INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 5, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Family House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 observation and a review of a freezer temperature log, during the physical plant inspection, the facility failed to provide documentation of frozen food being stored at or below 0 degrees Fahrenheit 10 out of 30 days during the month of April and 4 out of four days in the month of May.
The findings include:
The kitchen was inspected on May 5, 2014 at 10:30 am. The facility had one freezer available for use. The thermometer on the freezer read 30 degrees F at the time of the inspection.
The facility documented temperatures that exceeded 0 degrees F during the month of April on April 21, 22, 23, 24, 25, 26, 27, 28, 29 & 30, 2014. The facility documented temperatures that exceeded 0 degrees F during the month of May on May 1, 2, 3, & 4, 2014.
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Plan of Correction
The freezer temperature will kept at
0 degrees or below at all times. The ADL staff will record temperature in the log bog. If the ADL staff notice it's not at 0 degrees or below they will let the office manager or director know immediately. And if at anytime the freezer experiences any mechanical failures the repair person will be contacted that day by either the officer manager or the program director to make necessary repairs to keep temperature at 0 degree or below. The freezer was repaired on May 12, and was put back in use on May 13, and the temperature has been at 0 degrees or below from that date until now. |
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, the facility failed to document informed and voluntary consents in four of nine records reviewed.
The findings include:
Nine client records requiring documentation of informed and voluntary consents were reviewed on May 5, 2014. Client records # 2, 4, 5 and 9 lacked informed and voluntary consents for information that was released pertaining to the client.
In client #2's record the following letter dated 10/9/13 to a government agency had identifying information about the client with no consent to release on file for the government agency. Another letter dated 10/7/13 was sent out pertaining to the client that did not have the name of the person or agency documented. Additionally, there were several faxes sent out to the client's funding source with no documentation of a consent to release on file for the funding source; 9/3/13, 10/9/13, 11/8/13, 12/3/13, 12/27/13 and 1/6/14.
In client #4's record there were several documents sent out to an employee of another agency on the following date; 3/11/14, 4/1/14 and 5/1/14. The documents had identifying information about the client. Client #4 ' s record did not show documentation of consent to release for this employee.
In client #5's record the following letters dated 9/4/13 and 9/11/13 to a government agency had identifying information about the client with no consent to release on file for the government agency. Additionally, two letters dated 8/5/13 and 1/27/14 were sent out pertaining to the client that did not have the name of the person or agency documented
In client #9 ' s record there were several faxes sent out pertaining to the client on the following dates; 9/23/13, 1/21/14 and 4/17/14. Client #9 ' s record did not have documentation of consent to release on file for those agencies. Additionally, a letter dated 9/20/13 to a government agency had identifying information about the client with no consent to release on file for the government agency.
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Plan of Correction
The ADL and the Clinical staff will receive a training on the correct way to send correspondence and how to complete the voluntary consent to release information from a client. The training will be done by the Clinical Supervisor. The training will consist of the following. 1. Any correspondence that is sent to a agency or a person on behalf of a client first staff must have a signed consent to release this information to the agency or person signed by the client prior to releasing any information. The correspondence must include a persons name and agency name it will NOT be addressed to whom it concern and it will NOT be left blank.
2. All voluntary consent will include the name of a person to whom the information is being released to along with the phone number and signed by client prior to releasing any information.
Clinical supervisor will review and monitor all charts closely for next 30 days (June 30, 2014) to ensure that the consents are done prior to release of information and the correspondence has the name of the agency and persons to whom information is being released.
Training will be completed by June 6, 2014 by clinical supervisor. |