INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring inspection conducted on October 13, 2021 through October 14, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital 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 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection conducted on October 14, 2021, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents. The dumpster, located in the exterior fenced-in area of the property, did not have the lids attached to cover the trash properly at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New dumpster lids were ordered by the Environmental Services Coordinator and received by the Hospital on 10/27/2021.
Maintenance placed the lids on the dumpster located in the exterior, fenced in area of the Hospital in order to cover the trash properly.
In order to assure continued compliance, the Environmental Services Coordinator placed the task of monitoring the dumpsters located in the exterior of the building to the Monthly Environmental Rounds Checklist on 10/27/2021.
The results from this monthly monitoring will be reported to the Safety Committee at their quarterly meetings. |
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 a physical plant inspection conducted on October 14, 2021, the facility failed to ensure that each bedroom had a bed with a solid foundation and a fire retardant mattress in good repair. The mattress on the bed, located in bedroom # 205, had a large tear on the top of the mattress.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The mattress located in Patient Room #205 was discarded and replaced with a new mattress on 10/15/2021.
In order to assure continued compliance, the monitoring of all mattresses on all patient beds will be done on a monthly basis by the Maintenance Staff.
This task was added to the Monthly Environmental Rounds Checklist by Environmental Services Coordinator on 10/15/2021. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on the physical plant inspection conducted on October 14, 2021, the facility failed to ensure that each bathroom was ventilated by either an operable exhaust fan or a window. The bathroom in bedroom #204 and the bathroom in bedroom #206 did not have windows and the exhaust fans in both bathrooms were inoperable.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Maintenance staff repaired the exhaust fan in both Room 204 and 206 on 10/19/2021.
In order to assure continued compliance, the monitoring of all patient bathroom exhaust fans were added to the Monthly Environmental Rounds Checklist by the Environmental Rounds Coordinator on 10/19/2021.
The results of this monthly monitoring will be reported by the Environmental Services Coordinator to the Hospital's Safety Committee every other month. |
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 a physical plant inspection conducted on October 14, 2021, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The bathroom, located in bedroom # 205, appeared to have what looked like mildew around the base of the shower stall.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Housekeeping staff thoroughly cleaned the appearance of mildew at the base of the shower stall in room 205 on 10/15/2021.
The Maintenance staff then re-caulked the base of the shower stall in patient room 205.
In order to assure continued compliance, the thorough cleaning of all patient bathroom stalls will be monitored on a monthly basis by the Housekeeping staff.
This task was added to the Monthly Environmental Rounds Checklist form by the Environmental Services Coordinator on 10/15/2021 |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection conducted on October 14, 2021, the facility failed to limit smoking to the designated smoking areas. There was a strong and distinct cigarette smell in the bathroom of bedroom #208.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor conducted a staff meeting on 10/19/2021 with the the Admissions Intake Staff to remind the staff to thoroughly search all patients for any contraband in the Admissions Intake Unit (prior to escorting the patient to the unit).
The Director of Nursing also met with the Nursing staff on 10/18/2021 & 10/19/2021 to remind the Nursing staff of the importance of searching the patient upon their arrival to the unit.
Any contraband found on a patient is immediately taken from the patient and destroyed accordingly.
In order to assure continued compliance, the Clinical staff will notify Security of any smell of smoke, etc, in order for the security staff to perform a thorough search of the patient's room in question.
Results from any patient room search will be reported to the Safety Committee every other month.
Also, individuals admitted to Kensington Hospital who smoke are offered smoking cessation (nicotine patch).
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711.53(c)(3) LICENSURE Copy of Client Consent
711.53. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent to release information form was offered to the client in one of seven applicable client records reviewed.
Client # 19 was admitted to the residential non-hospital level of care on August 25, 2021 and was discharged on September 8, 2021. A release of information form to an emergency contact was signed and dated by the client on August 25, 2021, but there was no documentation that indicated a copy of the form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor provided an in-service training to all Counselors on 10/20/2021 to remind the counselors to ensure that a copy of a client Consent to Release Information form is offered to the client and documented on the medical record.
In order to assure continued compliance, the Clinical Supervisor will review medical records on a monthly basis to assure the client was offered a copy of the Consent to Release Information form and that it was properly documented on the medical record.
The results of this monitoring will be reported to the Performance Improvement Committee on a quarterly basis for the next 6 months or until 100% compliance is reached. |