INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 15 - 16, 2015 by staff from the Division of Drug and Alcohol 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.
|
Plan of Correction
|
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
|
Observations
Based on observation during a physical plant inspection, the facility failed to maintain the interior of the building so as to be free from any danger to health and safety.The findings include:A physical plant inspection was conducted with the facility director and maintenance manager on September 16, 2015 at approximately 9:00 AM. Client bedroom # 6, located on the second level, had a large crack in the ceiling plaster exposing the wood beneath. Directly below the left window and behind a client bed, cracked and peeling plaster was observed. The facility failed to maintain this bedroom so as to be free from any danger to health and safety of the residents. The maintenance manager confirmed that rain water had leaked into the building.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The presenting issue with room#6 was reviewed with our maintenance department. The supervisor for the maintenance department assessed the room and began to correct the problem to meet standards.
The Program Director will ensure that the maintenance department completes repairs by the designated time frame. The Program Manager and risk committee will continue to assess physical plant needs monthly and address any concerns or issues with the maintenance department. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of fire drill records, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.The findings include:Fire drill records were reviewed from April 2014 through August 2015. The facility's sleeping hours are from 11:00 PM through 6:30 AM. The facility conducted the following fire drills during sleeping hours: April 29, 2014 at 6:09 AM, January 31, 2015 at 6:00 AM and April 29, 2015 at 6:00 AM. A fire drill during sleeping hours was due to be conducted no later than October 31, 2014. The facility failed to conduct a fire drill during sleeping hours at least every 6 months.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The fire safety coordinator will conduct fire drills monthly, ensuring that once every 6 months a fire drill is conducting during the sleeping hours. Program Director will review fire drill log monthly to ensure they are being conducted on all shifts. |
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of the client records, the facility failed to obtain a written, informed and voluntary consent from the client that included the specific information to be disclosed and the purpose of disclosure in three of ten client records. The findings include:Ten client records were reviewed on September 15, 2015. Ten client records were reviewed for written, informed and voluntary consents from the client. The facility failed to obtain a written, informed and voluntary consent from the client that included the specific information and the purpose of disclosure in client records # 1, 2 and 4.Client # 1 was admitted into treatment on June 18, 2015. Client # 1 signed a consent to release information form for their physician on September 1, 2015. The consent to release information form did not include the specific information to be disclosed to their physician or the purpose of the disclosure.Client # 2 was admitted into treatment on June 4, 2015. Client # 2 signed a consent to release information form for their physician on September 1, 2015. The consent to release information form did not include the specific information to be disclosed to their physician or the purpose of the disclosure.Client # 4 was admitted into treatment on July 6, 2015. Client # 4 signed a consent to release information form for their physician on July 6, 2015. The consent to release information form did not include the specific information to be disclosed to their physician or the purpose of the disclosure.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director and Lead Counselors will ensure that consents are being completed properly. Program Director and lead counselors will monitor charts monthly to ensure that all consents include specific information to be disclosed and the purpose of the disclosure, and that consents are placed in the correct service category.All staff (counselors and administrative assistance) will receive a training in October on completing consents- addressing utilization of the appropriate consent and purpose and specific information to be released. Ongoing additional training will be provided as needed.
Program Director and Lead Counselors will review and audit all active client charts for accuracy of consents. New consents will be formulated as needed. |
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:
|
Observations
Based on a review of client records, the facility failed to document a complete client record including verification that work done by the client at the project was an integral part of his/her treatment and rehabilitation plan in ten of ten client records.The findings include:Ten client records were reviewed on September 15, 2015. Ten client records were reviewed for verification that work done by the client at the project was an integral part of his/her treatment plan. The facility failed to document a complete client record including verification that work done by the client at the project was an integral part of his/her treatment and rehabilitation plan in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.Client # 1 was admitted into treatment on June 18, 2015. An individual treatment plan was completed on June 29, 2015. The facility failed to document a complete client record including verification that work done by client # 1 at the project was an integral part of his/her treatment plan.Client # 2 was admitted into treatment on June 4, 2015. An individual treatment plan was completed on June 9, 2015. The facility failed to document a complete client record including verification that work done by client # 2 at the project was an integral part of his/her treatment plan.Client # 3 was admitted into treatment on April 18, 2015. An individual treatment plan was completed on April 24, 2015. The facility failed to document a complete client record including verification that work done by client # 3 at the project was an integral part of his/her treatment plan.Client # 4 was admitted into treatment on July 6, 2015. An individual treatment plan was completed on July 10, 2015. The facility failed to document a complete client record including verification that work done by client # 4 at the project was an integral part of his/her treatment plan.Client # 5 was admitted into treatment on April 8, 2015 and discharged on July 6, 2015. An individual treatment plan was completed on April 20, 2015. The facility failed to document a complete client record including verification that work done by client # 5 at the project was an integral part of his/her treatment plan.Client # 6 was admitted into treatment on March 11, 2015 and discharged on May 14, 2015. An individual treatment plan was completed on April 3, 2015. The facility failed to document a complete client record including verification that work done by client # 6 at the project was an integral part of his/her treatment plan.Client # 7 was admitted into treatment on April 6, 2015 and discharged on June 12, 2015. An individual treatment plan was completed on April 15, 2015. The facility failed to document a complete client record including verification that work done by client # 7 at the project was an integral part of his/her treatment plan.Client # 8 was admitted into treatment on May 18, 2015 and discharged on June 2, 2015. An individual treatment plan was completed on June 1, 2015. The facility failed to document a complete client record including verification that work done by client # 8 at the project was an integral part of his/her treatment plan.Client # 9 was admitted into treatment on January 22, 2015 and discharged on April 17, 2015. An individual treatment plan was completed on February 2, 2015. The facility failed to document a complete client record including verification that work done by client # 9 at the project was an integral part of his/her treatment plan.Client # 10 was admitted into treatment on April 10, 2015 and discharged on July 29, 2015. An individual treatment plan was completed on April 21, 2015. The facility failed to document a complete client record including verification that work done by client # 10 at the project was an integral part of his/her treatment plan.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Counselors will include components of work therapy in each individual's treatment plan. The counselors will provide a detailed description of the work therapy that is conducted, the time frames associated with the work therapy, and the therapeutic value of participation in the work therapy. Clients will continue to be provided with detailed information on the work therapy requirements in their client handbooks for reference as well.
Counselors have been retrained on the above area and changes have begun to be implemented. Program Director and lead counselor will ensure that work therapy is identified in the treatment plan, prior to signing off on them when completed. The Program Director and lead counselor will ensure all active charts are updated(including #1,#2, #3, and #4). The Program Director and lead counselor will continue to monitor charts randomly on a monthly basis to ensure ongoing progress. Lead counselors will address progress and/or ongoing concerns with counselors during their monthly supervision. The Program Director and Lead Counselor will continue to educate on this area during weekly treatment team meeting. |