INITIAL COMMENTS
|
This report is a result of an on-site licensure inspection conducted on January 7 & 8, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, ADAPPT 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:
|
Plan of Correction
|
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
Based on a physical plant inspection which included the inspection of mattresses and pillows throughout the facility as part of the onsite licensing inspection of January 7 & 8, 2013, the facility failed to ensure that all mattresses were in good condition.
The findings include:
58 mattresses were inspected for cleanliness and good repair during the physical plant inspection . The mattress type used had a shiny blue mattress cover made of durable fabric. Tears were noted in the following mattress covers:
Room # 10 had 4 beds and 2 torn mattresses were identified during the inspection.
Room # 9 had 4 beds and 4 torn mattresses were identified during the inspection.
Room # 7 had 7 beds and 5 torn mattresses were identified during the inspection.
Room # 6 had 6 beds and 3 torn mattresses were identified during the inspection.
Room # 5 had 7 beds and 2 torn mattresses were identified during the inspection.
Room # 4 had 6 beds and 2 torn mattresses were identified during the inspection.
Room # 3 had 7 beds and 3 torn mattresses were identified during the inspection.
Room # 2 had 7 beds and 5 torn mattresses were identified during the inspection.
Room # 1 had 6 beds and 4 torn mattresses were identified during the inspection.
A total of 30 mattresses were torn and in need of replacement.
The Director of maintenance confirmed these findings.
|
Plan of Correction
Two torn mattresses in Room #10 have been replaced.
Four torn mattresses in Room #9 have been replaced.
Five torn mattresses in Room #7 have been replaced.
A total of 5 mattresses in Room#6 were replaced.
A grand total of 46 mattresses have been ordered from "Bob Barker" with an expected delivery time of 5-6 weeks (or sooner). Upon delivery all of the remaining torn mattresses will be replaced.
Going forward, mattresses will be inspected for tears on a weekly basis by maintenance staff or designee. Maintenance/designee will inform the Director of the need to replace torn mattresses; at which time the Director will submit a request to purchase necessary mattress replacements. |
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
Based on a physical plant tour, a heater that was not permanently mounted or installed was located during the inspection.
The findings include:
A physical plant inspection took place on January 8, 2013 at 9:00 A.M. During this inspection, it was observed that there was heater in a counselor's office that was not permanently mounted.
The director of maintenance confirmed this finding.
|
Plan of Correction
The referenced heater has been permmanently removed from the counselor's office. Going forward any request (medical or otherwise) for the use of a heater will require that said heater be either installed or mounted.
Staff has been made aware of this policy and maintenance personnel/designee will do a visual check of the facility on a daily basis to ensure this deficiency does not re-occur |
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
Based on the physical plant inspection, the results of client interviews and documentation presented to Division staff at the time of the inspection, the facility failed to ensure that it was free of rodent and insect infestation at all times.
The findings include:
Four clients were randomly selected for interviews during the onsite physical plant inspection of January 8, 2013. Invoices from two pest control contractors were reviewed and a physical plant inspection which included an inspection of all mattresses and pillows in the facility was completed also on this date.
Clients interviews verified there were observations of bedbugs in the bedroom areas of the facility. One client reported that bedbugs had been caught in his room. Invoices from the pest control contractor verified the presence of bed bugs from 11/2012 through January 9, 2013. Dead bed bugs were observed on mattresses in room 5 on January 8, 2013. The exterminator was completing another treatment to room #4 and 5 as the physical plant was in process. The exterminated showed this licensing inspector nine photographs of bedbug findings that were taken the morning of the inspection. Room # 4 had live bedbugs on the sheet during the physical plant January 8, 2013.
Review of the topical creams in the client medication storage area and confirmation with staff who administered medication confirmed two clients were receiving treatment from the facility doctor for bedbug bites.
|
Plan of Correction
ADAPPT will take the following control measures to prevent or eliminate infestations:
ADAPPT Policy 705.9 (1)will be made known to all staff and clients arriving at ADAPPT.
(1) The residential facility shall "Be free of rodent and insect infestation".
During orientation case managers/counselors shall provide all clients with policy information regarding bed bugs and prevention/treatment procedures. Each client shall be required to sign-off to indicate they have received the policy and understand the information provided.
New residents shall be required to shower and launder all clothing as soon as physically possible upon entering the facility. A designated waiting area furnished with plastic chairs shall be provided.
Residents' clothing shall be bagged, sealed, and then placed in a dryer on high heat by desinated staff as soon as possible within 24 hours. A change of clothing will be provided at this time.
Wooden beds will progressively be replaced with metal or laminate bed frames. The wooden beds will be disposed of properly.
Mattresses with tears, holes, or other openings will be discarded. Maintenance personnel will inspect mattresses on a weekly basis.
