INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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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 on August 27, 2019 around 2:30pm, the facility's dumpster was observed to have a broken lid that exposed the trash.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director Contacted Waste management on the afternoon of 8/27/19, and requested that they either fix or replace the dumpster with the broken lid. Waste Management replaced the dumpster on 8/28/19. Dumpster inspection will be added to the safety and security checklist that is completed weekly to ensure that dumpsters are secure and intact. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of seven client records, the facility failed to document a completed consent to release information in one records, as there were forms that were missing required information.
Client #2 was admitted on July 23, 2019 and was still active at the time of the inspection. There was a consent to release form, signed and dated on August 21, 2019 to an external provider, but the consent form did not include specific information disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client Chart #2 was remedied for this consent on 8/28/19. All staff were retrained on the expectation that all consents must have the information that would be disclosed/purpose checked off as well as a signature. Clinical director will be checking the charts on a monthly basis to ensure that the consents are completed in the proper fashion. |
715.17(c)(3)(i-v) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(3) Inspection of storage areas. A narcotic treatment program shall inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
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Observations
Based on a physical plant insepction conducted on August 27, 2019, it was observed that the refrigerator in the medical room storing medication also housed food, drinks and condiments.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The food items were removed from the refrigerator on 8/27/19. All staff were retrained of the expectation that no food items(condiments or otherwise) are to be stored in the medical room refrigerator on 9/11/19.The refrigerator will be inspected on a monthly basis by facility Director to ensure that the refrigerator has not food items stored in it. It was inspected on 9/18/19, there was nothing but medical supplies in the medical room room refrigerator. |