INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 20, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gratitude 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:
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Plan of Correction
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705.5 (i) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(i) Each bedroom shall have a window with a source of natural light.
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Observations
Based on a physical plant inspection, the facility failed to ensure each bedroom have a window with a source of natural light. Bedroom #4 has skylight windows that were boarded up without any other natural source of light in the room.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Maintenance Supervisor met on June 26, 2023 to review. Maintenance will replace enclosed sky lights in bedroom #4 by August 1, 2023. Executive Director will ensure project is completed by this date. |
705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to keep cooking and eating utensils in a clean and enclosed area. Cooking utensils were being stored hanging in an open area in the kitchen and bins that were not covered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed food service preparation regulations with BHT Supervisor on June 26, 2023. All utensils will be kept in a closed container with a lid. Risk committee will monitor monthly during the facility walk thru for compliance. Executive Director will address any ongoing issues with BHT Supervisor during monthly supervision. |
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 one of three applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur within seven days after discharge by phone.
Client # 7 was admitted on November 29, 2022 and was discharged on April 13, 2023.
There was no follow-up information available in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor reviewed follow up policy with administrative assistant on June 28, 2023. Discussed documenting within seven days of discharge. Discussed documenting if there was no forwarding information for the client, if they were unable to be reached. Executive Director and Clinical Supervisor will review compliance during monthly chart audits. Any additional concerns will be addressed in monthly supervision with the Executive Director. |
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 seven of seven client records reviewed, the facility failed to provide a complete client record to include verification that work done by the client at the project is an integral part of their treatment and rehabilitation plan.
Client # 1 was admitted on March 29, 2023 and was still active at the time of the inspection. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 2 was admitted on April 26, 2023 and was still active at the time of the inspection. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 3 was admitted on March 23, 2023 and was still active at the time of the inspection. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 4 was admitted on April 12, 2023 and was still active at the time of the inspection. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 5 was admitted on April 6, 2023 and was discharged April 20, 2023. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 6 was admitted on March 31, 2023 and was discharged May 16, 2023. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 7 was admitted on November 29, 2022 and was discharged April 13, 2023. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor will review utilization of work therapy in individual treatment plans at clinical team meeting on July 12, 2023. Clinical staff will ensure work therapy is added to treatment plans detailing involvement in employment, volunteer work, or life skills. Executive Director and Clinical Supervisor will complete monthly chart audits to review progress. Clinical supervisor will address any ongoing concerns during individual supervision. |