INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 9, 2012 by staff from the Division of Drug and Alcohol Program Licensure and an off-site review of documentation provided by the facility on 1/17/2012.. Based on the findings of the on-site inspection and the off-site documentation review, Tradition 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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705.2 (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 during a physical plant inspection, client interviews and a review of a report provided by the Chief Executive Officer (CEO) on January 17, 2012, 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:
During interviews on January 9, 2012 four clients were asked to answer a series of questions. All clients reported the presence of mice, lice and scabies.
On January 9, 2012 a physical plant inspection was conducted approximately between 1:30 PM to 2:00 PM. During the inspection the following concerns were identified:
1. at approximately 1:42 PM, it was noted that the plastic covering on the mattress nearest to the window in bedroom # 12 was cracked on both sides and could allow for potential spread of disease or insect infestation.
2. at approximately 1:44 PM, three (unset) mouse traps were found on the kitchen counter.
3. at approximately 1:57 PM, mouse droppings were detected in between the cushions of the blue chair in the basement lounge.
4. at approximately 1:58 PM, cushions on the sofa were observed to be soiled and ripped.
The Facility Director and Maintenance Director were present during the inspection and confirmed the findings.
On January 17, 2012, the CEO provided the following report after completing an onsite inspection of the facility:
"Client complaint of mattresses being taken outside and returned back into the facility after a few hours is valid due to the replacement process. There was a misunderstanding of how many mattresses were being delivered on 1/3/12. Thus ten were removed from Trad House, but only 5 were in stock and delivered. Maintenance will ensure arrival of new mattresses before removal of the old ones."
In response to client complaints that the number of washing machines are inadequate:
"Discussed with (name redacted) CEO, (name redacted) VP of Operations, and (name redacted), Program Director on 1/13/12. Determined this need to be warranted and Tradition House will add an additional washer and dryer."
In response to the allegation that one staff office was messy with food:
"When we toured the facility on 1/13/12, the counselor office was found to be messy with open food wrappers on the desk and paper on the floor. Deemed unprofessional and unacceptable. Counselor was talked to on 1/14/12 via a counseling session by Program Director and informed that this is unacceptable."
"When the facility was toured on 1/13/12, we did determine that some of the furniture did look worn and has some tears. It will be replaced. New furniture will be placed in the living room on the main floor and downstairs in the basement lounge."
"We did discover evidence of mice when we toured the facility on 1/13/12. This occurs when the temperature changes dramatically. We determined that a more aggressive approach is needed."
In addition, the CEO's January 17, 2012 report confirmed the presence of lice and scabies.
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Plan of Correction
New mattresses for all 24 beds were ordered and delivered. Final delivery occurred on 1/17/12.
7 Victor Pest Chaser electronic sound emitter devices were purchased and placed throughout the house in order to better control the mice population. On 1/27, upon asking clients whether or not they have continued to see any mice, their answer was "no". Continued monitoring of the presence of mice will be conducted by the program director, maintenance man, and facility risk committee members via weekly physical plant inspections.
New furniture was ordered on 1/4/12 to include three new sofas, one new loveseat, and one new chair, in addition to two replacement cushions in order to replace those pieces that are worn. Scheduled to ship the week of 2/13/12. VP of Operations to ensure delivery.
An additional washer and dryer were ordered for the house. The plumbers were in to install additional hook-up lines on 2/7/12. Washer and dryer arrived on 2/7/12. Complete hook-up for use complete on 2/8/12. Maintenance man coordinated project. Program director confirmed completion.
Counselor office issue was addressed by program director. It was cleaned within 3 days (by 1/16) and has been neat and clean since. Compliance to professional cleanliness of office space will be adhered to by program director via monthly physical plan inspections.
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705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on observation during a physical plant inspection on January 9, 2012 and a review of a report provided by the Chief Executive Officer (C.E.O.) on January 17, 2012, the facility failed to provide a mattress in good repair for each of the residents.
The findings include:
On January 9, 2012, a physical plant inspection was conducted. During the inspection at approximately 1:42 PM, it was noted that the plastic covering on the mattress nearest to the window in bedroom # 12 was cracked on both sides and could allow for potential spread of disease or insect infestation.
The Facility Director and Maintenance Director were present during the inspection and confirmed the findings.
On January 17, 2012, the C.E.O. provided the following report after completing an onsite inspection of the facility:
"Client complaint of mattresses being taken outside and returned back into the facility after a few hours is valid due to the replacement process. There was a misunderstanding of how many mattresses were being delivered on 1/3/12. Thus ten were removed from Trad House, but only 5 were in stock and delivered. Maintenance will ensure arrival of new mattresses before removal of the old ones."
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Plan of Correction
24 new mattresses for each client bed were ordered and delivered. Final delivery date occurred on 1/17/12. Program director will ensure that if any of these mattresses become torn, replacement mattresses will be ordered immediately. This will be monitored via monthly physical plant inspection by program director and facility risk committee members. |
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 inspection of the physical plant, and a review of a report provided by the Chief Executive Officer (CEO) on January 17, 2012, the facility failed to ensure the food storage areas were free of dust and dirt.
