INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on by staff from the Division of Drug and Alcohol Program Licensure on October 15, 2009. Based on the findings of the on-site complaint investigation, Gaudenzia Common Ground 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 and a plan of correction is due on November 11, 2009.
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Plan of Correction
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on observation and a tour of the physical plant, the facility failed to maintain each bathroom in a clean and sanitary manner at all times.
The findings include:
On October 15, 2009 at 2:17 PM, during the tour of the facility, mold was present in the bathroom that patients in rooms # 14 and 16 shared, and the shower curtain was also very moldy in this bathroom. Additionally, there was mold in the bathroom shared between patients in rooms # 13 and 15.
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Plan of Correction
Bathrooms will be maintained in a clean and sanitary manner at all times.
Bathrooms were immediately cleaned, mold was treated, and shower curtains were replaced with new curtains.
Routine cleaning will occur weekly. Bathrooms will be inspected daily and documentation of unacceptable conditions will be noted on the daily maintenance run sheet. The designated Staff on Duty for each day shall be responsible for coordination of inspections and cleaning.
Target Resolution Date: 11/12/09 |
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 the physical plant tours and observation, the facility failed to clean and disinfect eating, drinking and cooking utensils properly and store utensils in an enclosed area.
The findings include:
A physical plant tour was conducted on October 15, 2009 from 12:20 P.M. until 12:45 P.M. and from 2:00 P.M. - 3:15 P.M. The facility failed to follow their policy and procedure titled PROGRAM MANAGEMENT POLICY & PROCEDURE FOR FOOD PREPARATION & DIETETIC SERVICES (Residential) dated January, 2009
1. Subsection X. Dishwashing 2 d. Manual cleaning and sanitizing of dinnerware stipulated that when doing dishes manually, dishes were to be sanitized in the third compartment of three-compartment sink in sanitizing tablet solution per package directions. Based upon an interview with the facility kitchen staff and clients assigned to conduct work therapy in the kitchen, contradicting information on the number of sanitation tablets to be used was not consistent. The kitchen staff worker reported that five tablets were to be used if the sink was half full. The clients assigned to work therapy in the kitchen reported that three tablets should be used. Those interviewed reported that staff and clients had not been measuring the amount of water that was being put in the sink nor had they been testing it to ensure that the chemical sanitizer they were using was adequate to kill the germs and not leave a chemical residue on the dishes. The licensing specialist supervisor and licensing specialist requested that the cook measure the water to see how much sanitizing disinfectant should be used according to the directions on the bottle. The cook measured the water in the sink while the licensing specialists observed. The amount of water that had been used should have utilized 10 sanitizing tablets. The facility failed to use the correct amount of sanitizing tablets. The cook also showed the licensing specialist supervisor that the measuring pitcher that was put away was not cleaned by the person who made "Kool- Aid" prior to her using it.
2. Subsection X. Dishwashing 2 f. Manual cleaning and sanitizing of dinnerware stipulated that dishes were to be air-dried when doing dishes manually. Based on observation the clients assigned to work therapy in the kitchen were towel drying cups and stacking them prior to proper air-drying.
3. Based on a physical plant tour conducted on May 15, 2009 between 2:00 p.m. and 3:15 p.m. the facility failed to ensure that utensils were stored in an enclosed area. The utensils were stored in open containers.
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Plan of Correction
The Cook will assure conformance with all licensing regulations and agency policies around the cleaning of all eating, drinking and cooking utensils and all food preparation areas after each usage and storage of the utensils in a clean enclosed area.
Regulations, policies, and protocols were reviewed with the cook and other staff, including but not limited to proper use of sanitizer, air drying of dishware and cups, and enclosed storage of silverware. Same information has been included in the orientation of clients assigned to kitchen related work therapy.
The Cook will monitor ongoing conformance and report findings in her monthly QI report for review by the regional QI committee and Safety Committee.
Target resolution Date: 11/12/09
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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 upon physical plant tours conducted between the hours of 12:20 P.M. and 12:45 P.M. and 2:00 P.M - 3:15 P.M. and staff interviews, conducted on October 15, 2009 the provider failed to ensure that the facility followed their policy and procedures for Bed bugs.
Findings include:
On October 15, 2009 physical plant tours were conduced between the hours of 12:20 P.M. and 12:45 P.M. and 2:00 P.M. - 3:15 P.M. In addition interviews were conducted with the Clinical Director, Central Region Property Manager, House Manager, Cook/House Manager, and Nurse confirming that the facility was not following their policy and procedures for bed bugs and that the facility's Central Region Property Manager found two bed bugs in room # 11 and past evidence in room 12 and treated the room for bed bugs approximately eight days ago. The Central Property Manager was not sure if it was last Thursday or the Thursday before. In addition the Nurse confirmed in a telephone conversation on October 16, 2009 that there were client's reporting bug bites.
