INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on June 15, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Focus 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facilities May and June work schedule, an interview with the administrative assistant, and copies of staff Cardio Pulmonary Resuscitation (CPR) certification and First Aid cards provided by the facility for the staff working during the month of May and June, the facility failed to ensure that CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills was onsite during the project's hours of operation.
The findings include:
On June 15, 2011, copies of staff CPR and First Aid cards and the May 2011 and June 2011 work schedule as provided by the facility were reviewed.
Employee # 3's CPR certification expired March 2011.
Employee # 3 is scheduled to work on the 4 PM - 12 AM shift.
There was no documentation that any other employees working the 4 PM - 12 AM shift on the identified dates below had CPR certification.
Based on the work schedule and the CPR and First Aid cards provided by the facility, the facility failed to provide CPR coverage on the 4 PM - 12 AM shift on the following dates:
May 2, 4, 7, 8, 14, 21, 27, 28, 29, and 30, 2011.
June 3, 2011 and
June 6, 2011.
Based on the work schedule and the CPR and First Aid cards provided by the facility, the facility failed to provide CPR coverage on:
5/3/11 & 5/4/11 from 5 PM - 12 AM
5/5/11 from 7 PM - 12 AM
5/11/11 from 10 PM - 12 AM
5/12/11 from 10 PM - 12 AM
5/13/11 from 10 PM - 12 AM
5/16/11 from 10 PM - 12 AM
5/17/11 from 10 PM - 12 AM
5/18/11 from 10 PM - 12 AM
5/19/11 from 7 PM - 12 AM
5/25/11 from 10 PM - 12 AM
5/26/11 from 7 PM - 12 AM
6/2/11 from 7 PM - 12 AM
6/6/11 from 8 PM - 12 AM
6/10/11 from 8 PM - 12 AM
6/11/11 from 8 PM - 12 AM
6/12/11 from 8 PM - 12 AM
6/13/11 from 8 PM - 12 AM
6/14/11 from 8 PM - 12 AM
6/17/11 from 8 PM - 12 AM
6/18/11 from 8 PM - 12 AM
The administrative assistant confirmed that employee # 3's CPR certification had expired on March 2011. The facility director confirmed that the facility was out of compliance on the identified dates and times.
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Plan of Correction
Employee #:3 has been scheduled for CPR/First Aid certification and will be certified by July 1, 2011. Focus House will have at least one person trained in CPR/First Aid skills on site during the total project hours of operation. The Program Supervisor will ensure that all Focus House employees are CPR/First Aid Certified. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the facilities training files, a review of Staffing Requirements Facility Summary Report, and an interview with the administrative assistant, it was determined that the facility director did not have the minimum training hours for the annual training year.
The findings include:
A review of the facility director's training file revealed that the required twelve clock hours of training annually was not complete.
The facility director only completed ten training hours for the year ending.
In addition, the Staffing Requirements Facility Summary Report which was completed by the facility on June 15, 0211 documented ten training hours for the 2010 training year.
The administrative assistant confirmed that the facility director did not complete the required twelve hours of training.
This is a repeat citation.
The facility was cited at the last year inspection on June 4, 2010, as the facility director failed to obtain the minimum training hours.
In response to the citation issued on June 4, 2010 the facility's plan of correction submitted on 6/29/2010 and approved on 6/29/2010, stated the following:
"Program Supervisor has/will complete a minimum of 12 clock hours of training that is required annually in areas such as: Fiscal Policy. Program Supervisor has scheduled trainings for the 2010 year."
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Plan of Correction
Program Supervisor has completed 12 clock hours of training for the training year 2011. Program Superviosr will comeplete a minimum of 12 clock hours of training hereafter. Program Supervisor will schedule and complete a minimum of 12 clock hours of trainings for the 2012 year. Going forward - The Division Director will ensure that a minimum of 12 clock hours is scheduled for the Program Supervisor. In addition the Division Director will request training certifications monthly and ensure that the training certificates are on file and that the minimum training hours have been complete prior to the end of the training year |
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 observation during a physical plant inspection, and an interview with the facility director, the facility failed to keep cold food at or below 40 F degrees, hot food at or above 140 F degrees, and frozen food at or below 0 F degrees, as required by regulation.
The findings include:
The facilities kitchen and food storage area was inspected on June 15, 2011 at approximately 3 PM. One out of two freezers in the facilities basement had a temperature greater than 0 F degrees. The thermometer in the freezer read a temperature of 20 F degrees.
In addition, the temperature log posted next to the freezer for the month of June 2011, indicated that the freezer measured 20 F degrees for the entire month of June 2011.
The facility director confirmed at the time of the physical plant inspection and the exit interview that the freezers temperatures was 20 F for the entire month of June 2011.
This is a repeat citation.
The facility was cited at the last year inspection on June 4, 2010, as the freezer measured at a temperature of 15 F degrees.
In response to the citation issued on June 4, 2010 the facility's plan of correction submitted on 6/29/2010 and approved on 6/29/2010, stated the following:
"Program Supervisor submitted work order for freezer. Freezer was serviced and is now operating at 0 degrees. Program Supervisor has implemented a temperature check list for each shift to read the thermometers and document temperatures every hour to ensure that frozen food is kept at 0 degrees or below and cold food is kept at a temperature at or below 40F degrees."
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Plan of Correction
The facility freezer has been serviced on 06/27/2011 by contractor. Contractor found temperature gauge needed to be replaced. In addition Program Directorheld an in service group on reading the temperature gauge and documenting the reading. The Freezer is now operting at 0 degrees fahrenheit. |
709.28(c) 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:
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Observations
Based on a review of client records, a review of clinical documents and an interview with the facility director, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one of eight client records.
The findings include:
On June 15, 2011 eight client records were reviewed for documentation of an informed and voluntary consent.
The facility did not obtain an informed and voluntary consent for the disclosure of client information in client record # 6.
The facility failed to obtain an informed and voluntary consent for the disclosure of client information to a government agency.
Client # 6 was admitted to the program on 4/11/11, and is still an active client.
On 5/17/11 the case manger submitted a letter to a government agency without the informed and voluntary consent from the client for the disclosure of information contained in the client record. The letter detailed the client's progress, activity, and behavior since being admitted into the program.
On 5/24/11 the case manager documented on an activity note that the defenders association was contacted via the telephone regarding client # 6's noncompliance with program rules.
The client was with the case manger when the defenders association was contacted, but the client refused to speak with the governmental agency.
At the time of review the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information.
The facility failed to obtain an informed and voluntary consent which adheres to the requirements specified at 28 Pa. Code subsection 709.28; 42 CFR Part II subpart C subsection 2.31(b); and 4 Pa. Code 255.5(b).
The facility director confirmed that client record # 6 did not contain an informed and voluntary consent.
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Plan of Correction
The Program Supervisor will review and monitor all Confidential Request for Information Forms monthly to ensure compliance. Compliance will include the following; the person's name, the agnecy or organization to which disclosure is made, specific information disclosed and the prupose of disclosure. The consent forms will adhere to the requirements specifiend at 28 Pa. Code 42 CFR, and 4 Pa. Code 255.5 Consent forms have been signed by client #6. Before disclosure of client information is given to a government agency or other Program Supervisor will have consent to release information by client. Program Director will make certain that all clients' sign informed and voluntary coensent forms upon admission to project and as needed throughout the duration of services. |