INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on June 5, 2017 by staff from the Division of Accountability and Program Improvement. Based on the findings of the on-site complaint investigation, Tradition House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
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.
|
Observations
A physical plant inspection was conducted on June 5, 2017. Based on this inspection, the facility failed to keep the exterior of the building in good repair as evidenced by the ceilings in the kitchen and Bedroom #20 having water damage.
|
Plan of Correction
On May 23, 2017 we received new fold out screens for the bedrooms that did not have screens. This will ensure proper ventilation, as well as, safety for all residents. Bedroom#20 had a new latch installed so it opens properly. This will eliminate residents propping windows open with objects. Bedroom#31 had a new screen installed on 6/09/17. |
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.
|
Observations
Clients and staff were interviewed on June 5, 2017. Based on these interviews, the facility failed to ensure that each client was provided with a bed with solid foundation and fire retardant mattress as it was reported that clients were sleeping on mattresses on the floor of other rooms and on the sofas while Bedroom #31 was being treated for bedbugs.
|
Plan of Correction
In the event of a situation where residents will be displaced from their room, all residents will be provided a solid bed frame and fire retardant mattress. The Program Director will educate all staff on this policy and ensure it is implemented in all cases. |
705.5 (h) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(h) Each bedroom shall be ventilated by operable windows or have mechanical ventilation.
|
Observations
A physical plant inspection was conducted on June 5, 2017. Based on this inspection, the facility failed to ventilate each bedroom by operable windows as the window in Bedroom #20 was held open by a paper towel roll and the window in Bedroom #31 had a ripped screen.
|
Plan of Correction
On May 23, 2017 we received new fold out screens for the bedrooms that did not have screens. This will ensure proper ventilation, as well as, safety for all residents. Bedroom#20 had a new latch installed so it opens properly. This will eliminate residents propping windows open with objects. Bedroom#31 had a new screen installed on 6/09/17.
|
705.5 (k) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(k) Bedrooms located in a basement shall meet the following requirements:
(1) The bedroom shall have wall, floor and ceiling coverings such as tile, linoleum, paneling or dry wall.
|
Observations
Clients and staff were interviewed on June 5, 2017. Based on these interviews, it was reported that a sofa was moved to the basement for a client to sleep on to quarantine this client for a period of five to eight days.
|
Plan of Correction
If medical conditions that require quarantine arise, we will move forward with a referral to a medically supervised level of care or medically discharge to home with proper aftercare. |
705.5 (k) (2) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(k) Bedrooms located in a basement shall meet the following requirements:
(2) The bedroom shall have a protective fire wall between the residents and any furnace.
|
Observations
Clients and staff were interviewed on June 5, 2017. Based on these interviews, it was reported that a sofa was moved to the basement for a client to sleep on. There was no protective fire wall between the resident and the furnace.
|
Plan of Correction
The furnace in the downstairs lounge will be removed by 8/1/17 and replaced with an approved wall mount heater. If medical conditions that require quarantine arise, we will move forward with a referral to a medically supervised level of care or medically discharge to home with proper aftercare. The Halfway House Nurse will arrange proper medical referrals and appointments. The Program Director and Primary Counselor will facilitate the transfer or discharge. |
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.
|
Observations
A physical plant inspection was conducted on June 5, 2017. Based on this inspection, the facility failed to ensure that storage areas for food were free of food particles, dust, and dirt as there were rodent droppings in the food storage areas.
|
Plan of Correction
A deep clean of the food dry storage was conducted on 6/1/17. Cleaning/dusting of this room will be a daily chore. All food has been placed in plastic storage bins for proper storage. Staff will check daily to ensure there is no evidence of rodent droppings. Staff began completing a daily check list for the kitchen area on 6/16/17, to ensure it remains clean and sanitary. As of 6/16/17, there have been no signs of rodent droppings in the kitchen or food storage area. We will continue to have regular monthly checks from Ehrlich to ensure there are no further issues regarding the rodents. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
|
Observations
A physical plant inspection was conducted on June 5, 2017. Based on this inspection, the facility failed to store all food items off the floor as there was a crate of onions and boxes of produce on the basement floor.
|
Plan of Correction
Staff will ensure that all food bins are kept on the storage shelves. Staff and clients will be educated on proper food storage. A checklist has been posted for the kitchen and dry food storage, regarding regulations for these areas. |
705.7 (b) (7) 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:
(7) Prohibit pets in the food preparation area.
