INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 25, 2012 through July 26, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Interim House West 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:
|
Plan of Correction
|
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on a review of training files, the facility failed to document a mechanism to collect feedback on completed training in four of four records.
The findings include:
On July 25, 2012, four employee records requiring documentation of feedback on completed training were reviewed. The facility failed to document the submission of feedback forms in four of four employee records reviewed, # 1, 2, 3, and 5.
There were no documented feedback forms for the 2011 training year.
The Project Director was interviewed on July 25, 2012 at which time she confirmed that feedback forms were not being documented after the completion of employee training.
|
Plan of Correction
IHW's staff development policy will include the following:
- Upon completion of staff training, all employees will receive a training documentation form.
- The training form will identify the training session, date, presenter, subject time and length.
- On the reverse side, the staff will answer a series of questions that evaluate the effectiveness of the training.
- All training forms will be collected and forwarded to IHW's training coordinator.
The program director will review the staff development training policy at the employee meeting on September 5, 2012. IHW clinical director will monitor compliance and adherence to this standard on a quarterly basis.
|
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
|
Observations
Based on observation during a physical plant inspection, the facility failed to ventilate bathrooms by exhaust fan or window.
The findings include:
On July 26, 2012, at approximately 10 AM a physical plant inspection was conducted.
The facility failed to ventilate bathrooms by exhaust fan or window in two of seventeen bathrooms inspected.
It was observed that one of three child care bathrooms on the first floor lacked ventilation by exhaust fan or window. The fan in the exhaust was observed motionlesnot operable at the time of inspection.
It was observed that the beauty salon's bathroom located in the basement lacked ventilation by exhaust fan or window. The exhaust fan in the beauty salon was not operable at the time of inspection.
The maintenance man and the Project Director confirmed the findings. The Project Director stated "the motors in the exhaust fans were not operable and that the parts were ordered."
|
Plan of Correction
On 7/26/12. Oreilly's Heating and Air conditioning service performed an inspection of both exhaust fans and noted that the motors were defective. New fans were ordered and replaced on 8/2/12.
The facility maintenance person will perform weekly inspections of all bathrooms to ensure all fans are working and bathrooms remain ventilated. The facility manager and program director will monitor compliance on basis.
|
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 shall include, but not be limited to:
(1) Confidentiality of client identity and records.
|
Observations
Based on a physical plant inspection and observation, the facility failed to maintain confidentiality of client identity.
Findings:
On July 26, 2012, at approximately 8:20 AM a "Visitor's Sign In/Out Log" book was observed at the front desk on the counter to the facility entrance. The facility failed to maintain confidentiality of client identity.
The sign in book included a list of the date, the first and last names of the visitors, clients and/or staff and the time in, and time out.
During the exit interview the Project Director confirmed that the "Visitor's Sign In/Out Log" book included the client's first and last name.
|
Plan of Correction
Effective 8/6/12, the IHW's visitor log form was revised to only include the name of the person entering the building, time of arrival and time of departure. No client or staff names will be included in the log.
The program director met with all staff and residents on 8/5/12 to review the new visitor procedure form and to alert them to the implementation date of 8/6/12.
The administrative assistant will monitor compliance with this standard and inform the program director on a monthly basis.
|
709.32(a) LICENSURE Medication Control
709.32. Medication control.
(a) Projects which furnish pharmaceutical services shall comply with all applicable Federal, State and local ordinances, statutes and regulations regarding the storing, compounding, administering or dispensing of medication.
|
Observations
Based on a review of the facility's policy and procedures manual, administrative documentation, and a conversation with nursing staff, the facility failed to dispose medication according to policy.
Findings:
The facility policy titled "Disposal of Medications" states:
"To ensure client medications that are discontinues, expired or received and stored at admission are not retained indefinitely on the premises.
1. A few days before clients are discharged from the program, the nurse will review medications taken by the client during his/her stay in treatment. The nurse will notify the client's prescribing physician that the client will need new written prescriptions upon discharge from the Program. When medications are to be continued after discharge the client will receive medications on hand and a new prescription for continuation.
2. Medications not continued at discharge or discontinued during the clients treatment stay are discarded in the following manner: Pills, liquids, creams, etc. are returned to the pharmacy for disposal and destruction.
Based on a review of administrative documentation the facility failed to comply with the policy and procedures manual as the facility does not return discontinued medication to the pharmacy for disposal and destruction. The facility documented on "Interim House West-Medication Disposal Report" form from April 23, 2012 through July 24, 2012 that the method of disposal for all medications was "flushed." The facility documented flushing pills, liquids, and creams. Prior to April 23, 2012 the facility documented returning medication to the pharmacist.
The facility's nurse was interviewed on July 26, 2012 at which time she stated, "The pharmacy no longer accepts discarded medication back." The nurse confirmed during the interview that the facility has "returned to flushing medications." During the exit interview the Project Director confirmed the findings. She stated "the pharmacy does not want to take back medication."
|
Plan of Correction
Effective 8/15/12, IHW's nursing staff will comply with its written Disposal of Medication Policy. All discontinued medication will be given to Banks Pharmacy for Disposal. The facility will no longer flush/dispose of any medication.
The program director will re-distribute and review this policy with all staff (including bank's pharmacy staff). IHW's Coordinator of Health Services will monitor adherence to this standard and report compliance to program director on a monthly basis
|