INITIAL COMMENTS
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This report is a result of complaint investigation conducted on 10-21-14, by staff from the Program Licensure Division. Based on the findings of the complaint investigation, the allegations made against Pennsylvania Associates dba Mount Pocono Medical,were partially substantiate and Pennsylvania Associates dba Mount Pocono Medical 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation during the onsite inspection, the facility failed to ensure that counseling sessions could not be heard outside the counseling room.
The findings include:
An onsite inspection was conducted on 10-21-14 and the Licensing Specialists were able to hear conversations in the adjoining counseling office.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director placed white noise machines in strategic areas so conversations cannot be overhead on 10/21/14. Staff were notified and trained on 10/21/14. The facility director will conduct random visits to offices to ensure that conversations cannot be overheard on a monthly basis. |
709.30(1) LICENSURE Client Rights
709.30. Client rights.
(1) A person receiving care or treatment under section 7 of the act (71 P. S. 1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on an interview with the Facility Director during an onsite inspection, the facility failed to ensure that patients were not verbally abused by staff.
The findings include:
The Facility Director was interviewed on 10-21-14 regarding allegations that one of the clinicians had been rude and unprofessional with patients. The Facility Director acknowledged that one of his clinicians was rather direct which may have been perceived as rude and the Facility Director has addressed this with the clinician.
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Plan of Correction
All staff review the employee handbook which contains the professional ethical code of conduct during pre-service/orientation period with the Facility Director. All staff sign off on the review of the employee handbook. All staff will be trained again by 12/10/14 on the professional code of ethics. |
715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
Based on an interview with the Facility Director, the facility failed to ensure that all patients were medicated within 15 minutes of arrival at the dispensing area.
The findings include:
The Facility Director was interviewed on 10-21-14 regarding allegations that patients had to wait more than 15 minutes to be dosed after arrival at the facility. The Facility Director stated that at times patients had waited up to an hour from the time they arrived until they were dosed. Facility Director indicated this was due in part to scheduling for take homes and they had worked to revise scheduling situations and he believes this is now corrected.
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Plan of Correction
Mt Pocono provides adequate nursing staff for dispensing. The front desk staff will observe the clock in the lobby. When the line becomes long and there is a wait of more than 15 minutes the second line to dispense is utilized. The front desk will notify the Executive Director or Lead Nurse when there is a long line with a wait time of more than 15 minutes. The Executive Director or Lead Nurse will instruct nursing to open the second window. A training will be completed to the personnel by 12/31/14. |