INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 22, 2010- June 24, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Libertae Family House, Libertae, Inc. 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 and a plan of correction is due on July 21, 2010.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the agency manual during the onsite inspection, the facility failed to document a training procedure which included who is responsible for the completion of the overall training plan and the annual evaluation with time frames for the required components.
The findings include:
The agency training policy and procedure was reviewed during the annual licensing inspection on June 22, 2010. The procedure did not document who, by job title is responsible for the completion of the overall annual training plan and the annual evaluation. The procedure did not document the time frames for completion for each of the required components of the staff development program.
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Plan of Correction
The Clinical Director is the responsible party. On 6/24/2010 A training plan and policy was completed, and presented to the State Licensing Inspector and was approved.
The Clinical Director and other Middle Management obtained further clarification on this requirement by the State Inspector on 6/24/2010 which served as an initial training. This policy was further reviewed in the Middle Management meeting held on 7/1/2010
The Clinical Director will monitor semi-annually this proceedure to ensure follow through. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a facility tour on June 23, 2010 and an interview with the operations manager, the facility failed to provide an exhaust fan or window in two bathrooms.
The findings include:
A facility tour was completed on June 23, 2010, between 9:35 AM and 10: 15 AM Based on observation, the facility failed to ventilate two bathrooms on the second floor with an exhaust fan or window. The bathroom between bedrooms 1 and 2 and the bathroom between rooms 6 and 7 failed to have a working exhaust fan. This was also confirmed by observation and an interview with the operations manager who was conducting the tour at 9:50 a.m.
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Plan of Correction
The Executive Director and the Operations Manager are the responsible parties. The Maintenance person is under the Executive Directors supervision.
The Maintenance person was informed on 6/24/2010 when the state licensing inspector was here on premises.
The Maintenance person purchased and installed the exhaust fans for between the bathrooms for bedrooms 1 and 2; as well as 6 and 7 on 7/14/2010.
The Operations Manager supervises the Resident Managers who do the house maintenance check weekly. A training with the Resident Manager took place on 6/24/2010 concerning the exhaust fans.
The Executive Director will continue to conduct regular monthly supervision of the Maintenance person as he/she continues to ensure the exhaust fans are functional.
The Operation Manager will continue to conduct regular monthly supervisions with Resident Managers and address any concerns at the monthly department meetings.
The Resident Manager will bring any deficiencies to this area (exhaust fans between bedrooms) to the attention to the Maintenance person as they arise. |
705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on observation and a staff interview, the facility failed to store utensils in a clean enclosed area.
The findings include:
A facility tour was conducted on June 23, 2010 between the hours of 9:35 a.m. and 10:15 am. The kitchen was toured at 10:05 a.m. The eating utensils were not stored in an enclosed area as they were observed to be stored in open containers on the kitchen counter. This was also observed and confirmed by the operations manager who was conducting the tour.
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Plan of Correction
The respoonsible party is the Food Service Director.
The Food Service Director was informed on 6/24/2010 of the need to enclose containers with the eating utensils. The Food Service Director covered the utensils as soon as it was brought to his attention.
The Food Service Director conducted a training with the residents and food service assistant on the regulation of such a practice on June 30, 2010 during his regular Nutrition Group.
The Food Service Director will spot check on a weekly basis as well as continue to train new residents during orientations on a monthly basis. |
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 inspection of the physical plant and a staff interview, the facility failed to provide documentation of hot food temperature logs.
The findings include:
The physical plant was toured on June 23, 2010 from 9:35 a.m. to 10:15 a.m. The facility failed to provide a hot food temperature log. The facility failed to document hot food temperatures ensuring hot food is served at or above 140 degrees. A staff interview confirmed that hot food temperatures were unable to be confirmed.
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Plan of Correction
The Executive Director is the responsible party. The Executive Director will ensure that the Food Service Director and the Food Service Director assistant properly enact this regulation.
On 6/24/2010 a food temperature tracking chart was created and posted for use by the cooks.
