INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted June 3-4, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Place 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff.
The findings include:
The SRFSR was reviewed on June 3, 2015 for staff compliance with required HIV/AIDS and TB/STD training. One out of one staff for which the training was due, specifically record # 6, did not recieved the training within the required timeframe. Employee # 6, a PT Program Monitor, was hired on March 8, 2013. Training was due by March 8, 2015. HIV/AIDS training was not completed until April 7, 2015 and TB/STD had not been completed until April 24, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director reviewed all personnel files to verify employees dates of hire. All employees that were still in need of the required HIV/AIDS and TB/STD trainings were informed of the 1 year DDAP expectation for Clinical Staff and the 2 year DDAP expectation for non-clinical staff. Facility Director will also be reviewing the DDAP expectations with any new hires from this point forward. Date completed 6/10/15 |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on an inspection of the physical plant, the facility failed to ensure the hot water temperature did not exceed 120 degrees Fahrenheit.
The findings include:
A physical plant inspection was conducted on June 4, 2015 from approximately 9:30- 10:15 AM. During the physical plant inspection, it was noted that the hot water temperature registered at 128.5 degrees Fahrenheit in the bathroom in suite 14; 125 degrees Fahrenheit in the bathroom in suite 16; and 126 degrees Fahrenheit in the bathroom in suite 21.
The findings were reviewed with facility staff during the during the physical plant tour.
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Plan of Correction
Maintenance Supervisor turned temperature down on the water heater on 6/4/15 @ 11:00am. Maintenance Supervisor rechecked the water temperature in bathroom suites 16 and 21, on 6/4/15 @ 4:00pm, and both rooms read at 120 degrees Fahrenheit. The Maintenance supervisor will check the water temperature in random rooms on a weekly basis, and log which rooms were checked on the Weekly Safety checklist. He will ensure that he uses different rooms by referencing the Weekly Safety Reports. This will permit the Maintenanace Supervisor to remedy any issues with the water heating system in an immediate fashion. Date completed:7/24/15 |
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 facility's medication storage area inspection log, the facility failed to document quarterly inspections of the medication storage area.
The findings include:
The medication area inspection log was reviewed on June 4, 2015 from the time period covering October 2014 to June 2015. The facility failed to document the inspections of the medication storage area during December 2014.
These findings were reviewed and confirmed with facility staff during the licensing process.
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Plan of Correction
Facility Director reviewed DDAP regulation with LPN on quarterly medication storage inspections expectation. LPN is to notify Facility Supervisor if Inspections are not being held in the required quarters of the year: March, June, September, and December. Facility Director will review contract with the Pharmacy, and have them hold the required quarterly inspections. If pharmacy fails to complete this expectation, Facility Director will secure a new Pharmacy to supply medications to the facility. Date of Completion 6/10/15 |