INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 4 and 5, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Harrisburg Concept 90 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 March 18, 2008.
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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 upon a review of the temperature logs for the kitchen and an interview with the staff person in charge of dietary services during the licensing inspection on February 4, 2008, the facility failed to ensure that cold foods were kept at 40 degrees or less, that hot foods were kept at or above 140 and that frozen foods were kept at or below 0 The facility lacked documentation of hot and cold serving temperatures for all meals on August 16-31, 2007.
Documentation for food temperatures for the periods of September 26 - 30, 2007 and October 1-12, 2007 were missing. The facility was missing documentation of cold food temperatures from October 16 to February 4, 2008. Freezer temperatures exceeded 0 on January 1 -6, 27 and 28, 2008 and February 1-3, 2008. Refrigerator temperatures exceeded 40 from October 16, 17, 22 & 23, 2007; November 1, 4, 8, 10 13 & 19, 2007, December 13, 2007; and January 1-6, 2008.
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Plan of Correction
1. Freezer and Food temperatures will
be monitored and documented in timely manner.
Persons resonsible: Program Director
Cook Manager |
705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
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Observations
Based upon observation during the licensing inspection on February 4 and 5, 2008, during the facility tour, it was noted that the facility failed to ensure that a minimum of one operable, automatic smoke detector was provided on each floor, including the basement and attic. The basement lacked an automatic smoke detector.
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Plan of Correction
1. Automatic smoke detectors were installed (wired)into fire alarm system on 2nd floor and basement on February 12, 2008 |
705.10 (b) (2) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(2) On floors with resident bedrooms, maintain a smoke detector which shall be located within 15 feet of each bedroom door. On floors with no resident bedrooms, the smoke detection device shall be located in a common area or hallway. All detection devices shall be interconnected.
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Observations
Based upon observation during the licensing inspection on February 4 and 5, 2008, during the facility tour, it was noted that the facility failed to maintain a smoke detector located within 15 feet of each bedroom door. The distance between the bedroom doors of rooms 211 and 213 to the nearest smoke detector exceeded 15 feet.
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Plan of Correction
1. Smoke detectors were wired and spaced to meet BDAP regulations on February 12, 2008 by Tyco Fire & Security of New Cumberland, PA. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based upon a review of facility documents and an interview with facility staff, on February 4 and 5, 2008, the facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The audit for the 2006-2007 fiscal year had not yet been completed.
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Plan of Correction
1. The audit for 2006-07 was completed in December of 2007. During the Board of Directors Meeting of December 2007, the Fiance Comittee reviewed and accepted the audit findings. The audit is being prepare for submission to Bureau of Drugs & Alcohol Licensure.
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709.28 (c)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based upon client records reviewed during the licensing inspection of February 4 and 5, 2008 the facility failed to inform the client as to whom information was being released to. Three of four records reviewed, #3, 4 & 5, contained a form titled "Medical Release" which was a general consent to release information. The form failed to indicate who the information will be released to.
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Plan of Correction
1. Use of this consent form has been discontued as of February 6, 2008.
2. A new consent form has been implemented which reflects and individualizes the client's medical needs and services.
Person responsible :
Program Director |
709.32(c)(4) 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:
(4) Methods for control and accountability of drugs.
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Observations
Based upon a review of client Medication Administration Records (MAR) during the licensing inspection on February 5, 2008, the facility failed to follow facility policy and properly document client medications in one of three client records reviewed, specifically client record #1.
On the following dates: 10/27/07, 11/11/07, 11/22/07, 11/25/07 & 12/09/07, the MAR for client record #1 lacked staff and client initials indicating that the medication was taken, or a circle on that date with an explanation as to why the client did not receive the medication.
A note in the MAR for December 25, 2007 indicated that the client didn't feel like coming for medications at 8 am for the multivitamin; however, the client's initials appear for the metropol as though the client showed up for his/her medications.
On January 1, 2008, the client's initials had been entered in the MAR for his/her dose of prilosec, a multivitamin and metropol, but then the initials were covered with white-out. White out cannot be used for corrections on official documents.
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Plan of Correction
1. All staff will be trained in client medical documentation procedures.
2. The training process will be completed by April 30, 2008
Person responsible: Program Director |
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 upon a review of client records on February 5, 2008, the facility failed to properly document the client's medications to include the name of the medication, dosage and/or frequency of use, in two of three client records reviewed, specifically client records #1 and 3.
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Plan of Correction
1. All staff will be trained in client medication procedures by April 30, 2008.
Person responsible: Program Director |