INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11 through June 12, 2012, 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.
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the residential facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
A physical plant inspection was conducted on June 12, 2012. During the inspection, at approximately 9:40 a.m., a four foot by two foot plastic light cover was observed to have standing water in the fixture. The area of standing was approximately 36" long by 18 " wide. The light fixture was located in the staff lounge in the basement. On the first floor, there were seven ceiling tiles observed in the area that had water damage and were discolored. Bedroom # 21 had an area of approximately three feet by two feet with exposed pipes and wiring. The shared bathroom between room 20 and 21 had a cracked light cover that had sharp edges where a piece of the cover had been removed. The second floor hallway had two light fixtures that were missing covers. The lights were located across from the laundry area and across from room 24. The third floor hallway had a light fixture located across from the laundry area that was missing a light cover. Bedroom # 9 had a section of the wall approximately six feet by seven feet in length that had unfinished dry wall. There is also an area approximately six feet by two feet in the ceiling in need of repair.
These areas of concern were confirmed by the Operations Manager and was not disputed.
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Plan of Correction
The respoonsible party is the Executive Director, Operations Manager and Maintenance staff.
The process of correction began on 6/13/2012 by removing the water from the light fixture in the staff lounge in the basement.
On 7/16/2012 a meeting between the Executive Director, Assistant Director, Operations Manager, and Maintenance took place to devise a plan of completion for correction for the bedrooms #21 and #9.
Repairs and finishing wall board as well as covering any and all pipes and wiring to bedroom #21 to be completed by 8/3/2012 and the same repairs to bedroom #9 will be completed by 8/3/2012.
On 6/20/2012 The cracked light fixture in the bathroom between rooms #20 and #21 will be replaced.
All missing light covers on all floors will be replaced by 7/22/2012.
The Operations Manager and Residence Manager will monitor the repairs until completion during regular rounds.
The Maintenance will monitor that all wiring is dry and safe in the staff lounge during regular maintenance.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation during the physical plant inspection, the facility failed to ensure that all heaters were permanently mounted or installed.
The findings include:
The physical plant inspection took place on June 12, 2012. At 10:30 am., two heaters that were not permanently mounted or installed were observed during the physical plant tour. There was one heater located in the life skills office and one heater was in the general area of the building.
This finding was confirmed by the resident manager and not disputed.
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Plan of Correction
Responsible Party Operations Manager, Resident Manager and Social Services Director.
Both the heater in the donation pile and in the Life Skill's office were disguarded immediately.
On 6/19/2012 the Social Service Director and Operations Manager reviewed with the team the state standard pertaining to the use of heaters.
Operation Manager will review this information in the staff meeting held for all staff on 7/2/2012.
The Resident Manager will monitor the general areas of the building to assure any donations of heaters are disgarded immediately.
Supervisors will monitor offices during monthly supervisions to assure any heaters are permanently mounted to the wall or removed immediately.
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709.32(c)(2) 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:
(2) Drug storage areas.
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Observations
Based on observation, the facility failed to keep topical medications kept separate from oral medications in their drug storage area.
The findings include:
The physical plant inspection took place on June 12, 2012. During the inspection, the drug storage areas were observed at 9:55 a.m. The medication cart had client's topical medications stored with their oral medications.
This finding was confirmed by the resident manager.
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Plan of Correction
Responsible Party: Operations Manager and Resident Manager
All Topical medications were removed to the top drawer of the med cabinet. This was corrected during the inspection.
Operations Manager will review the storage protocols for topical medications with all staff at the staff meeting on 7/2/2012.
Resident Manager will monitor to assure Topical and oral medications are separate during monthly medication inventory. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document the lengths and patterns related to the client's progression of drug and alcohol use in three of five records.
The findings were:
Five patient records were reviewed on June 12, 2012. All records required documentation of drug and alcohol history that included lengths and patterns related to the client's progression of use. The facility failed to document the lengths and patterns related to the client's progression of use in patient records # 3, 4, and 5.
This finding was discussed with the clinical supervisor and was not disputed.
