INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection to the on-site licensure inspection conducted on June 22, 2010- June 24, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
The follow-up inspection was conducted on December 22, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the onsite follow-up inspection, Libertae Family House Libertae, 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 and a plan of correction is due on February 3, 2011.
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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 observation, a physical plant inspection and an interview with the facility director, 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 residents, employees and visitors.
The findings include:
A physical plant inspection was conducted on December 22, 2010 at approximately 3 PM.
1. It was observed during the physical plant inspection that the heating system closet on the second floor was used for storage. The facility had cardboard gift boxes, vacuum cleaners, bulletin boards with paper attached, household cleaners, and greasy soiled rags piled in the closet within 3 feet of the furnace creating a hazard of having combustibles stored in the heating system closet, reducing the ventilation for the heating system and reducing the work area around the heating equipment.
2. It was observed that there was an aerosol can sitting on top of one furnace within eight inches of the flu pipe.
3. It was observed that there were bags sitting on top of one heating unit located within eight inches of the flu pipe.
4. It was observed that the elevator equipment room located in the basement, near the child care area, had a damaged door and broken lock with sharp edges.
5. It was observed that there were greasy soiled rags, liquids, papers, and bags inside of the basement elevator equipment room.
6. It was observed that there were panels that were missing or hanging off of the facility's heating units.
The facility director confirmed the findings and when asked about the damaged door and lock, the facility director said that the fire department broke the lock to get into the room but that there was no fire.
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Plan of Correction
Responsible party: Executive Director and mantainence personnel.
Action taken for #1, 2, 3 and 6: Rooms were completely cleaned out, heater covers were put back on heaters, signs were posted on each door stating "no items cna be stored in this HVAC closet storage per state regulations" and pictures were taken and emailed as requested on 1/7/2011. It was verified that photos were recieved.
Action for #4 and 5
All materials were removed 12/23/2010.
A metal plate was put affixed to the door to cover the damaged ares and a new lock was installed. pictures were taken and emailed as requested on 1/10/2011. It was verified that photos were recieved.
Executive Director will monitor to assure that routine maintenence checks include HVAC closets and elevator room. This will reviewed during monthly physical plant meetings.
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on observation, a physical plant inspection and an interview with the facility's operations manager, the facility failed to provide slip-resistant surfaces in all bathtubs and showers.
The findings include:
A physical plant inspection was conducted on December 22, 2010 at approximately 3 PM.
It was observed that three out of eight bathrooms inspected, having showers/tubs, lacked slip-resistant surfaces in the shower, specifically the bathrooms for rooms # 18, 21 and 23.
The operations manager confirmed that the bathrooms for rooms # 18, 21 and 23 lacked slip resistant surfaces in the showers.
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Plan of Correction
Responsible party: Operations Manager & Resident Manager. Operations Manager assured that slip resitant bathtub mats were available and Resident Manager put these in the tubs in rooms 18, 21, and 23 on 12/23/2010. Resident Manager will continue to asssure that tubs have slip resitiant surfaces during weekly room checks. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on observation, a physical plant inspection and an interview with the operations manager on December 22, 2010, the facility failed to provide ventilation by an exhaust fan or window for toilets and washrooms.
The findings include:
A physical plant inspection was conducted on December 22, 2010 at approximately 3 PM.
It was observed that one out of nine bathrooms lacked ventilation by an exhaust fan or window.
The exhaust fan for the bathroom located between bedrooms 11 and 12 was not operable at the time of the inspection.
The operations manager confirmed that the exhaust fan for the bathroom located between bedrooms # 11 and 12 was not working.
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Plan of Correction
Responsible party: Operations Manager, Resident Manager
Action Taken: Maintenance personnel checked on 12/23/2010 and fan was in working order. Further inspection revealed that the resident had been unplugging the fan do to the noise. Maintenance personnel oiled the fan to reduce the noise.
Resident Manger will inspect bathrooms to assure fans they in working condition. Operations manager will monitor in supervision.
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705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on observation, a physical plant inspection and an interview with the operations manager, the facility failed to provide toilet paper at each toilet at all times.
The findings include:
A physical plant inspection was conducted on December 22, 2010 at approximately 3 PM.
It was observed that one out of nine bathrooms inspected lacked toilet paper, specifically, the child care center bathroom (both toilets).
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Plan of Correction
Responsible Party: Family Services Supervisor
Plan of Action: Toilet paper was refreshed on 12/22/2010.
Family Center staff check daily to assure there is paper on the roll, in the bathroom.
Family Services Supervisor will conduct random checks to assure this is being done.
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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 observation, a physical plant inspection and an interview with the operations manager, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
A physical plant inspection was conducted on December 22, 2010 at approximately 3 PM.
It was observed that two out of nine bathrooms inspected, had caulking that was pulling away and there was mold and mildew around the tub, specifically the bathrooms for rooms #18 and #23.
