INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 13 & 14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD - Womanspace 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 and an interview with the facility director, the facility failed to maintain cold food at or below 40findings include:An inspection of the facility ' s physical plant was conducted on July 13, 2011 between approximately 2:30 PM and 3:15 PM. At the time of inspection, the internal temperature of the refrigerator on the second floor was 50Fahrenheit. This refrigerator temperature was checked again on July 14, 2011 at approximately 9:00 AM, and the internal temperature was still 50Fahrenheit.An interview with the facility director on July 14, 2011 confirmed the findings.
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Plan of Correction
Program Director will purchase a new refrigerator to replace the refrigerator/freezer unit that was inspected on July 13, 2011 and July 14, 2011.
Staff will monitor the internal temperature of both refrigerator and freezer via thermometer twice daily and document temperatures in the temperature log.
in the event that internal temperatures do not meet the required standards consistently for a 72 hour period, Staff will arrange for Property Manager to service unit(s) in question. |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to maintain portable fire extinguishers on each floor.The findings include:An inspection of the facility's physical plant was conducted on July 13, 2011 between approximately 2:30 PM and 3:15 PM. The facility provided fire extinguishers on each floor, but the fire extinguishers were not wall mounted. The fire extinguisher in each of the client's bedrooms was not wall mounted. The fire extinguisher in the third floor administrative office was not wall mounted. An interview with the facility director on July 13, 2011 confirmed the findings.
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Plan of Correction
As of 8/2/11, all fire extinguishers in the building are wall mounted.
Staff will examine all fire extinguishers during monthly fire drill to ensure proper wall mounting.
In the event of any concerns, Staff will contact appropriate service providers to address concerns. |
705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to maintain at least one portable fire extinguisher in each kitchen.The findings include:An inspection of the facility's physical plant was conducted on July 13, 2011 between approximately 2:30 PM and 3:15 PM. At the time of inspection, the facility did not have a fire extinguisher in the kitchen.An interview with the facility director on July 13, 2011 confirmed the findings.
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Plan of Correction
As of 8/2/2011, there is currently a portable fire extinguisher wall mounted in the kitchen of this facility.
During monthly fire drill, Staff will examine the portable wall mounted fire extinguisher to ensure placement.
In the event of any concerns, Staff will schedule appropriate services. |
709.32(c)(7) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(7) Medication errors and drug reactions.
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Observations
Based on a review of the facility's medication control policy, a review of client medication administration records, and an interview with the facility director, the facility failed to follow their policy on Medication Error and Drug Reactions. The findings include:On July 14, 2011, the facility's medication control policy and the medication administration records for eight clients were reviewed. The facility did not contact the prescribing physician for medication errors, as stated in the facility's medication control policy.The facility's policy titled "Policy on Medication Errors and Drug Reactions" states:A medication error may be considered one of the following:Taking the wrong medication Medication not takenTainted medicationIncorrect dosageIn the event of a medication error without apparent reaction, staff will contact the prescribing physician to determine correct course of action. The nurse or designated staff will record the incident in the client's file.Client # 5 was prescribed Ferrous Sulfate, 325mg, 3 times a day. During the month of July 2011, Client # 5 did not receive this medication as prescribed on July 1, 2, 3, 4, 8, 9, 10 and 13. The facility was unable to provide evidence that the prescribing physician was contacted to determine the correct course of action. Client # 5 was also prescribed Clindamycin HCL, 300 mg, 1 capsule, 4 times daily. During the month of July 2011, Client # 5 did not receive this medication as prescribed on July 7, 9, 10 and 11. The facility was unable to provide evidence that the prescribing physician was contacted to determine the correct course of action. Client # 6 was prescribed Ferrous Sulfate, 220mg, twice a day. During the month of July 2011, Client # 6 did not receive this medication as prescribed on July 3, 5, 6, 7, 8, 9, 10, 11 and 12. The facility was unable to provide evidence that the prescribing physician was contacted to determine the correct course of action.Client # 7 was prescribed Chlorpromazine, 100mg, 1 Tablet at bedtime.During the month of July 2011, Client # 7 did not receive this medication as prescribed on July 6, 8, 9, 10, 11, 12 and 13. The facility was unable to provide evidence that the prescribing physician was contacted to determine the correct course of action.Client # 8 was prescribed Penicillin, 500mg, 1 Tablet every 6 hours.During the month of July 2011, Client # 8 did not receive this medication as prescribed on July 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12. The facility was unable to provide evidence that the prescribing physician was contacted to determine the correct course of action.An interview with the facility director on July 14, 2011 confirmed the findings.
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Plan of Correction
Program Director, Assistant Director and Nurse will review current Medication Policy and make appropriate changes.
Nurse will develop a "Medication Error Follow Up" template, to be reviewed by Program Director.
Program Director or desigated staff member will train Staff on current medication policy and, specifically, medication error protocal and the above mentioned template.
