INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 28-29, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia DRC Inc. 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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705.7 (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.
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Observations
Based on a physical plant inspection, the facility failed to maintain frozen food at or below 0 findings include:
An inspection of the facility's physical plant was conducted on November 29, 2011 between approximately 11:30 AM and 12:30 PM. At the time of inspection, the internal temperature of the freezer in the kitchen was 5 and the walk-in Freezer on the on the second floor was 6
During the month of November 2011, the kitchen freezer temperature log stated the temperature was consistently above 0 The lowest recorded temperature for the kitchen freezer in November 2011 was 5 and the highest recorded temperature was 13 the month of November 2011, the second floor walk-in freezer temperature log stated the temperature was consistently above 0 The lowest recorded temperature for the second floor walk-in freezer in November 2011 was 6 and the highest recorded temperature was 9 findings were confirmed by the facility director on November 29, 2011.
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Plan of Correction
On December 19, 2011 American Kitchen recalibrated the freezer temperatures in the internal freezer in the kitchen and the walk-in Freezer on the second floor.
On January 9, 2012 a training will be provided to the kitchen staff on Policy 705.7 (b)(5) Food Service.
The freezer temperature will be monitored twice daily. Once in the morning and once in the evening to be in compliance with Policy 705.7 (b)(5)Food Service which states that that frozen food should be at or below 0F.
Persons Responsible:
Deputy Division Director
Inpatient Program Director
Director of Facility and Food Services
Timeframe for Completion:
February 29, 2012 |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's fire drill log, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
The facility's fire drill log was reviewed on November 29, 2011. From November 2010 to November 2011, the facility's fire drill log indicated all stairways were used during each of the fire drills.
The findings were confirmed by the facility director on November 29, 2011.
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Plan of Correction
Effective December 2011 the Inpatient Program Director will prepare and document the use of alternate exit routes during Fire Drills.
On January 5, 2012 a training will be provided to Inpatient staff on Policy 705.10 (d)(6) Fire Safety.
The Fire Drills will be documented and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Division Director
Inpatient Program Director
Timeframe for Completion:
February 29, 2012 |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to document the specific client information to be disclosed on a release of information form. in nine of nine client records.
The findings include:
On November 30, 2011, nine client records requiring documentation consent to release information forms were reviewed. The facility failed to document the specific information to be disclosed to the "Emergency Contact" on the consent to release information forms in nine of nine records reviewed, client records # 1, 2, 3, 4, 5, 6, 7, 8 and 9.
Client # 1 was admitted on 10/24/11. The release of information form signed by client # 1 on 10/24/11 did not include the specific information to be disclosed to the "Emergency Contact".
Client # 2 was admitted on 10/3/11. The release of information form signed by client # 2 on 10/3/11 did not include the specific information to be disclosed to the "Emergency Contact".
Client # 3 was admitted on 9/26/11. The release of information form signed by client # 3 on 9/26/11 did not include the specific information to be disclosed to the "Emergency Contact".
Client # 4 was admitted on 9/13/11. The release of information form signed by client # 4 on 9/13/11 did not include the specific information to be disclosed to the "Emergency Contact".
Client # 5 was admitted on 11/13/11. The release of information form signed by client # 5 on 10/24/11 did not include the specific information to be disclosed to the "Emergency Contact".
Client # 6 was admitted on 11/14/11. The release of information form signed by client # 6 on 11/14/11 did not include the specific information to be disclosed to the "Emergency Contact".
Client # 7 was admitted on 9/6/11. The release of information form signed by client # 7 on 10/24/11 did not include the specific information to be disclosed to the "Emergency Contact".
Client # 8 was admitted on 9/26/11. The release of information form signed by client # 8 on 10/24/11 did not include the specific information to be disclosed to the "Emergency Contact".
Client # 9 was admitted on 9/28/11. The release of information form signed by client # 9 on 10/24/11 did not include the specific information to be disclosed to the "Emergency Contact".
The findings were confirmed by the facility director on November 30, 2011.
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Plan of Correction
The Inpatient Program will obtain an informed and voluntary consent from the client for the disclosure of specific information disclosed in the chart.
On January 13, 2012 a record-keeping training will be facilitated to review the Confidentiality Request to Release Information Form and DOH Policy 709.28(c)(2).
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Division Director
Inpatient Program Director.
Timeframe for Completion:
February 29, 2012 |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, and/or attitude toward treatment.
