INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 8 and 9 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Treatment Trends Inc. Keenan House 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 January 5, 2011.
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Plan of Correction
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705.5 (c) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(c) No more than four residents may share a bedroom.
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Observations
Based on a physical plant inspection, the facility failed to have no more than four residents per room.
The findings include:
Twelve patient bedrooms were inspected at 12:30 PM and an interview with the Facility Director at 1:30 PM confirmed that the facility had five extra beds in place in the patients' bedrooms. The facility had 2 extra beds in room # 201 and 2 extra beds in room # 203 with a total of 6 patients per bedroom. The facility also had one extra bed in room # 101. Documentation of past fire drills on 8-27-2010(97), 8-14-2010 (98), 3-30-2010 (99), and 4-20-2010(97) confirmed the facility was over capacity.
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Plan of Correction
Due to discharge difficulties, Keenan House exceeded capacity upon inspection and was thus out of compliance with Sleeping Accommodations standard 705.5. On 12/22/2010 Keenan House ceased admission of female clientele until the situation could be reamedied. Discharge plans were reviewed and the team made arrangements to move clients as soon as it responsibily possible. Beds will be removed upon client discarg and will not be replaced.
One (1) bed was removed on 1/4/2011 upon client discharge. Subsequent discharges/bed removals are as follows:
One (1) on 1/10/2011, One (1) on 1/18/2011 and two (2) on 1/24/2011. This will reduce the total of beds to 95 which brings Keenan House into complience of standard 705.5.
In addition, the Clinical and Admissions directors will contine to meet to review new discharge protocols to ensure accurate census projection. |
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 on patient staff interviews, the facility failed to follow their policy and procedure for bed bug infestation.
The findings include:
Based on an interview of patients and the facility director on December,20010 at 1:00 PM, the facility failed to have a insect free facility. The physician treated a bug bitten patient at 10: 00 AM in the examining room. The patients interviewed complained about the bug bites they were getting as they slept. Upon inspection of a residential floor, this inspector viewed that several different patients' laundry were together in mesh bags and not plastic bags as indicated in their policy and procedure The facility failed to follow through with policy to contain infestation of bed bugs.
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Plan of Correction
As the United States battled with Bed Bug infestation, so too did Keenan House. Terminix was utilized to combat these pests at first sight. Metal beds were purchased to replace wood beds in rooms that were resisting treatment. Bed Bug proof covers were purchased for the entire house and placed upon the beds. New admission and cleaning procedures were developed with Terminix input. At this writing, January 6, 2011, no Bed Bugs sightings or signs have been reported by staff or clients. Keenan House is Bed Bug free and in compliance with general safety and emergency proceedure 705.9 |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on the review of client records, the facility failed to document the record of services in six of ight client records
The findings include:
Eight records were reviewed on December 10, 2010. The record of services was required in eight client records. The facility failed to document activities in the record of services in client records # 1,2, 5, 6, 7, and 8. An interview with facility staff confirmed the record of service had not been discontinued.
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Plan of Correction
The Clinical Supervisor has reviewed with Clinical staff the correct system of documentation of services on the Record of Service sheet. This was completed on January 3, 2011. The Clinical Supervisor and Director will review charts to ensure that compliance with Records of Service standard 709.53 is met. |
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, the facility failed to document progress notes in six of eight client records.
The findings include:
Six records were reviewed on on December 9th and 10th , 2010. Progress notes were required in eight client records. The facility failed to document progress notes in client records #1 ,2 and 5, 6,7, and 8. In addition, an interview took place on December 10, 2010 with the Facility Director and Clinical Supervisor to explain progress notes must be documented on the record of service each time the patient has a individual or group session.. Canceled counseling may not be documented as services received.
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Plan of Correction
The Clinical Supervisor met with staff on 1/3/2011 to review the proper documentation techniques on the Record of Service. In addition the staff reviewed how to properly document when a planned primary group is cancelled in order to conduct a whole house meeting. The Clinical Supervisor and Clinical Director will review charts to ensure standard 709.53(a)(5) is met. |