INITIAL COMMENTS
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This report is a result of an unannounced follow-up inspection of incident reports received by the Department. The inspection was conducted on March 13, 2012 by staff from the Division of Drug and Alcohol Program Licensure Based on the findings of the on-site inspection, Pyramid Healthcare, Inc. 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 (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, the facility failed to keep the facility in good repair at all times for the safety and well-being of residents, employees, and visitors.
The findings include:
The physical plant inspection was conducted on March 13, 2012. Based on observation during the inspection two patient bedrooms had baseboard heaters that failed to have a cover in patient rooms 102 and B-15.
The detox program director confirmed this finding.
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Plan of Correction
Maintenance supervisor will ensure baseboard heaters have a cover in rooms 102 and B-15 and will continue to monitor baseboards by adding to the weekly walk through maintenance inspection checklist. This will be completed by 4/6/12. |
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 the incident reports received by the Department, a physical plant inspection, review of the facility's policy and procedure for bed bugs, and patient record reviews, the facility failed to ensure the facility was free of rodent and insect infestation.
The findings include:
The facility's policy on Cimex Lectularius Linnaeus (bed bugs) was reviewed. The policy failed to include measures for prevention of bed bug infestation. Staff were interviewed and confirmed that there were no measures in place that required all patients to launder their belongings in hot water prior to storage to aid in the prevention of bed bugs. Additionally, patients were permitted to keep their luggage brought in the facility in their assigned room.
The physical plant was inspected on March 13, 2012. The male detoxification unit was not in use at the time of the inspection. The male detox unit was quarantined and had "caution" tape posted across the doorway. Staff interviews with the infection control nurse and detoxification program director confirmed that the male detoxification unit had been inspected on March 12, 2012 by their pest control company and had confirmed bed bugs in rooms B-3, B-5 and B-7.
Patient records were reviewed and patients were also interviewed.
Patient # 1 had confirmed bed bug bites.
Patient # 2 had confirmed lice and scabies.
Patient # 3 had confirmed scabies.
The findings were confirmed by the infection control nurse and program director.
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Plan of Correction
On 3/14/12 pest control company completed heat treatment in rooms B1,B3,B5 and B7 in the detox unit. The unit remained closed until carpeting steam cleaned and rooms sanitized. Heat treatment effective with no further interventions needed. To Prevent reoccurence client's belongings will be laundered on admission if indicated and stored in plastic bins throughout the course of treatment. The clients luggage will be stored in the confiscation room in air tight plastic bags until discharge from the facility. The wooden bed frames have been replaced with metal bed frames in the detox unit. Infection control nurse updated the current bed bug policy to include measures to prevent bed bud infestation. Maintenance and housekeeping staff will conduct visual inspections daily to ensure no reoccurence. Pest control company is providing trainings on inpection & prevention to ensure facility remains free of bug bugs.Infection control nurse updated the current lice policy and developed a new scabies policy which both include step by step protocols for treatment. Nursing and designated staff members will inspect all clients upon admission to the program for any rashes, bites or lice. Positive results will be reported to the infection control nurse immediately and policy and procedure will be followed. The new and updated proposed policies are in the process of being approved by the board. This will be completed by 5/14/12. |