INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 1-2-2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Harwood 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 December 23, 2010.
|
Plan of Correction
|
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records on December 2, 2010, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment.
The findings include:
Based on a review of five client records, one record was required to have a notification of termination. The notification of termination was missing in one of three client records reviewed. Client record #5 had documentation in the progress notes concerning the the termination from the counselor and signed by the counselor but failed to have the client sign notification of the termination..
|
Plan of Correction
It is the responsibility of the staff on duty at the time of involuntary discharge to complete discharge notification form. Discharge forms were updated and will be included in client record with other continuing care paperwork.
All staff will be trained on the new Discharge Notification form by 12/20/2010. The clinical team was trained on 12/6/2010.
It is the responsibility of the clinical supervisor to ensure that the Discharge Notification form is documented in each client record.
It is the responsibility of the program director to ensure overall compliance. |
705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
|
Observations
Based on an inspection of the physical plant, the facility failed to provide a method to determine the temperature of the food served and prepared by the residents.
The findings include:
The physical plant was inspected on December 2 ,2010 between 11:30 AM an 12:30 PM. A interview with the Facility Director and the Clinical Supervisor at 12:30 PM confirmed that the facility was unaware of the temperature of the food being served on a daily basis to the patients who lived there and failed to present a method to determine the temperature of the food being prepared at the facility. Hot food being prepared by the patients living at the facility must be 140 degrees or higher .
|
Plan of Correction
It is the responsibility of the person cooking the meal to check the temperature of the hot food (140 degrees F)before serving the food and document temperatures in hot temperature book located in kitchen.
It is the responsibility of the staff on duty for ensuring that residents cooking the meal are following the procedure.
It is the responsibility of the clinical supervisor to ensure that all residents are informed of this procedure by including the food temperature check at or above 140F in the daily reminder list read each moring after goals meeting.
All staff will be informed of the hot food temperature check by 12/20/2010.
Program director will ensure overall compliance. |