Case Managers/Counselors will educate residents on the nature of the problem, early signs of infestation, the severity of an infestation, the need to treat it proactively, and the preventative steps that can be taken to avoid getting bed bugs in one's room.
The Manager of Operations/designee shall conduct on-going staff training sessions to educate about bed bugs, how to detect them, how to prevent infestations, and how to prevent infestations from spreading.
Random spot checks shall be conducted in all buildings along with weekly inspections performed by staff and ADAPPT's contracted pest management service provider.
Residents shall be encouraged to wash clothes and bedding on a regular basis.
Residents shall be encouraged to come forward and identify infestation. All reports of bed bugs shall be taken seriously.
If an infestation is confirmed, all bedding and clothing shall be sealed in clear plastic bags and laundered in the hottest cycle possible for the fabric. Clothes, blankets, pillows, bags, and other possessions that are not essential during a resident's stay shall not be brought into the facility.
ADAPPT/CEC contracts with a certified pest management provider who has developed a comprehensive pro-active plan which includes a weekly pest management service and consultation to control and eliminate the infestation of bed bugs.
Any resident or staff member that suspects a bed bug issue through unidentified bug bites, or visual sight of bed bugs shall immediately notify a Supervisor. The Shift Supervisor shall notify maintenance personnel/designee who shall check the area in qustion. The Supervisor or designee shall look for witness of bed bugs, e.g., blood spatters, excretory matter of the bugs themselves. Any of these sightings shall prompt immediate contact with the pest control provider for service.
If upon inspectiion by the supervisor/designee, no bugs or signs of infestation are found in the area in question it shall be noted and addrssed at the next weekly service.
In addition to scheduled weekly spraying for bed bugs, areas that were reported throughout the week as potential problems , along with random spot checks shall be conducted at the facility as part of our standard service.
The Facility Director shall be responsible for the overall maintenance and adherence to this policy. |
705.9 (5) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(5) Notify the Department within 48 hours of a fire, other disaster or situation which affects the continuation of services.
|
Observations
Based on a review of the facility's on-site exterminator reports, the facility failed to contact the department of a situation that effects the continuation of services, in this case bed bug infestation.
The findings include:
During an on-site physical plant inspection on January 8, 2012, a review of the facility's extermination records for one year and the review of two complaints from residents confirmed the facility failed to inform the department of an on-site bedbug infestation at the facility.
The on-site inspection confirmed the clients were being moved out of their bedrooms as the bedbugs were being treated and the clients had to heat their belongings at the area laundry mat. As these steps were being taken, the clients were removed from their treatment services.
The Facility Director confirmed that the facility failed to report the bedbug infestation to the department.
|
Plan of Correction
The Director or designee will notify the Department within 48 hours to report any situation that effects the continuation of services, e.g., infestations,fire, etc.
All current staff and clients have been verbally advised to report to supervisory staff any indication of any situation that would effect the continuation of services which would include any sightings of bed bugs.
During orientation all clients will be provided policy information regarding bed bugs, and will be educated on the nature of the problem, the severity of an infestation, the need to treat pro-actively, and the preventive steps that can be taken to avoid getting bed bugs in one's room.
The Deputy Director will ensure that staff training sessions will be held periodically by supervisory staff to educate about bed bugs, how to detect them, how to prevent infestations, and how to prevent infestations from spreading. Supervisory staff at these trainings will also re-enforce the need to immediatley report any sightings or associated complaints. |
709.54(a)(5) LICENSURE Personal hygiene
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(5) Personal hygiene for those in food preparation areas.
|
Observations
Based on a review of facility policies and procedures an on-site physical plant inspection, the facility failed to ensure that staff wore hair nets or protective head covers during the preparations of meals.
The findings include:
Facility policy states that hair nets or protective head gear are to be worn during the preparation of food.
During the on-site inspection of the residential kitchen area on January 8, 2013, the facility failed to have all staff wear hair nets or protective head covers during the preparations of meals.
Three of the four employees required hair protection. Two employees failed to have hair nets on during the preparation of food.
This finding was confirmed by the director of maintenance on January 8, 2013 at 10:00 A.M. during the on-site physical plant inspection.
|
Plan of Correction
The Food Services Manager/Designee shall ensure by a daily visual check that all food service personnel adhere to ADAPPT Policy 13002. related to 709 (a) (4), which states the following.
"Hairnets, or hats, shall be worn to confine hair to prevent food contamination. Personnel with very long hair shall tie their hair back and shall wear a hat and hair net. Hats and hair nets shall be clean at all times."
A copy of ADAPPT Policy 13002 has been re-distributed to all food service personnel. There were no questions regarding the policy and all have signed that they have read and understand it. |