INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 20, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Colonial House 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 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents. The dumpsters outside the facility were overflowing and the lids were not closed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Manager will ensure that all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents are properly stored in the trash dumpster. This will become part of the daily facility walk-through to ensure that all trash is properly disposed of.
The Program Manager will also ensure that there are enough scheduled trash pickups during the course of the week to ensure that the amount of trash waste and pickups are conducive. |
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 a physical plant inspection, the facility failed to keep cooking and eating utensils in a clean and enclosed area. Cooking utensils were being stored hanging in an open area in the kitchen. Silverware was being stored in the cafeteria in bins that were not covered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Manager will ensure that the kitchen staff will keep all cooking and eating utensils in a clean and enclosed area. These cooking utensils cannot be hanging in an open area in the kitchen. All silverware will be stored in the cafeteria in bins that are covered.
The Program Manager will review this with the kitchen staff and will monitor this during a daily walk-through of the facility. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on the review of the facility policy and procedure manual, the procedures for confidentiality of client identify and records state that client records are to be secured in a locked clinical supervisor's office. After a physical plant inspection, it was observed that the client records were being stored in a medical office that multiple employees have access to.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Direct will ensure that the policy and procedure for securing clients records will be changed to state that an identified room (client file room) will be identified and all current client records will be stored in this room. Only clinical staff, Facility Director and Project Director will have access to this room.
It will be the responsibility of the Clinical Supervisor to ensure that all charts are properly stored daily in the client file room and that all charts are accounted for.
This will be implemented on or before 12/15/20
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