INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 18, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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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 conducted on September 18, 2020, the facility failed to keep cold food at or below 40 degrees Fahrenheit as the thermostat for the main refrigerator in the kitchen, read 45 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia, Focus House Division Director requested maintenance to look at the Focus House refrigerator to identify why it continues to go to 45 degrees.
Gaudenzia, Maintenance Department accessed the refrigerator and determined that in order for the refrigerator to remain at 40 degrees or below it must be kept on Cooling Dial 3.
Staff was instructed to keep the refrigerator on 3 in order to comply with DDAP Regulation 705.7 (b) (5)
All staff were informed that during their House runs they are to ensure the temperature is not above 40 degrees, as well as ensure that the temperature dial is on #3. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection conducted on September 18, 2020, the project failed to secure hard copy client records within locked storage containers. Active client records were observed to be stored on top of a storage container in the facility director's office.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On September 24, 2020 a Commercial (2) File locked Drawer was ordered to secure resident charts.
The Program Supervisor will be responsible for ensuring that client records are secured properly in locked file cabinet and will remain in locked office of Program Supervisor to ensure compliance with DDAP Regulation 709.28(b).
The acquisition for the file cabinet is included as part of the POC. |
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.
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Observations
The project failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of seven client records reviewed.
Client #3 was admitted on April 15, 2019 and was discharged on February 10, 2020. There was documented contact with a family member on December 11, 2019 and January 27, 2020; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #5 was admitted on October 17, 2019 and was still active at the time of the inspection. There was documented contact with a family member on April 30, 2020 and July 31, 2020; however, there was no proper consent to release information form signed by the client prior to disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative Assistant and Program Supervisor will ensure that all residents residing in the program complete Consent to release information for all applicable supports, family members, doctors, Case Managers, and any other outside entities.
Program Supervisor will audit current charts to ensure consents are present, current and updated as needed to ensure continued compliance with DDAP Regulation 709.28(c).
Program Supervisor will complete monthly chart audit to ensure ongoing compliance with DDAP Regulation
709.28(c).
Focus House Division Director, and Program Supervisor informed the Focus House Staff of the proper way to handle phone calls, or visit when they are uncertain there is a consent, or if they are unable to access chart to confirm there is a consent on September 24, 2020.
Program Supervisor during the November Staff meeting scheduled for 11/25/2020 will address the proper procedures for answering the phones when uncertain if their is a consent, or when they don't have access to the charts to confirm that there is a consent for purpose of ensuring ongoing compliance with DDAP Regulation 709.28 (c).
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