mattresses and box springs in good repair.
Findings:
Room # 243 - the mattress and box spring are worn and stained.
Room # 202 - the mattress was dipping in the middle.
The findings were discussed with facility staff.
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Plan of Correction
Both mattresses and box springs in question have been replaced with new mattresses and the bed frame in 202 has been replaced with a new one.
When a resident leaves, there is a checkout form which is completed by the staff on shift. This form indicates the condition of the mattress, frame, box spring, and pillows. When any of these items are determined to be in poor repair, the Lead Recovery Support Specialist will immediately remove the worn items, report them to the book keeper who will complete an audit on the items for fiscal reasons, then instruct the Lead RSS to dispose of them.
New pillows have been ordered by the Director of the program. The Director is responsible for maintaining a surplus of mattresses in good condition to replace old and worn mattresses. This has been amended to be included as an expense in the 2021 budget submitted to Divisional Headquarters of the Salvation Army to insure funds are available for replacement.
The Director will meet with the Lead RSS weekly to review building maintenance issues and immediately replace or remove items which are not in good repair. |
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
Based on a physical plant inspection on December 28, 2020, the facility failed to maintain the bathrooms in a functional manner at all times.
The smaller second floor bathroom was missing a mirror light cover and had a loose shower flange.
The larger second floor bathroom had loose and broken shower flanges
The findings were discussed with facility staff.
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Plan of Correction
Plumber has been called replaced shower flanges 1/12/2021.
Light cover for second floor bathroom has been ordered and will be installed when it arrives.
The Lead Recovery Support Specialist will do a monthly check of the building for maintenance/facilities issues and immediately notify the Program Director of any deficient items, including but not limited to shower facilities.
The daily shift checks the other Recovery Support Specialists complete has been amended to include a daily check of the shower facilities including but not limited to any of the hardware.
When broken or disrepair items are identified in any of these checks, the Director will be notified and immediately contact a plumber or the appropriate maintenance personnel to repair it as quickly as possible.
The Director is responsible for making sure the daily and monthly building maintenance and facilities checks are completed and done thoroughly.
This corrective action plan has been implemented effective 1/5/2021. |
709.34 (c) (5) 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:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a review of the unusual incident reports on December 28-29,2020, the facility failed to document an outbreak of a contagious disease requiring a report to the Department within 3 business days.
Findings: A staff member tested positive for COVID-19 on December 8, 2020.
The findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
UIR's were sent on the day in question but the director did not have access to the ERS and was unable to login, so the UIR was sent to DDAP and to Allegheny County reporting the incident via email attachment.
Copies of the sent emails were forwarded to DDAP investigators on 12/29/2020 to show they were completed and sent accordingly and within the time frame necessary. Email also indicated difficulty logging in to electronic reporting system at the time the emails were sent.
The Director is responsible for for insuring all UIRs are submitted within the appropriate time frame and catalogued on site. All printed UIRs will be kept in a binder in the Director's office.
This POC has been implemented as of this report as this was practice since 5/4/2020 when new Director was hired at Harbor Light Center. All issues related to login have been resolved after Director contacted DDAP. |