INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19, 2012 to September 20, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc.Winner Co-Occuring Women and Children Program 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 ensure that hot food was served at or above 140 F.
The findings include:
A physical plant inspection was conducted on September 20, 2012. During the inspection, the Licensing Specialist asked to see a food serving temperature log. A food serving temperature log was not presented for review; therefore, there was no way to determine if hot food at the facility had been served at or above 140 F.
The findings were confirmed during an interview with the cook on September 20, 2012 at approximately 11:00 A.M.
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Plan of Correction
Temperature logs are in place and being
used for cold food in the refrigerator, frozen food in the freezer, and hot food. Facility Cook is completing the temperature logs daily and making sure with that cold food is kept at or below 40 F, hot food at or above 140 F, and frozen food at or below 0 F. Cook will review logs with Program Director daily. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record that included documentation of the problems encountered in the facility at the time of the drill.
The findings include:
Fire drill records were reviewed on September 19, 2012. The records were reviewed from the period covering June 2012 to August 2012. The facility did not document problems encountered at the time of the drill in three of three months reviewed, specifically, June 2, 2012; June 8, 2012; June 30, 2012; July 13, 2012; July 15, 2012; July 28, 2012; August 12, 2012; August 18, 2012; and August 30, 2012.
The findings were confirmed during an interview with the facility director on September 19, 2012 at approximately 10:30 A.M.
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Plan of Correction
The fire drill log page has been changed to include a box at the bottom of each drill to indicate whether or not any problems/issues were found during the drill. A training with staff was done on October 1, 2012. The House manager on Duty at the time of the drill will be responsible to document any problems found during the drill. The Day Shift House manager will insure proper documentation. Director will review log monthly to insure compliance. |
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, and/or attitude toward treatment.
The findings include:
The facility's policy titled: "Delivery of Rehabilitation Clinical Process & Procedures (Long-Term/Short-Term Residential Programs)," states:
"Biopsychosocial History and evaluation within 5 days."
On September 19, 2012 to September 20, 2012, five records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, and/or attitude toward treatment in four of five records reviewed, specifically, client records # 2, 3, 4, and 5.
Client # 2 was admitted on June 7, 2012. The psychosocial evaluation was completed on June 12, 2012. However, the psychosocial evaluation did not include and evaluation of the client's support systems, coping mechanisms, and attitude toward treatment.
Client # 3 was admitted on July 30, 2012. The psychosocial evaluation was completed on July 30, 2012. However, the psychosocial evaluation did not include and evaluation of the client's support systems, coping mechanisms, and attitude toward treatment.
Client # 4 was admitted on July 20, 2012. The psychosocial evaluation was completed on July 20, 2012. However, the psychosocial evaluation did not include and evaluation of the client's assets/strengths, support systems, and coping mechanisms.
Client # 5 was admitted on September 4, 2012. The psychosocial evaluation was completed on July 20, 2012. However, the psychosocial evaluation did not include and evaluation of the client's support systems, coping mechanisms, and attitude toward treatment.
The findings were confirmed during an interview with the clinical supervisor on September 20, 2012 at approximately 3:00 P.M.
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Plan of Correction
Program Director did in-service training with Intake Supervisor and clinical team on clinical assessments on October 4, 2012. Clinical Supervisor will review psychosocial assessments monthly for compliance. Program Director will review quarterly for compliance. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document the long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan.
The findings include:
On September 19, 2012 through September 20, 2012, five client records requiring documentation of short-term and long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan were reviewed. The facility did not document the long-term goals for treatment in five of five records reviewed, specifically, client records # 1, 2, 3, 4, and 5.
Client # 1 was admitted July 18, 2012. The individual treatment and rehabilitation plan was completed on July 19, 2012, but it did not include documentation of the long-term goals for treatment as of September 20, 2012.
Client # 2 was admitted June 7, 2012. The individual treatment and rehabilitation plan was completed on June 8, 2012, but it did not include documentation of the long-term goals for treatment as of September 20, 2012.
Client # 3 was admitted July 30, 2012. The individual treatment and rehabilitation plan was completed on August 2, 2012, but it did not include documentation of the long-term goals for treatment as of September 20, 2012.
Client # 4 was admitted July 20, 2012. The individual treatment and rehabilitation plan was completed on July 23, 2012, but it did not include documentation of the long-term goals for treatment as of September 20, 2012.
Client # 5 was admitted September 4, 2012. The individual treatment and rehabilitation plan was completed on September 6, 2012, but it did not include documentation of the long-term goals for treatment as of September 20, 2012.
The findings were confirmed during an interview with the clinical supervisor on September 20, 2012 at approximately 3:00 P.M.
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Plan of Correction
Program Director did in-service training with Clinical Staff on how to formulate long term goals on a treatment plan. Primary Counselors are responsible for documenting long term goals are included on the treatment plans. As part of CQI process, program director will review monthly to ensure compliance. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to verify that work done by the client at the project is an integral part of her treatment and rehabilitation plan.
The findings include:
On September 19, 2012 through September 20, 2012, five client records requiring documentation for verification that work done by the client at the project is an integral part of her treatment and rehabilitation plan. The facility did not document verification of work therapy in the comprehensive treatment plan or treatment plan updates in five of five records reviewed, specifically, client records # 1, 2, 3, 4, and 5.
Client # 1 was admitted July 18, 2012. The comprehensive treatment plan was completed July 19, 2012 and treatment plan updates were completed August 2, 2012; August 16, 2012; and September 16, 2012. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan updates. However, client record # 1 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of September 20, 2012.
Client # 2 was admitted June 7, 2012. The comprehensive treatment plan was completed July 19, 2012 and treatment plan updates were completed July 6, 2012; August 6, 2012; and September 5, 2012. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan updates. However, client record # 2 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of September 20, 2012.
Client # 3 was admitted July 30, 2012. The comprehensive treatment plan was completed August 2, 2012 and treatment plan updates were completed August 16, 2012 and August 30, 2012. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan updates. However, client record # 3 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of September 20, 2012.
Client # 4 was admitted July 20, 2012. The comprehensive treatment plan was completed July 23, 2012 and treatment plan updates were completed August 6, 2012 and August 19, 2012. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan updates. However, client record # 4 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of September 20, 2012.
Client # 5 was admitted September 4, 2012. The comprehensive treatment plan was completed September 6, 2012. The facility was required to document work therapy on the comprehensive treatment plan. However, client record # 5 did not include documentation of work therapy in the comprehensive treatment plan as of September 20, 2012.
The findings were confirmed during an interview with the clinical supervisor on September 20, 2012 at approximately 3:00 P.M.
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Plan of Correction
Program Director did in-service training with with clinical staff on how to implement work therapy into treatment planning. Primary counselors will document work therapy on treatment plans and Clinical Supervisor will be responsible to ensure work therapy is written in the plans. Program Director will monitor treatment plans monthly as part of the CQI process. |