The findings include:
On January 9, 2012, a physical plant inspection was conducted. During the inspection at approximately 1:55 PM, mouse droppings were found on top of several canned food items in the dry storage area located in the basement. Additionally, the shelves on which the canned food items were stored were stained with mold and droppings that appeared to be stuck to the shelves.
The Facility Director and Maintenance Director were present during the inspection and confirmed the findings.
On January 17, 2012, the C.E.O. provided the following report after completing an onsite inspection of the facility:
"We did discover evidence of mice when we toured the facility on 1/13/12. This occurs when the temperature changes dramatically. We determined that a more aggressive approach is needed."
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Plan of Correction
7 Victor Pest Chaser electronic sound emitter devices were purchased and placed throughout the house in order to better control the mice population. On 1/27, upon asking clients whether or not they have continued to see any mice, their answer was "no". Continued monitoring of the presence of mice will be conducted by the program director, maintenance man, and facility risk committee members via weekly physical plant inspections.
The dry storage area was cleaned thoroughly with the help of Pyramid's housekeeping staff. A team of 5 of them came in a total of 4 times to clean the entire facility. Completed on 1/27/12. Program director has coordinated with this team to have them come clean the entire house quarterly. Program director will ensure this occurs.
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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.
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Observations
Based on an inspection of the physical plant, client interviews, and a review of facility incident reports presented on January 9, 2012, and a review of a report provided by the Chief Executive Officer (CEO) on January 17, 2012, the facility failed to keep the facility free of rodent and insect infestation.
The findings include:
On January 9, 2012, a physical plant inspection was conducted. During the inspection at approximately 1:57 PM, mouse droppings were detected in between the cushions of the blue chair in the basement lounge.
Additionally, photographs were reviewed from an anonymous complainant, which displayed two mice stuck to a glue trap in the kitchen of the facility.
The Facility Director and Maintenance Director were present during the inspection and confirmed the findings.
On January 9, 2012, during the onsite investigation, the corporate office faxed 5 incident reports to the Division of Drug and Alcohol Program Licensure office in Harrisburg relating to an outbreak of scabies and lice at the facility.
Incident report #1
"At approximately 6 pm on 12/23/2011, (name redacted), LPN/Infection Control Nurse, received a call from (name redacted), DON, that there were clients at our Traditions Halfway House located at 830 6th avenue Altoona Pa 16602 that have suspected scabies. There were 6 girls that were presenting with signs and symptoms of scabies."
Incident report #2
"In the am on 12/31/2011, (name redacted), CRNP, personally examined 5 of the girls in our Traditions Halfway House located at 830 6th Avenue Altoona PA 16602 that were still having signs and symptoms of scabies. Later that day (name redacted) LPN/Infection Control Nurse was made aware that there were possibly more clients in need of a second treatment."
Incident report #3
"At approximately 2:00 pm on 12/31/2011, (name redacted), LPN/Infection Control Nurse, received a call from the tech working at Traditions Halfway House... that a client had left AMA the night before and was seen at her local emergency dept and was diagnosed with having head lice. ... At approximately 2:30 pm, the tech brought approximately 18 clients to our Duncansville IP facility... Four out of the 18 clients had signs of head lice."
Incident report #4
"At approximately 10:30 am on 1/2/2012 (name redacted), LPN/Infection Control Nurse, was notified by a tech that there were possibly more female clients that need treated for head lice. (Name redacted) LPN/Infection Control Nurse went to the house and personally checked approximately 10 of the clients including five clients that had a head lice treatment already. ... all five clients still have small amount of nits noted. All clients will be rechecked on 1/7/2012 which is 7 days after first treatment and as needed if there are clients that are symptomatic."
Incident report #5
"At approximately 2:00 pm on 1/4/2012, (name redacted), LPN/Infection Control nurse, went to our Traditions Halfway House ... and personally examined all of the girls in the house for a recheck of scabies. ... Two of the girls still having some complaints of signs and symptoms of scabies, all of the other girls had no signs or symptoms at this time."
Additionally, interviews with clients on January 9, 2012, included statements regarding a facility infestation os mice lice and scabies. See PP009 for additional information regarding the client interviews.
On January 17, 2012, the C.E.O. provided the following report after completing an onsite inspection of the facility:
"We did discover evidence of mice when we toured the facility on 1/13/12. This occurs when the temperature changes dramatically. We determined that a more aggressive approach is needed."
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Plan of Correction
7 Victor Pest Chaser electronic sound emitter devices were purchased and placed throughout the house in order to better control the mice population. One of these devices was being utilized; however, it was determined that more were needed. On 1/27, upon asking clients whether or not they have continued to see any mice, their answer was "no". Continued monitoring of the presence of mice will be conducted by the program director, maintenance man, and facility risk committee members via weekly physical plant inspections.
If medical complaints are made, Medical Services Coordinator is contacted immediately. She then notifies the DON who gives further instruction. A CRNP comes to the facility once per week to see any/all clients who complain of any medical symptoms. Any major medical issues are referred directly to Pyramid's Medical Director. Program director and DON will monitor and oversee this process. Adherence will be measured via monthly supervision by Program Director with the Medical Services Coordinator.
