INITIAL COMMENTS
|
This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 21, 2010 licensure renewal inspection. The follow-up inspection was conducted on November 9 and 10, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Gaudenzia Common Ground 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 and a plan of correction is due December 1, 2010
|
Plan of Correction
|
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.
|
Observations
Based on an inspection of the physical plant, the facility failed to ensure that grounds of the facility are clean, safe, sanitary, and in good repair.
The findings include:
An inspection of the facility was conducted on November 10, 2010 from approximately 10:15 to 11:15 am. During the inspection, it was found that several of the bedroom windows were pulling away from the building, had visible mold, and the wooden frames were rotted and had chipped paint. This was noted specifically in bedrooms # 9, 10, and 11.
The sheets on the window beds in rooms # 5 and 9 both had stains that resembled human blood drippings.
The ceiling tiles in the first floor hallway outside of the house manager's office had visible signs of water damage. Additionally, the ceiling in the stairway near the elevator had missing plaster which needed to be replaced.
The border cove along the first floor hallway was missing.
The facility manager was present during the inspection and verified the inspector's findings.
|
Plan of Correction
The Program Director submitted acquisition requests/work orders to the Central Region Physical Plant Manager and Central Region Director requesting resolution of all issues identified.
An outside vendor was contracted to complete requested repair work. Repairs to windows including caulking and securing the existing windows , making them air and water tight was completed 12/17/10.
The same contractor will be painting all window sills.
Interior window casings were cleaned.
The border cove along the first floor hallway which was removed for floor renovation has been replaced.
A vendor has been contracted for plaster repair to ceiling.
New sheet sets were obtained for all beds.
The Program Director was not present during the inspection, but will assume responsibility for following up on progress with the Central Region Physical Plant Manager, Division Director, and Central Region Director.
Target Resolution Date: 12/31/10 |
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.
|
Observations
Based on an inspection of the physical plant and a review of the bed log, the facility failed to keep the facility free of rodent and insect infestation.
The findings include:
An inspection of the facility was conducted on November 9, 2010 from approximately 10:00to 11:30 am. During the inspection, it was found that the bed closest to the door in bedroom #9 had what appeared to be three dried drops of blood near the foot of the bed consistent with bed bug bites. They were about an eighth of an inch apart in a triangular formation.
The bed closest to the window in bedroom #10 had what appeared to be multiple blood stains as well.
On November 10, 2010 I returned to the facility to check the bedrooms for more signs of bed bug infestation. All but one of the beds inspected had a fresh set of sheets. Blood stains were present again in bedroom # 9 but this time they were on the bed closest to the window. Furthermore the bed check log had been reviewed. The facility does a bed check twice a day, to inspect for bed bugs. The log documented actual bed bug sightings on October 16th in room #4 and November 7th in room #9. It was also noted that no bed check was conducted on the evenings of November 2nd and 4th.
|
Plan of Correction
The Program Director reviewed the corporate bed bug policy and protocols with staff. Staff failure to adhere to all protocols including completion and documentation of twice daily bed bug inspections will result in individual staff corrective action.
The Central Region Physical Plant Manager, a Certified Commercial Pesticide Applicator is scheduled to treat the entire facility including but not limited to bedrooms, offices, and common areas involving all furniture, disassembled beds, carpet, baseboards, receptacles, light switches, etc... on 12/22/10.
All client belongings/suitcases will again be laundered/treated and stored as per protocol.
All sheets/bed linens were replaced. All mattresses/pillows are covered by bed bug certified encasements.
The Central Region Physical Plant Manager will perform weekly inspections of all bedroom and other rooms, as well as random audits of staff pest inspection logs.
The Division Director will conduct weekly monitoring of protocol adherence.
The Program Director will monitor ongoing compliance and report through the monthly Quality Improvement/Safety process.
Target Resolution Date: 12/31/10 |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
|
Observations
Based on an inspection of the physical plant, the facility failed to ensure that interior exits and stairs would remain lit at all times.
The findings include:
An inspection of the facility was conducted on November 10, 2010 from approximately 10:15 to 11:15 am. During the inspection, it was found the lights in the stairway by the back elevator, as well as the lights in the stairway by the kitchen were controlled by a light switch and could be turned off.
|
Plan of Correction
The Central Region Physical Plant Manager modified the light switches in the stairway by the back elevator, as well as the lights in the stairway by the kitchen and replaced the plate coveres so that the lights cannot be turned off.
Emergency lighting mechanisms also remain in place.
The Program Director will monitor ongoing conformance.
Resolved: 12/2/10
|
709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
|
Observations
Based on a review of client records, the facility failed to accurately document the vital signs in the physical examination in two out of two detox client records.
The findings include:
On November 9, 2010 two detox client records were reviewed. The facility neglected to record vital signs during the time of the physical examination in both client records. The vitals signs which appeared on the physical examination were not recorded the day the physical was completed, but instead the vitals were previously recorded from the nursing assessment which is completed upon the client's arrival.
Client # 3 was admitted on November 5, 2010 , the nursing assessment was completed on November 5, 2009. The physical examination was completed on November 6, 2009. The vital signs on the physical exam were transposed from the previously recorded, nursing assessment.
Client # 4 was admitted on November 4, 2010 , the nursing assessment was completed on November 4, 2010 . The physical examination was completed on November 6, 2010 . The vital signs on the physical exam were transposed from the previously recorded, nursing assessment.
|
Plan of Correction
The Program Director reviewed with nursing staff the protocol for documentation of vital signs on the physical examination form. The Physician or Nurse shall ascertain client vital signs at the time of the physical examination and document findings on the PE form.
Assigned Nurses and the Administrative Coordinator will monitor conformance during ongoing record audits and report findings to the Program Director and to the Quality Improvement Committee.
Target Resolution Date: 12/10/10 |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
|
Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a discharge summary within 7 days of discharge in two of two inpatient client records.
The findings include:
On November 9, 2010 four inpatient records were reviewed. A discharge summary was required in two of those records, specifically records # 5 and 6. The facility's policy states that a discharge summary is to be completed within seven days of discharge.
Client record # 5 was admitted on August 2, 2010 and discharged on August 30, 2010. The discharge summary was due by September 6, 2010. The discharge summary had not been completed as of the date of inspection.
Client record # 6 was admitted on August 25, 2010 and discharged on September 14, 2010. The discharge summary was due by September 21, 2010. The discharge summary had not been completed as of the date of inspection.
|
Plan of Correction
The policy for completing a discharge summary within 7 days of discharge and entering it into the client record were reviewed with clinical and nursing staff.
The Clinical Supervisor and Administrative Coordinator will monitor ongoing conformance via monthly chart audits and report findings to the Program Director and Quality Improvement Committee.
Target Resolution Date: 1/1/2011 |