The findings include:
On November 30, 2011, six client records requiring psychosocial evaluations were reviewed. The facility failed to document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, and/or attitude toward treatment in six of six client records reviewed, # 1, 2, 3, 4, 5 and 6.
Client # 1 was admitted on 10/24/11. The psychosocial evaluation in client # 1's record did not include an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 2 was admitted on 10/3/11. The psychosocial evaluation in client # 2's record did not include an assessment of the client's coping mechanisms and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 3 was admitted on 9/26/11. The psychosocial evaluation in client # 3's record did not include an assessment of the client's assets/strengths, support systems, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 4 was admitted on 9/13/11. The psychosocial evaluation in client # 4's record did not include an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 5 was admitted on 11/14/11. The psychosocial evaluation in client # 5's record did not include an assessment of the client's assets/strengths, coping mechanisms, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 6 was admitted on 11/14/11. The psychosocial evaluation in client # 6's record did not include an assessment of the client's assets/strengths and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The findings were confirmed by the facility director on November 30, 2011.
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Plan of Correction
The Inpatient Program Counselors will start to document psychosocial evaluations based on their evaluation of the client's support systems, assets/strengths, and negative factors as outlined in DOH Policy 709.51 (b) (6).
On January 13, 2012 a record-keeping training to include how to complete the Psychosocial Evaluation per DOH Policy 709.51 (b) (6)
All Psychosocial Evaluations will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Division Director
Inpatient Program Director
Inpatient Clinical Supervisor
Timeframe for Completion:
February 29, 2012
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include type and frequency of treatment and rehabilitation services.
The findings include:
On November 30, 2011, seven client records were reviewed for type and frequency of treatment and rehabilitation services. The facility failed to document treatment plans to include type and frequency of treatment and rehabilitation services in four of seven client records reviewed, # 1, 3, 4 and 7.
Client # 1 was admitted on 10/24/11. The treatment plan in client # 1's record dated 10/25/11 did not include type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on 9/26/11. The treatment plan in client # 3's record dated 9/28/11 did not include type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on 9/13/11. The treatment plan in client # 4's record dated 9/19/11 did not include type and frequency of treatment and rehabilitation services.
Client # 7 was admitted on 9/6/11. The treatment plan in client # 7's record dated 9/12/11 did not include type and frequency of treatment and rehabilitation services.
The findings were confirmed by the facility director on November 30, 2011.
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Plan of Correction
The Inpatient Program will develop the individual treatment and rehabilitation plan with the client and document the type and frequency of the services provided.
On January 13, 2012 a record-keeping training to include a review of treatment plan standards per DOH 709.52 (a) (2) to ensure that all staff document the type and frequency of treatment and rehabilitation services on the treatment plan.
All Treatment Plans will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Division Director
Inpatient Program Director
Inpatient Clinical Supervisor
Timeframe for Completion:
February 29, 2012
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709.52(a)(3) LICENSURE Support service type
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include a proposed type of support service in five of seven records reviewed.
The findings include:
On November 30, 2011, seven client records requiring treatment plans were reviewed for documentation of support services. The facility failed to document treatment plans to include a proposed type of services in five of seven client records reviewed, # 2, 3, 4, 5, 6 and 7.
Client # 2 was admitted on 10/3/11. The treatment plan in client # 2' s record dated 10/4/11 did not include a proposed type of support service.
Client # 3 was admitted on 9/26/11. The treatment plan in client # 3's record dated 9/28/11 did not include a proposed type of support service.
Client # 4 was admitted on 9/13/11. The treatment plan in client # 4's record dated 9/19/11 did not include a proposed type of support service.
Client # 5 was admitted on 11/14/11. The treatment plan in client # 4's record dated 11/20/11 did not include a proposed type of support service.
Client # 6 was admitted on 11/14/11. The treatment plan in client # 4's record dated 11/18/11 did not include a proposed type of support service.
Client # 7 was admitted on 9/6/11. The treatment plan in client # 7's record dated 9/12/11 did not include a proposed type of support service.
The findings were confirmed by the facility director on November 30, 2011.
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Plan of Correction
The Inpatient Program will develop the individual treatment and rehabilitation plan with the client and document the proposed type of support service.
On January 13, 2012 a record-keeping training will be facilitated to include a review of treatment plan standards per DOH Policy Support Service Type 709.52 (a) (3) to ensure that all staff document support services on the treatment plan.
All Treatment Plans which include support services will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Deputy Division Director
Inpatient Program Director
Inpatient Clinical Supervisor
Timeframe for Completion:
February 29, 2012
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