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to notify the client, in writing, of a decision to involuntarily terminate her treatment in one of one records. The findings include: On July 14, 2011, one involuntarily terminated client's record was reviewed for a termination letter, specifically record # 2. The facility did not notify the client in writing of the decision to involuntarily her terminate treatment. The facility's policy titled "POLICY ON INVOLUNTARY TERMINATION OF TREATMENT" states: The following may result in immediate discharge: use of alcohol or other drugs, violence, and leaving the program without permission (AWOL). A client may request reconsideration of the decision to be involuntary discharged. Written notice will be given to the client with reason and right to appeal. The client has 24 hours to appeal such a decision. The request must be in writing within 24 hours of discharge notification and submitted to the Director. A decision will be made and client notified by the Director and/or the clinical team within 24 hours of receipt of the written appeal. A copy of the appeal along with the disposition/reevaluation of the discharge decision will be kept in the client's case record. During the 24-hours period the client's aftercare plans will be made. The client will leave Womanspace if the decision for discharge is upheld.Client record # 2 contained a discharge progress note that stated the client was "administratively discharged" for "behaviors that serve to create an unsafe environment" , but the client record did not contain a termination letter. An interview with the facility director on July 14, 2011 confirmed the findings.
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Plan of Correction
Program Director,or designated staff member, will retrain all Clinical and Administrative Staff on the facility policy titled, "Policy on Involuntary Termination," including current, "Notice of Involuntary Termination."
Staff will present any Client being administratively discharged with a written "Notice of Involuntary Termination." This notice will explain the decision and remind Client of her rights. Client and Staff will have an opportunity to sign and date the notice; a copy will be offered to the CLient and a copy will be placed in her record.
Program Director, or designated Staff will review the Client record prior to Client discharge to ensure that the record contains a written "Notice of Involuntary Termination."
Program Director and designated Staff will review current "Policy on Involuntary Termination," including current, "Notice of Involuntary Termination," and make necessary revisions to address concerns regarding Clients who pose a threat to the safety and security of the facility and/or the individuals who live and work in said facility.
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709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to inform a client of the right to request reconsideration of the decision to terminate her treatment in one of one records.The findings include: On July 14, 2011, one involuntarily terminated client's record was reviewed for documentation of the client being given the opportunity for reconsideration of the facility's decision to terminate her treatment. The facility failed to inform the client of her right to request reconsideration of the facility's decision to terminate her treatment in client record # 2.The facility's policy titled "POLICY ON INVOLUNTARY TERMINATION OF TREATMENT" states: The following may result in immediate discharge: use of alcohol or other drugs, violence, and leaving the program without permission (AWOL). A client may request reconsideration of the decision to be involuntary discharged. Written notice will be given to the client with reason and right to appeal. The client has 24 hours to appeal such a decision. The request must be in writing within 24 hours of discharge notification and submitted to the Director. A decision will be made and client notified by the Director and/or the clinical team within 24 hours of receipt of the written appeal. A copy of the appeal along with the disposition/reevaluation of the discharge decision will be kept in the client's case record. During the 24-hours period the client ' s aftercare plans will be made. The client will leave Womanspace if the decision for discharge is upheld.Client record # 2 did not include documentation of the right to request reconsideration. Additionally, this information is not included in the facility's client orientation documents. An interview with the facility director on July 14, 2011 confirmed the findings.
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Plan of Correction
Program Director,or designated staff member, will retrain all Staff on the facility policy titled, "Policy on Involuntary Termination," including current, "Notice of Involuntary Termination."
In each case of an involuntary termination, Staff will present Client being administratively discharged with a written "Notice of Involuntary Termination," which, will serve as a written means of informing the Client of her right to request rconsidderation of the decision to terminate her treatment. Client will receive a copy of this form and one will be placed in client's case record.
To date, Client Intake Paperwork has been amended, to include under the current "Client Rights and Responsibilities" document, Section VI. "Right to Request Reconsideration for an Involuntary Termination." This Addition states the following;
"VI. Right to Request Reconsideration for an Involuntary Termination
A. Clients have the right to request reconsideration if given a Notice of
Involuntary Termination of Treatment.
1. The Client will be presented with written notice. The written notice will include the reason for the Involuntary Termination and the right to appeal.
2. The Client appeal is to be written (assistance will be given to those in need) and submitted to the Director within 24 hours of the time of notification.
3. A decision will be made and the Client will be notified by the Director or designated Staff member within 24 hours of receipt of the written appeal.
4. In the event of a health or safety concern, the Client will be referred for housing (shelter, safe haven, Recovery House, etc.) and offered Aftercare Planning. Should the decision for involuntary termination be reversed, the Client will return to Womanspace Philadelphia to continue treatment." This document is explained and reviewed at Intake by the Staff member designated to review the Intake documentation with the Client upon admission. Client will be offered a copy of this document.
Program Director will review Intake Packet to ensure that clients are being informed of the Right to Request Reconsideration for Involunary Termination upon Admission.
Program Director and designated Staff will review current "Policy on Involuntary Termination," including current, "Notice of Involuntary Termination," and make necessary revisions to address concerns regarding Clients who pose a threat to the safety and security of the facility and/or the individuals who live and work in said facility. |