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Plan of Correction
The responsible party is the Clinical Director.
The Clinical Director on 6/13/12 added a narrative portion to the existing chart in the biopsychosocial that has the clinicians report specific progresion and amount of use over time through to current use. An example of what was expected was distributed to the front office staff to add to amend admission packet copies as well as to all clinicians and clinical interns for immediate implementation.
On 6/13/12 a training with all clinicians took place to review the change made to the Biopsychosocial, what the narrative was to include by reviewing the provided example as well as to insure the replacement of all old versions of the biopsychosocials. patient records #3,4,and 5 were reviewed in order to clarify.
The Clinical Director will monitor the consistency of the content to ensure it is specific to progression of use over time during regular chart reviews in individual supervisions as well as during random chart reviews.
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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 the review of client records, the facility failed to document a treatment plan update at least every thirty days in two of five client records.
The findings include:
Five client records were reviewed on June 12, 2012. Treatment plan updates were required in five client records. Based on the regulation and the facility's policy, the facility failed to document a treatment plan update every thirty days. The facility documented late treatment plan updates in client records # 3 and 5.
Client # 3 was admitted on January 26, 2012. The initial treatment and rehabilitation plan was documented on February 21, 2012. The treatment and rehabilitation plan update was due on March 22, 2012. The facility documented the treatment and rehabilitation plan update on March 31, 2012. This was 9 days late.
Client # 5 was admitted on August 24, 2011. The facility documented the initial treatment and rehabilitation plan on September 26, 2011. The treatment and rehabilitation plan update was due on October 26, 2012. The facility documented the treatment and rehabilitation plan update on November 8, 2011. This was 13 days late. There was a subsequent treatment plan updates documented on December 7, 2011 and January 9, 2012. There was a treatment plan update due on February 9, 2012, however, it was documented on February 13, 2012. This was four days late.
This finding was discussed with the clinical supervisor and was not disputed.
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Plan of Correction
The responsible party is the Clinical Director.
On 6/19/2012 during the clinical team meeting a review of charts #3 and #5 was apart of the training on the importance of completing treatment plans within the state standard and Libertae time frame which is within 30 days for each update.
A reminder was issued to all clinicians and clinical interns that even one day over the due date the treatment plan is considered late.
The Clinical Director will monitor the consistency and completion of timely treatment plans during individual supervisions as well as during quarterly and random chart reviews. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on the review of the facility's policy and procedures and client records, the facility failed to document a case consultation within the facility's required time frame.
The findings include:
The facility's policy and procedures were reviewed on June 11, 2012. According to the facility's policy and procedures, case consultations will be documented every three months starting from the date of admission. The facility failed to document a case consultation every three months in records # 1, 3, and 5.
Client # 1 was admitted on December 14, 2011. A case consultation was due on March 14, 2012. The facility documented the case consultation on March 21, 2012. This was 7 days late.
Client # 3 was admitted on January 26, 2012. A case consultation was due on April 26, 2012. The facility documented the case consultation on May 2, 2012. This was 6 days late.
Client # 5 was admitted on August 24, 2011. A case consultation was due on November 24, 2011. The facility documented the case consultation on December 7, 2011. This was 13 days late.
This finding was reviewed with the clinical supervisor and was not disputed.
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Plan of Correction
The responsible party is the Clinical Director and the Assistant Director
On 7/09/2012 the Assistant Director gave to the Clinical Director the new revised policy for Case Consults.
The Case Consultation policy was changed from needing to be completed within "90 days from date of admission" to must be completed "at least quarterly"
This policy will be approved by the Board of Directors on 7/25/12.
A training will be conducted on 7/17/2012 during the joint house clinical team meeting to review charts #1,3, and 5. Then also a review of the new case consultation policy to ensure all case consultations are done quarterly. A copy of the policy will be distributed at this time for all clinicians and clinical interns to begin implementing it immediately.
The Clinical Director will monitor the consistent follow through on the case consultation policy during individual monthly supervision chart reviews as well as during quarterly and random chart reviews. |