1. An interview with the Central Region Property Manager was conducted via telephone on October 15, 2009 at approximately 12:15 p.m. - 12:20 p.m. in the Clinical Director's Office. The Central Region Property Manager did state that approximately 8 days ago he received complaints from the House Manager in reference to rooms # 11, 12, 14, and 15. He also checked room # 8 as a precaution due to the client who was assigned to that room had entered the program from a hotel in Harrisburg that is known to have bed bugs. The Central Region Property Manager did confirm that he found two bugs in the frame of a bed in room 11. He stated that one was definitely alive. He reported that he was not sure if the second bug was alive or not. He stated that when he uses a product on the beds that it can shoot out a past bed bugs that might have been dead. The Central Region Manager stated he did find past evidence of bed bugs in room 12. The Central Region Property Manager was questioned on the policy for the staff to screen, clean and store client's property upon admission to the program. He reported that the policy was distributed to all directors. He stated that he did not fumigate the property by setting off any bombs; however, they did treat all the rooms while he was investigating the allegations of bed bugs and intends to come back on Monday October 19, 2009 to do more.
2. An interview was conducted with the Clinical Director at 12: 18 P.M. on what the protocol is for dealing with client property when a enters the program. The Clinical Director stated that the bags are labeled and screened with gloved hands. The bags are then returned to the client and the bags are then taken to the client's room. The Clinical Director stated that some items are stored either in the hall closet or on shelves in the bathroom off of her office. She also reported that they do have a policy and procedure stating they are supposed to wash items before storage. The Clinical Director contacted the house manager on duty over the phone. The House Manager was questioned on what the protocol was for a new client coming into the facility and the House Manager was not aware of the policy that the client's property must be washed before storing. The Clinical Director then contacted the Cook/House Manager and she reported that she was aware of the policy to launder all clothing prior to storing in the client's room.
3. The Licensing Staff did interview the Cook/ House Manager at 2:00 P.M. and she reported that she is aware of what the policy is on laundering the client's clothes prior to storage and confirmed that a memo did go out about this procedure. However, the policy is not always followed depending on the number of admissions coming in at one time.
4. The facility failed to follow section (C)(5) of their policy and procedure titled "CLIENT INTAKE - HYGIENE AND CLOTHING SCREENING" Dated November, 2008. Section (C)(5) states: " The client's luggage and/or baggage are to be bagged and sealed and taken to storage. If the belongings have been brought in in [sic] plastic bags, those bags must be discarded immediately in an outdoor container after the belongings have been rebagged for removal to the laundry room and the luggage have been bagged for storage." It was observed during the physical plant tour from 12:30 P.M. and then again during the second tour at 2:00 P.M. to 3:15 P.M. that luggage and boxes were not bagged per policy and the luggage was placed in a storage closet on the second floor. It was observed that there were articles of clothing in two of the boxes, a pillow in another box. books and a radio in another box, and the boxes were not placed in proper storage bags. Additionally, luggage and duffel bags were in client bedrooms and not placed in storage per company policy. The Clinical Director confirmed that clients were permitted to keep their luggage and duffel bags in their rooms. There was a duffel bag observed in room #8 .
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Plan of Correction
The program will adhere to licensing regulations around the provision of a treatment facility that is free of rodent and insect infestation.
Program staff will adhere to all agency policies and protocols associated with pest control including bed bugs.
On 10/19/09, the Central Region Physical Plant Manager trained all program staff on bed bug protocols including but not limited to screening of client and client belongings, laundering of all clothing/shoes at admission, confiscation and sealed plastic storage of luggage, bags, etc..., handling of linens, room inspections, and immediate chemical treatment of sited bugs. Training feedback sheets were completed by staff.
The Program Director distributed copies of the bed bug and pest control policies and protocols to all staff. Staff signatures verifying receipt of information and intent to comply were obtained and forwarded to the agency Safety Committee on 10/22/09.
Ongoing room inspections are conducted twice daily by designated staff on duty and findings are documented in a log book.
Any bug findings are immediately reported to the Program Director who subsequently promptly reports such to the Central Region Director. The Central Region Director directs extermination services in collaboration with the Regional Physical Plant Manager.
Ongoing monitoring of protocol conformance is reported in daily logs and monthly reports completed by designated staff on duty and the Program Director then submitted to the QI and Safety Committees.
Targeted Resolution date: 11/12/09 |
709.53(a)(5) LICENSURE Progress Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on the review of client records and an interview with the Clinical Director, the facility failed to document progress notes in one of two client records.
The findings include:
Two records were reviewed on October 15, 2009. Progress notes were required in two client records. The facility failed to document progress notes in client record # 2. Client #2 was admitted on September 22, 2009. The Clinical Director reviewed the chart in question and confirmed that the notes were not present in the client file. She stated that the notes could be in the counselor's office waiting to be filed. They were not made available during the time of the inspection.
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Plan of Correction
The assigned Primary Counselor shall assure that there is a complete client record on an individual which includes information relative to the client's involvement with the project, including but not limited to progress notes.
The missing notes from record #2 were located and filed in the record.
The Clinical Supervisor discussed with clinical and medical staff the importance of timely filing of documents into the client record.
Ongoing conformance shall be monitored by the Clinical Supervisor and reported monthly to the regional QI Committee.
Targeted resolution Date: 11/12/09 |