With the initial complaint on 12/23 that scabies was suspected, all appropriate measures were taken to diagnosis and aggressively treat. All CDC guidelines were followed. Numerous follow up checks were completed until every client was clear. The initial diagnosis of lice was missed due to also having a scabies outbreak. It was, therefore, believed that the itching was a result of scabies. Once the lice was discovered, everyone was treated immediately and aggressively to a successful end. A follow up check was completed by the infection control nurse on 1/20/12 with no continuation of signs/symptoms and no new cases.
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709.54(a)(4) LICENSURE Safety/sanitation
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(4) Safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area.
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Observations
Based on observation during a physical plant inspection and a review of the facility's policy and procedure manual, the facility failed to maintain food preparation areas in accordance with the project's policies and procedures.
The findings include:
The facility's policy titled, "PHC 2.26 Dietetic", created 7/1/1999 and revised 7/1/2010, states:
Section IV Safety and Sanitation:
A.1. The kitchen serving and storage facilities are maintained in a safe manner and sanitary condition.
2. Dishes, glasses, flatware, serving utensils, cooking utensils and surface areas are sanitized according to State and Local regulations.
On January 9, 2012 a physical plant inspection was conducted. During the inspection at approximately 1:44 PM, three (unset) mouse traps were found on the kitchen counter.
The Facility Director and Maintenance Director were present during the inspection and confirmed the findings.
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Plan of Correction
7 Victor Pest Chaser electronic sound emitter devices were purchased and placed throughout the house in order to better control the mice population. One of these devices was being utilized; however, it was determined that more were needed. On 1/27, upon asking clients whether or not they have continued to see any mice, their answer was "no". Continued monitoring of the presence of mice will be conducted by the program director, maintenance man, and facility risk committee members via weekly physical plant inspections.
Pyramid's housekeeping staff, a team of 5, came in a total of 4 times to clean the entire facility. Completed on 1/27/12. Program director has coordinated with this team to have them come clean the entire house quarterly. Program director will ensure this occurs.
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709.17(a)(10) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
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Observations
Based on observation during a physical plant inspection, a review of facility incident reports and client interviews, all occurring on January 9, 2012, and a review of a report provided by the Chief Executive Officer (CEO) on January 17, 2012, the facility failed to ensure that the facility, by nature of its physical condition, would not endanger the health and safety of the public.
The findings include:
A physical plant inspection along with client interviews, on January 9, 2012, and a review of a report provided by the Chief Executive Officer (CEO) on January 17, 2012, revealed that 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.
See PP009 for additional information regarding the condition of the facility grounds.
A physical plant inspection on January 9, 2012, and a review of a report provided by the Chief Executive Officer (CEO) on January 17, 2012, revealed that the facility failed to ensure the food storage areas were free of dust and dirt. See PP077 for additional information regarding the food storage areas.
A physical plant inspection on January 9, 2012, along with a review of facility incident reports presented on January 9, 2012, and a review of a report provided by the Chief Executive Officer (CEO) on January 17, 2012, revealed that the facility failed to keep the facility free of rodent and insect infestation. The facility had an infestation of mice, lice and scabies. See PP091 for additional information regarding the infestation.
A physical plant inspection on January 9, 2012, along with a review of the facility's policy and procedure manual revealed that the facility failed to maintain the kitchen serving and storage facilities in a safe manner and sanitary condition. During the physical plant inspection at approximately 1:44 PM, three (unset) mouse traps were observed on the kitchen counter.
See L1827 for additional information relating to the kitchen serving and storage areas.
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Plan of Correction
7 Victor Pest Chaser electronic sound emitter devices were purchased and placed throughout the house in order to better control the mice population. One of these devices was being utilized; however, it was determined that more were needed. On 1/27, upon asking clients whether or not they have continued to see any mice, their answer was "no". Continued monitoring of the presence of mice will be conducted by the program director, maintenance man, and facility risk committee members via weekly physical plant inspections.
Pyramid's housekeeping staff, a team of 5, came in a total of 4 times to clean the entire facility. Completed on 1/27/12. Program director has coordinated with this team to have them come clean the entire house quarterly. Program director will ensure this occurs.
With the initial complaint on 12/23 that scabies was suspected, all appropriate measures were taken to diagnosis and aggressively treat. All CDC guidelines were followed. Numerous follow up checks were completed until every client was clear. The initial diagnosis of lice was missed due to also having a scabies outbreak. It was, therefore, believed that the itching was a result of scabies. Once the lice was discovered, everyone was treated immediately and aggressively to a successful end. A follow up check was completed by the infection control nurse on 1/20/12 with no continuation of signs/symptoms and no new cases.
If medical complaints are made, Medical Services Coordinator is contacted immediately. She then notifies the DON who gives further instruction. A CRNP comes to the facility once per week to see any/all clients who complain of any medical symptoms. Any major medical issues are referred directly to Pyramid's Medical Director. Program director and DON will monitor and oversee this process. Adherence will be measured via monthly supervision by Program Director with the Medical Services Coordinator. |