The operations manager confirmed that there was mold and mildew present in both bathrooms.
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Plan of Correction
Responible party: Operations Manager, Resident Manager and Maintenance personnel.
Action taken: On 12/29/2010 old caulk was removed and new caulk was applied. Tubs were cleaned.
Resident Manager will inspect on weekly rounds to ensure there is no mould and caulking is in good shape.
Operations Manager will do random checks to assure follow through. |
705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on observation, a physical plant inspection and an interview with the kitchen manager, the facility failed to clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
The findings include:
A physical plant inspection was conducted on December 22, 2010 at approximately 3:00 PM which would have followed the completion lunchtime meal by more than an hour and a half and would have preceded the the start and end of the evening meal.
It was observed that that there were dirty dishes in the sink at approximately 3:00 PM.
It was observed that one sink was filled with dirty dish water at approximately 3:00 PM
It was observed that the kitchen floor was dirty at approximately 3:00 PM.
The kitchen manager confirmed the above conditions and stated that the sink was stopped up with utensils, and that the floor is cleaned following the evening meal.
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Plan of Correction
Responsible Party: Executive Director and Food Services Director
On 12/22/2010 silverware was removed from garbage disposal and sink was cleaned.
Corrective action: On 1/7/11 staff met to discuss chore concerns. The chore list will be updated to include sweeping and mopping the floor after lunch prep.
All dishes will be washed and sinks routinely cleaned at lunch clean-up.
Food Service Director will monitor the completion of chores in the kitchen daily. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on observation, a physical plant inspection and an interview with the kitchen manager, the facility failed to store all food items off the floor.
The findings include:
A physical plant inspection was conducted on December 22, 2010 at approximately 3 PM.
It was observed that the facility had a crate with potatoes and onions sitting on the floor.
The kitchen manager confirmed that the potatoes and onions were not stored up off of the floor, but that they were in a crate sitting directly on the floor.
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Plan of Correction
Responsible party: Executive Director and Food Service Director.
Corrective action: On 12/2/2010 the crates with potatoes and onions were moved to a shelf assuring they are off the floor.
Pictures were taken and emailed as requested on 1/7/2011. It was verified that photos were recieved.
Food Service Director will monitor food items in the kitchen to assure none are on the floor.
Executive Director will review in supervision. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation, a physical plant inspection, and interviews with the operations manager and the facility director, the facility failed to secure client records within locked storage containers.
The findings include:
A physical plant inspection was conducted on December 22, 2010 at approximately 3 PM.
At the time of the inspection there were 14 boxes of unsecured client records in the Life Skill Counseling Area.
This room was being utilized by staff, residents, and visitors.
The operations manager and the facility director confirmed that there were 14 boxes of client records that were unsecured in the Life Skill Counseling Area.
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Plan of Correction
Responsible party: Clinical Director and Maintenance
On 12/22/2010 files were moved to a locked area.
The Clinical Director will continue to ensure that all boxes containing files dated beyond one year will be transferred from one locked area directly to storage.
The Clinical Director and Mainenance will monitor the protcol that takes place at the end of each fiscal year. This year august 30 2011. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of the facilities policy and procedure manual and an interview with the operations manager, the facility failed to provide document for quarterly inspections of the medication storage area in accordance with the facility's policies and procedures.
The findings include:
The facilities policy titled "INSPECTION OF MEDICATION STORAGE AREAS" states:
The Clinical Director will inspect the medicine storage area quarterly to ensure that these areas are maintained in compliance with Federal, State, and local regulations. A dated record of these inspections should be maintained in order to verify that:
1. Disinfectants and drugs for external use are stored separately from oral and injectable drugs;
2. Drugs requiring special conditions for storage to insure stability are properly stored:
3. Outdated drugs are removed and disposed of;
4. Administration of controlled drugs is properly documented;
5. Controlled substances and abusable drugs are stored in accordance with Federal, State, and program regulations;
6. Copies of drug-related regulations are available in appropriate areas.
At the time of inspection, a medication inventory will also be performed. All information is recorded on the Medication Inspection/Inventory Form.
On December 22, 2010, the medication control policy was reviewed, and a physical plant inspection was conducted.
During the physical plant inspection, while reviewing the medications room, the Licensing Specialist requested to see the the inspection log of the medication storage area.
The operations manager was unable to provide documentation for the quarterly inspections of the medication area.
The Operations Manager confirmed that the documentation of quarterly inspections of the medication storage area was not able to be provided.
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Plan of Correction
Responsible Party: Operations Manager and Resident Manager.
On 12/28/2010 Operations Manager created a checklist for drug storage area and inspection of drugs and addded it to the back of the checlist for House Stock Inventory already in place. This procedure was reviewed with Resident Managers.
On 12/29/2010 the Resident Managers completed the checklist during the quartly inspection of medicine cabinet as per our policy.
Operations Manager will monitor quarterly to assure this is being done during supervision. |