INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 10, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Treatment Trends, Inc. Keenan House 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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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on an onsite inspection conducted on February 10, 2021, the facility failed to maintain furnishings in a state of good repair.
The third floor lounge had ripped cushions on the couches and chairs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Operations Manager will oversee the removal, disposal, and replacement of cushions that were in disrepair with new cushions in a state of good repair.
A monthly safety inspection of the facility will be conducted by a designated clinical technician which includes an assessment of furnishings. A checklist will be completed and signed off by the Clinical Director. The checklist is forwarded to the Quality Assurance Coordinator who presents it at a monthly safety committee meeting for review/input.
Peer leaders from the client community join the staff meeting each Monday to present maintenance/safety issues and appropriate maintenance requests are submitted within 24 hours.
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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 an onsite inspection on February 20, 2021, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The third floor rear bathroom had a broken tile sticking out in the shower area that could cause injury to clients.
The third floor front bathroom had broken sink tiles that could cause injury to the clients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
QA Coordinator submitted a Maintenance Request form and added this as an action item to Safety Agenda. Maintenance Supervisor is responsible for ensuring work is completed.
A monthly safety inspection of the facility will be conducted by a designated clinical technician which includes an assessment of bathroom cleanliness, sanitation, and functionality. A checklist will be completed and signed off by the Clinical Director. The checklist is forwarded to the Quality Assurance Coordinator who presents it at a monthly safety committee meeting for review/input.
Peer leaders from the client community join the staff meeting each Monday to present maintenance/safety issues and appropriate maintenance requests are submitted within 24 hours.
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705.7 (b) (4) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on an onsite inspection on February 10, 2021, the facility failed to ensure that storage areas for foods are free of food particles, dust and dirt.
The refrigerator in the kitchen had rusty water in the bottom. Food supplies for the day were kept in the refrigerator.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Operations Manager immediately removed food items on 2/10/21 and put refrigerator out of service. Maintenance Department removed and disposed of the aforementioned refrigerator on 2/26/2021. A new refrigerator was delivered and installed on 2/22/2021.
The Lead Culinary Staff is responsible for the monthly checks of the refrigerator.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of 2020 fire drills, the facility failed to conduct unannounced fire drills at least once a month.
The facility failed to conduct a fire drill for the month of November 2020.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from a licensing inspection on January 16, 2020.
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Plan of Correction
The Clinical Technician Supervisor is responsible for assigning staff members to complete the drills, monthly, on the shifts indicated.
QA Coordinator shared the Fire Drill schedule with staff (varies monthly by shift/sleeping hours)
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on review of seven client records on February 10, 2021, the project failed to include documentation of the clients being notified that the project may not discriminate in the provision of services on the basis of age, creed, ethnicity, color, and marital status.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The QA Coordinator has updated the Client Rights form to ensure that it mirrors the DDAP standard regarding discrimination in the provision of services. This form was sent to program staff. |