This chart was presented to the State Licensing Inspector on 6/24/2010 and was approved.
Therometers were made available on 6/24/2010 for ongoing temperature checks and placed in the kitchen next to the temperature tracking chart.
The Food Service Director conducted a training for residents and the food service assistant around this regulation where a food temperature log is required. This training took place on 6/30/2010.
The Food Service Director Assistant will monitor that the food temperature proceedure is completed on a daily basis before every hot meal. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs, the facility failed to document the completion of monthly unannounced fire drills.
The findings include:
A review of the fire drill logs from June 2009 until June 2010 was conducted on June 23, 2010. There was no documentation that a fire drill was conducted for the month of October 2009.
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Plan of Correction
The Operations Manager is the responsible party.
The Operations Manager will monitor by conducting monthly reviews of the fire drill logs to ensure that all fire drills are completed as required.
The Operations Manager conducted a training with the Treatment Tech Staff on 6/19/2010 at the monthly department meeting. In this training the Operations Manager reviewed fire drill proceedures and specifically, the importance of rescheduling missed fire drills within that month.
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709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on the review of client files, the facility failed to offer a client a copy of a consent in three of four records reviewed
The findings include:
Client records were reviewed on June 23, 2010 and June 24, 2010. The facility failed to document whether the client was offered a copy of a consent in three of four client records reviewed, specifically client records # 1, 2, and 3.
Client # 1 signed a consent dated March 15, 2010; there is no documentation that the client was offered a copy of this consent.
Client # 2 signed a consent on March 18, 2010; there is no documentation that the client was offered a copy of this consent.
Client # 3 signed a consent for her probation officer on August 27, 2009; there is no documentation that the client was offered a copy of this consent.
Client # 3 signed a consent for her emergency contact on September 17, 2009; there is no documentation that the client was offered a copy of this consent.
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Plan of Correction
The Clinical Director is the responsible party.
The Clinical Director during the clinical team meeting on 7/13/2010 reviewed the Utilization process for obtaining consent and ensuring all admitted clients receive a copy of their consents and that it is indicated as evidenced by placing a checkmark in the box on the consent form.
On 7/13/2010 the Clinical Director informed the utilization department as well as the assigned therapists for clients #1, and #2, that while it was confirmed that copies were given to these current clients the box on the consent needed to be checked.
For client #3 she is no longer a resident at Libertae.
The Clinical Director will monitor during supervision with Utilization and during therapists spot chart checks as well as during quarterly chart checks that all consents were copied to client and that it is indicated on the consent form. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of client records, the facility failed to have the prescribing physician sign off on verbal orders within 24 hours.
The findings include:
Four client records were reviewed on June 23, 2010 and June 24, 2010. The facility failed to include the physician's signature for a verbal orders in two of four client records, specifically client records # 2 and 3. An interview with the project director confirmed that there was not a procedure in place for verbal orders to be signed off by a doctor within 24-hours.
Client # 2 was prescribed Fluxamine, 100 mg, one tablet to be taken at 9:30 PM. On May 28, 2010, there was a note on the client medication record that a medication change per the doctor was to take one tablet at 6:30 a.m. and another one at 9:30 p.m. The facility failed to secure the doctor's signature for this verbal order.
Client # 3 was prescribed Pre-natal Plus. There was a note on the medication to "discontinue resident gets sick." This was dated 11/3/09 and signed off by a resident technician. The facility failed to provide a doctor's signature with the discontinuation of this medication.
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Plan of Correction
The Clinical Director is the responsible party.
The Clinical Director heard back from a Licensing agent on 8/11/2010 informing us that the following procedure is approved:
After speaking with the Clinical Director and/or Operation Manager staff verbal orders will be documented as such by the staff who receives the verbal order over the phone. The doctor will fax, scan, or email, the signed order to the facility within 24 hours of making the verbal order. When the doctor comes to the facility the next time the original signature will be attached to the scanned/faxed/ or emailed signed order that was already received by the facility.
