INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gratitude 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 on August 22, 2024, the facility failed to ensure cold food was at or below 40F. The facility did not have a mechanism to ensure the temperature of cold food was at or below 40F.
Two of the refrigerators, #2 and #7, in the facility kitchen were not operating at a temperature of 40F or below.
These findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Maintenance staff checked facility refrigerators #2 and #7 on 8/23/24 and filters were replaced. New thermometers were placed into each refrigerator on 8/23/24. At this time, temperatures were reading within range. Maintenance staff and BHT Supervisor will continue to monitor daily temperatures and ensure efficiency. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in one of two applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in DDAP Licensing Alert 02-21.
Client # 5 was admitted on May 3, 2024, and was discharged on May 11, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility, against medical advice, as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor will review protocol for notifying emergency contact when a client leaves treatment against facility advice, during clinical staff meeting on August 29, 2024. Staff will also be re-educated to document in the clinical chart if they refused to sign an ROI for an emergency contact and circumstances of this. Executive Director and Clinical Supervisor will review this while completing discharge chart audits to ensure ongoing compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of three applicable client records.
Client #2 was admitted on July 9, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was completed on July 11, 2024, and the update was due no later than August 11, 2024; however, the next update was completed on August 15, 2024.
Client #4 was admitted on April 17, 2024, was discharged on July 17, 2024. A treatment plan update was completed on May 17, 2024, and the update was due no later than June 17, 2024; however, the next update was completed on June 19, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review timelines for completion of treatment plan updates with clinicians during clinical staffing on August 29, 2024. She will monitor compliance during monthly chart audits. Any ongoing issues with be address by clinical supervisor during monthly supervision. |
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 a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of four applicable discharged records reviewed. The facility ' s policy is to follow-up with discharged clients within seven days of discharge.
Client #4 was admitted on April 17, 2024, and was discharged on July 17, 2024. A follow-up contact was to be completed no later than July 24, 2024; however, there was no documentation in the client record that it had been completed.
Client #6 was admitted on July 10, 2024, and was discharged on July 19, 2024. A follow-up contact was to be completed no later than July 26, 2024; however, there was no documentation in the client record that it had been completed.
This is a repeat citation from the June 20, 2023 licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed this during supervision on August 27, 2024 with the administrative assistant. Discussed documenting within seven days of discharge to ensure compliance. Discussed documenting if there was no forwarding information for the client or if they were unable to be reached. Executive Director reviewed with administrative assistant that this is a repeat citation. Executive Director and Clinical Supervisor will review compliance during monthly chart audits. Any additional concerns will be addressed in monthly supervision with the Executive Director. |
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 a review of client records, the facility failed to provide a complete client record to include verification that work done by the client at the project is an integral part of their treatment and rehabilitation plan, in seven out of seven client records reviewed.
Client # 1 was admitted on July 25, 2024, and was still active at the time of the inspection. The client's treatment plan goals did not reflect that work completed by the client, at the facility, were part of their rehabilitation plan.
Client # 2 was admitted on July 9, 2024, and was still active at the time of the inspection. The client's treatment plan goals did not reflect that work completed by the client, at the facility, were part of their rehabilitation plan.
Client # 3 was admitted on August 12, 2024, and was still active at the time of the inspection. The client's treatment plan goals did not reflect that work completed by the client, at the facility, were part of their rehabilitation plan.
Client # 4 was admitted on April 17, 2024, and was discharged July 17, 2024. The client's treatment plan goals did not reflect that work completed by the client, at the facility, were part of their rehabilitation plan.
Client # 5 was admitted on May 3, 2024, and was discharged May 11, 2024. The client' s treatment plan goals did not reflect that work completed by the client, at the facility, were part of their rehabilitation plan.
Client # 6 was admitted on July 10, 2024, and was discharged July 19, 2024. The client's treatment plan goals did not reflect that work completed by the client, at the facility, were part of their rehabilitation plan.
Client # 7 was admitted on March 1, 2024, and was discharged April 1, 2024. The client's treatment plan goals did not reflect that work completed by the client, at the facility, were part of their rehabilitation plan.
This is a repeat citation from the June 20, 2023 licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor will review utilization of work therapy in individual treatment plans at clinical team meeting on August 29, 2024. Clinical staff will ensure work therapy is added to treatment plans detailing involvement in employment, volunteer work, or lifeskills. Executive Director and Clinical Supervisor will complete monthly chart audits to review progress. Clinical Supervisor will address any ongoing concerns during individual supervision. |