INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 29 - 30, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc - Crossroads 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
The facility failed to keep frozen food at or below 0 based on a physical plant inspection conducted during the annual licensing inspection on November 29, 2016.
The freezer located at the rear of the kitchen area was observed to have a temperature of 10 on November 29, 2016 at approximately 2:00 PM. The freezer temperature logs indicated the temperature had been between 6 and 12 for the month of November 2016.
Facility staff confirmed the freezer had been operating above 0
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Plan of Correction
The current freezer will not be used and will be replaced by 01/13/2017.
Maintenance Supervisor and Kitchen Supervisor will acquire estimates from a vendor to replace the freezer identified as being above the required temperature of 0 degrees. These estimates will be acquired by 12/16/2016.
Director of Finance and Division Director will order a replacement freezer by 01/03/2016.
All food in freezers will be stored at or below 0 degrees.
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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 facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in five of fourteen client records reviewed during the annual licensing inspection conducted on November 29 - 30, 2016. In addition, the project exceeded the limitations imposed at 4 Pa. Code 255.5 (b) in three of fourteen client records.
A consent to release information was not documented for the insurance company and the facility disclosed by fax the client's name and diagnosis when requesting prior authorization for medications in the following client records.
Client # 7 was admitted into treatment on October 1, 2016 and discharged on October 28, 2016. The disclosure occurred on October 2, 2016.
Client # 10 was admitted into treatment on August 30, 2016. The disclosure occurred on October 31, 2016.
Client # 12 was admitted into treatment on June 21, 2016 and discharged on September 15, 2016. The disclosures occurred on July 21, July 31 and August 21, 2016
Client # 13 was admitted into treatment on August 16, 2016 and discharged on September 28, 2016. The disclosure occurred on September 9, 2016.
Client # 14 was admitted into treatment on February 12, 2016 and discharged on March 11, 2016. The disclosure occurred on February 15, 2016.
The following client records were not compliant with 4 Pa. Code 255.5 (b), as the consents to the probation office indicated urine results would be released.
Client # 1 was admitted into treatment on June 2, 2016 and discharged on June 6, 2016. The consent was signed by the client on June 2, 2016.
Client # 6 was admitted into treatment on September 1, 2016. The consent was signed by the client on September 1, 2016.
Client # 8 was admitted into treatment on November 8, 2016. The consent was signed by the client on November 8, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review confidentiality and guidelines related to confidentiality with all staff by 12/31/2016.
Program Director will highlight specific areas of concern related to prior authorizations and urines when completing the internal training on confidentiality with staff by 12/31/2016.
Program Director and Clinical Supervisor will complete monthly chart audits specifically looking at confidentiality and the proper completion of informed consents. The results of these chart audits will be shared in the agencies monthly quality improvement meeting. These results will begin being shared and discussed in January 2017. Any continued concerns will be identified and resolutions will be developed in this QI meeting.
Consents will be obtained from the identified clients prior to any additional releases to the insurance companies. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
The facility failed to document a complete client record in four of nine residential client records reviewed during the annual licensing inspection conducted on November 29 - 30, 2016.
A record of service was not documented in the following client records.
Client # 7 was admitted into treatment on October 1, 2016 and discharged on October 28, 2016.
Client # 12 was admitted into treatment on June 21, 2016 and discharged on September 15, 2016.
A case consultation was not documented in client record # 11.
Client # 11 was admitted into treatment on August 2, 2016 and discharged on August 30, 2016.
Progress notes and a discharge summary were not documented in client record # 12.
Client # 12 was admitted into treatment on June 21, 2016 and discharged on September 15, 2016. The client was receiving one individual counseling session per week. The only individual progress notes documented were dated June 21 and August 24, 2016.
Follow-up information was not documented in client record # 14.
Client # 14 was admitted into treatment on February 12, 2016 and discharged on March 11. 2016.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director will review all required documentation for a client record with program staff by 01/13/2017.
Program Director will review specific time frame requirements for all required documentation in the clients record with program staff by 01/13/2017.
Program Director and Clinical Supervisor will complete monthly chart audits to assure client records are being completed effectively and timely. These chart audits will begin in December 2016. |