|
Observations
A physical plant inspection was conducted on June 5, 2017. Based on this inspection, the facility failed to prohibit pets in the food preparation area as there was a cat in the facility that had free range of the house.
|
Plan of Correction
Staff will ensure that no animals are in the kitchen/dining area at all times. The cat is no longer at Traditions House, effective 6/15/17. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
A physical plant inspection was conducted on June 5, 2017. Based on this inspection, the facility failed to permanently mount or install heaters as there was a space heater in a counselor's office in the basement.
|
Plan of Correction
The space heater was removed from the office on 6/8/17. All staff were addressed on regulations regarding the use of space heaters on 6/15/17. |
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.
|
Observations
A physical plant inspection was conducted on June 5, 2017. Based on this inspection, the facility failed to be free of rodent and insect infestation as there was evidence of rodent infestation throughout the facility. In addition, both staff and clients reported that the facility had bed bugs but and that Bedroom #31 was treated over the weekend.
|
Plan of Correction
Ehrlich will continue to provide services to assist with the rodent infestation. We have scheduled with Ehrlich to have the bedbug canine at Traditions House on July 19, 2017 to ensure no further issues with bed bugs. |
705.9 (2) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(2) Require that pets housed in the residential facility are cared for in a safe and sanitary manner.
|
Observations
Clients and staff were interviewed on June 5, 2017. Based on these interviews, the facility failed to ensure that the pets housed at the facility were cared for in a safe and sanitary manner. In addition, a client's medical record was reviewed. It indicated the client was sent to UPMC Altoona on May 4, 2017 and again on May 5, 2017 due to a rash on her skin. The client was then sent to a dermatologist on May 11, 2017. The diagnosis was Generalized Papular Urticaria. Part of the treatment was to check the facility cat for fleas. The cat was not treated for fleas until June 1, 2017 as evident by a Shift Log entry on that date that read the cat was bathed and treated for fleas. It was reported that multiple clients had allergic reactions to the cat.
|
Plan of Correction
The cat is no longer at the facility as of 6/15/17. Ehrlich conducted a flee inspection on 6/15/17, which indicated no signs of flee infestation. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
A physical plant inspection was conducted on June 5, 2017. Based on this inspection, the facility failed to ensure that the date of the annual fire inspection was on the inspection tag as a fire extinguisher in the second-floor hallway was missing an inspection tag.
|
Plan of Correction
The fire extinguisher on the 2nd floor was checked and a new inspection tag was added on 6/8/17. The risk members will continue to check extinguishers during monthly risk walk-throughs. |
709.34 (c) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(5) Outbreak of a contagious disease requiring CDC notification.
|
Observations
Clients and staff were interviewed on June 5, 2017. Based on these interviews, the facility failed to file a written unusual incident report with the Department within 3 business days following the outbreak of a contagious disease requiring CDC notification as the Department was not notified that one client had shingles and another one client had chicken pox.
|
Plan of Correction
In the event that a client receives a diagnosis of chicken pox or shingles, an unusual incident report will occur withing 3 business days following the outbreak. Infection Control Nurse will review facility Infection control reports 30 days pre and post exposure to identify any client exposures. This will be in effect immediately. |
709.17(a)(8) 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:
(8) Mistreating or abusing individuals cared for or treated by the facility.
|
Observations
Clients and staff were interviewed on June 5, 2017. Based on these interviews, Tradition House, by nature of its physical condition and its mishandling of a communicable disease, has mistreated individuals cared for and treated by the facility.
|
Plan of Correction
If medical conditions that require quarantine arise, we will move forward with a referral to a medically supervised level of care or medically discharge to home with proper aftercare. |
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.
|
Observations
A physical plant inspection was conducted on June 5, 2017. Based on this inspection, Tradition House failed to ensure that the facility, by nature of its physical condition, would not endanger the health and safety of staff, clients, and the public. The facility was infested with bed bugs and rodents and had a pet that posed a health risk due to improper care of the animal.
See PP091 for additional information regarding the infestation. See PP093 regarding the care of the pet.
|
Plan of Correction
Pyramid Healthcare will continue to provide a standing contract with Ehrlich Pest Control Services. Services will continue to include spraying, canine services etc. Risk Management will continue to do weekly walk-through to monitor progress with these areas. |