The Clinical Director and the Operations Manager will conduct a training with the Therapists and Resident Managers on 8/15/2010 pertaining to this procedure for verbal consents from the psychiatrist.
The Clinical Director along with the Operations Manager (supervises Treatment techs who assist with medications) will continue to monitor on a bi-weekly basis in consultations with consulting psychiatrist as well as with therapists and Resident Managers to ensure that this procedure is followed. |
709.32(c)(3) 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:
(3) Inspection of storage areas.
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Observations
Based on a review of the policy and procedure manual and an interview with the operations manager, the facility failed to document inspections of the medication storage area.
The findings include:
On June 22, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, an inspection of the medication storage area will be completed by the resident managers in each house on a quarterly basis to ensure that these areas are maintained in compliance with federal, state, and local regulations. The facility failed to provide documentation for inspections of the medication storage area on a quarterly basis.
The Operations Manager confirmed that medication storage area inspections were not documented.
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Plan of Correction
The Operations Manager and Resident Manager are the responsible parties.
On 6/23/2010 the Operations Manager developed and presented to the Licensing Inspector a house medication stock inventory checklist chart and it was approved.
On 6/23/2010 the Operations Manager trained the Resident manager to the house medication stock inventory checklist chart. The Resident Manager will conduct quarterly inventories to ensure all house stock medications are present and accounted for as well as not out of date. This is to ensure that procedure falls in line with the federal, state, and local regulations.
The Operations Manager will monitor quarterly to ensure documentation and the follow through of this procedure. |
709.32(c)(6) 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:
(6) Inventories.
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Observations
Based on a review of the policy and procedure manual and an interview with the Operations Manager, the facility failed to document inventories of client medications, as required by regulation.
The findings include:
The regulation requires an inventory of the medications used by clients. On June 22, 2010 the policy and procedure manual was reviewed. Per the agency policy and procedure manual, an inventory of the client medications will be completed by the resident manager on a bi-weekly basis. The facility failed to provide documentation for client medication inventories on a bi-weekly basis.
The Operations Manager confirmed that the facility failed to have documentation of bi-weekly medication inventories.
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Plan of Correction
The Operation Manager and the Resident Manager (overnight) are the responsible parties.
On 6/22/2010 the Operations Manager presented to the Licensing Inspector the current inventory list and it was reviewed and approved.
On 6/25/2010 The Operations Manager met and trained the Resident Managers (day and overnight)around the inventory documentation procedures.
The Operations Manager will continue to have the Resident Manager (overnight) file all future inventories for future review as it meets compliance regulation.
The Operations Manager will monitor the night time activity log to ensure the inventory list is being completed and filed as regulation and Libertae policy and procedure manual requires. |
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Based on the review of client records and the facility policy and procedure manual, the facility failed to document reasons for medication refusals according to facility policy and procedure.
The findings include:
Based on the review of the policy and procedure manual on June 22, 2010 and client record reviews on June 23 and 24, 2010, the facility failed to document client medication refusals for one of four records reviewed, specifically client # 1.
The policy and procedure manual was reviewed and the policy on refusal of medications was stated as follows:
Medication is a critical component to the well being of the individual and the manageability of the community. When a resident rejects her medications, she will be encouraged to be adherent, with assurances that her concerns will be taken immediately to her therapist to facilitate contact with the psychiatrist of physician for re-evaluation of appropriateness of diagnosis, evaluation of side effects or how to withdraw appropriately from the prescription.
* Staff with whom she is rejecting her medication will listen to the reason and log them appropriately for her therapist, clinical director, psychiatrist or prescribing physician. Staff will have the resident sign off on the medication refusal form.
*A copy of this form will be given to the client's therapist.
Client record #1 was prescribed Gabapentin. This client was to take one tab by mouth three times a day. The client missed the following doses:
5/05/2010; one dose was missed.
5/07/2010; one dose was missed.
5/10/2010; one dose was missed.
5/13/2010; one dose was missed.
