INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center Inc. - Moffett 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 February 11, 2011.
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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 an inspection of the physical plant and an interview with the clinical supervisor, the facility failed to provide documentation of frozen food being stored at or below 0 degrees Fahrenheit, as required by regulation.
The findings include:
The kitchen was inspected on January 12, 2011 at 11:00 AM. Per regulation, a residential facility that operates an onsite food preparation area or a central food preparation area shall keep frozen food at or below 0 degrees Fahrenheit. The facility had one freezer available for use. The thermometer on the freezer showed the temperature to be 12 degrees Fahrenheit. A temperature log was reviewed which documented freezer temperatures above 0 degrees Fahrenheit consistently for the month of January 2011. The temperature logs indicated the freezer temp as high as 16 degrees Fahrenheit. The freezer temperature was checked again at 1:30 PM and 2:45 PM and the thermometer showed a reading of 12 degrees Fahrenheit and 10 degrees Fahrenheit respectively.
The clinical supervisor was interviewed on January 12, 2011 at approximately 11:10 AM. The clinical supervisor verified that the temperature was not at or below 0 degrees Fahrenheit. It was reported that a work order had been entered to repair the freezer.
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Plan of Correction
A work order was submitted prior to inspection to have freezer repaired. Gateway maintenance department came and repaired freezer on 1/13/11. Tom Rutter House night monitors will begin to monitor freezer temperature to ensure accuracy of temperature readings.
The night monitor will record temperature reading in logs. The logs will be reviewed by life skills counselor on weekly basis. The life skills counselor will report any temperature discrepancies to clinical manger. The clinical manager will submit a work order to Gateway maintenance department for repair.
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709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client records and an interview with the clinical supervisor and facility director, the facility failed to document an individualized treatment and rehabilitation plan in three of six client records.
The findings include:
Eight client records were reviewed on December 16, 2010 and January 12, 2011. Six client records required the completion of individual treatment and rehabilitation plans. Per regulation, the facility is required to complete an individualized treatment and rehabilitation plan with clients. The facility failed to document an individualized treatment and rehabilitation plan in client records # 5, 7 and 8.
Client # 5 was admitted into treatment on October 13, 2010. The treatment and rehabilitation plan was completed on October 13, 2010. The treatment plan for client # 5 was not individualized. The treatment plan in client record # 5 was identical to the treatment plans in client records # 7 and 8. Each treatment plan had identical long and short term goals, objectives, type and frequency of services and support services. The name of the client was the only item that was different on each treatment plan.
Client # 7 was admitted into treatment on September 7, 2010. The treatment and rehabilitation plan was completed on September 7, 2010. The treatment plan for client # 7 was not individualized. The treatment plan in client record # 7 was identical to the treatment plans in client records # 5 and 8. Each treatment plan had identical long and short term goals, objectives, type and frequency of services and support services. The name of the client was the only item that was different on each treatment plan.
Client # 8 was admitted into treatment on October 14, 2010. The treatment and rehabilitation plan was completed on October 14, 2010. The treatment plan for client # 8 was not individualized. The treatment plan in client record # 8 was identical to the treatment plans in client records # 5 and 7. Each treatment plan had identical long and short term goals, objectives, type and frequency of services and support services. The name of the client was the only item that was different on each treatment plan.
The clinical supervisor and facility director were interviewed on January 12, 2011. They reviewed each treatment plan and confirmed they were identical.
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Plan of Correction
The Clinical manager will schedule a training with Moffett House therapists to review the individualizing of initial treatment plans. The clinical manager will meet with therapists on a weekly basis in clinical meeting reviewing treatment planning and documentation. The clinical meeting will ensure that treatment plans are indivdualize upon a client's admission into the Moffett House.
The facility director and clinical manager will review treatment plans on a monthly basis ensuring that treatment plans are individualized.
The training will be schedule in the next thirty day. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of facility policy and procedure, client records and an interview with the facility director, the facility failed to document follow-up information, as per facility policy, in four of four client records.
The findings include:
Eight client records were reviewed on December 16, 2010 and January 12, 2011. Four client records were closed. All four of the closed client records required documentation of a follow-up. Per agency policy, a follow-up will be conducted within 30 days of discharge. The facility did not document follow-up within 30 days of discharge in client records # 1,2,3 and 4.
Client # 1 was admitted into treatment on May 7, 2010 and discharged on November 8, 2010. Follow-up was due to be completed no later than December 8, 2010. The follow up for client #1 was conducted on December 28, 2010.
Client # 2 was admitted into treatment on July 6, 2010 and discharged on August 30, 2010. Follow-up was due to be completed no later than September 30, 2010. The follow up for client #2 was conducted on October 19, 2010.
Client # 3 was admitted into treatment on February 15, 2010 and discharged on April 18, 2010. Follow-up was due to be completed no later than May 18, 2010. The follow up for client #3 was conducted on June 1, 2010.
Client # 4 was admitted into treatment on May 5, 2010 and discharged on August 2, 2010. Follow-up was due to be completed no later than September 2, 2010. The follow up for client #4 was conducted on September 14, 2010.
The facility director was interviewed on January 12, 2011 and confirmed that the follow up contact documentation is created and maintained by the research department. There was no other documentation available.
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Plan of Correction
Gateway follow-ups are conducted through Research and Evaluation Department. The Moffett House will follow present policy of submitting client data upon admission to Research and Evaluation department. Upon discharge, the Clinical manager will have the administrative assistant forward updated client data to Research and Evaluation Department. This will assist in timely follow-ups by Research and Evaluation Department.
The Director of Halfway House will discuss follow-up procedure with Director of Research and Evaluation Department. |