5/25/2010; two doses were missed.
5/26/2010; one dose was missed.
5/27/2010; one dose was missed.
6/01/2010; one dose was missed.
6/09/2010; one dose was missed.
6/10/2010; two doses were missed.
6/13/2010; two doses were missed.
The facility failed to complete a medication refusal form or indicate why this client missed taking her medications.
Client # 1 was prescribed Bupropion. This client was to take one tab by mouth two times a day. The client missed the following doses:
5/10/2010; missed one dose.
5/11/2010; missed one dose.
5/13/2010; missed one dose.
5/18/2010; missed one dose..
5/25/2010; missed one dose.
5/26/2010; missed one dose.
5/27/2010; missed one dose.
The facility failed to complete a medication refusal form or indicate why this client missed taking her medications.
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Plan of Correction
The Operations Manager is the responsible party.
On 7/19/2010 the Operations Manager conducted a training at the monthly Department Meeting. This training included highlighting the medication refusal forms and procedure to utilize them. All aspects of medications procedures were reviewed in this training with an extensive Question and Answer period.
On 7/16/2010 client#1 was consulted by Therapist and Clinical Director in regards to her past refusals. Client #1 was re-educated about Libertae's refusal procedures. In this same meeting the consulting psychiatrist was contacted pertaining the necessity for a medication check on 7/23/2010 for the purposes of re-evaluation and the history of refusals.
The Operations and Resident Managers will monitor medication logs bi-weekly to ensure the documentation and procedures are followed according to Libertae's policy and procedure manual. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on the review of client records and the facility policy and procedure manual, the facility failed to document follow-up information in one of two required client records.
The findings include:
Four records were reviewed on June 23, 2010 and June 24, 2010. Follow-up information was required in two client records. The facility did not document follow-up information in client record # 3.
According to the facility policy and procedure manual that was reviewed on June 22, 2010, the facility will conduct follow-up on a client if they have participated for at least one month.
Client # 3 entered treatment on 8/27/2009 and was discharged on 11/10/2009. The facility failed to document any follow-up information for this client.
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Plan of Correction
The Clinical Director is the responsible party.
NOTE: Client #3 left the facility Against Facility Advice (AFA)on 11/10/2010 and the therapist is no longer employed with Libertae.
The Clinical Director will conduct a training with the therapists on 7/23/2010 in the monthly Department Meeting to review and re-emphasize the necessity for procedural follow up calls at 7 days post discharge if they participated for at least one month.
The Clinical Director will monitor that proper follow up information is gathered and contact is attempted to the client discharged during bi-weekly supervisions w/ random spot chart reviews and regular general chart reviews.
The Clinical Director will be updated monthly by the Outreach Coordinator of further follow up attempts and successful contacts pertaining to ongoing progress of the discharged clients.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document that work done by the client at the project is an integral part of the treatment and rehabilitation plan in two of four client records.
The findings include:
Four records were reviewed on June 23, 2010 and June 24, 2010. Verification of work as an integral part of the treatment and rehabilitation plan was required in four client records. The facility did not document work as an integral part of the treatment and rehabilitation plan in client records #1 and # 2.
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Plan of Correction
The Clinical Director is the responsible party.
Note: Work therapy contents pertaining to chores is obtained in other sections of the chart however, it was not captured in the Work Therapy /Rehabilitation plan portion of the treatment plans for client's #1 and #2.
On 7/13/2010 during the combined clinical team meeting, the Clinical Director conducted a training on the "Work Therapy"/ Rehabilitation Plan section of the treatment plans and the required contents that needed to be reflected from the official chart documentation.
Clarification around how the clients progress needed to be reflected in this section was provided. An assessment of the progress is also required in this section of the treatment plan as it pertains to Work therapy progress.
The Clinical Director will continue to monitor upon signing treatment plans that the work therapy (chores) is transferred into the problem indices section entitled Work therapy. This monitoring will take place also in individual supervision (random spot checks of charts) and during regular chart reviews.
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