INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 21 - 22, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Together 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 the physical plant inspection, the facility failed to keep frozen food at or below 0 degrees Fahrenheit in one of two freezers.
The findings include:
A physical plant inspection was conducted on April 24, 2014, at approximately 10:30 AM.
The freezer temperatures read 0 F degrees at the time of inspection. However, a review of the freezer temperature log, specifically for freezer # 1 indicated that the freezer measured above 0 F degrees for the entire month of March and April. Based on the temperature log, the average temperature for the month of March and April was 15 degrees Fahrenheit.
The Dietary Manager confirmed at the time of inspection that the freezers temperature exceeded 0 F for the month of March and April.
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Plan of Correction
The freezer temperature will be monitored twice daily. Once in the morning and once in the evening to be in compliance with Policy 705.7 (b)(5)Food Service which states that that frozen food should be at or below 0F.
An In Service Training with the Kitchen Staff occurred on June 9, 2014 to ensure that the kitchen staff were aware of the times to monitor the freezer temperature according to Policy 705.7 (b)(5)Food Service.
The Food Services Manager will monitor the temperature log daily to ensure that the freezer is checked twice daily and documented on the Refrigerator/Freezer Temperature Log.
Persons Responsible:
Deputy Division Director
Together House Program Director
Food Services Manager
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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:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release client information form, failed to include one or more of the required elements listed under 28 Pa. Code on consent to release client information forms, and/or failed to comply with the restrictions imposed at 4 Pa. Code 255.5(b), in seven of sixteen client records reviewed.
The findings include:
28 Pa. Code states:
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:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Expiration date of the consent.
4 Pa. Code 255.5 (b) 91-5) states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Sixteen client records requiring documentation of informed and voluntary consent to release client information forms were reviewed on April 21 - 22, 2014. The facility failed to obtain an informed and voluntary consent to release client information form, failed to include one or more of the required elements listed under 709.28(c) on consent to release client information forms, and/or failed to comply with the restrictions imposed at 4 Pa. Code 255.5(b), in client record # 1, 2, 3, 7, 9, 11 and 13.
Client # 1 was admitted to the program on 1/31/14 and was still an active client as of 4/21/14. The record contained two consent to release client information forms for a government agency that were signed by the client. The facility failed to document the specific information disclosed on both consent to release client information forms. The record also included three consent to release client information forms that were signed by the client. The facility failed to document the name of the person, agency or organization to whom disclosure is made, the specific information disclosed, and the purpose of the disclosure on all three consent forms.
Client # 2 was admitted to the program on 2/12/14 and was still an active client as of 4/21/14. The facility failed to document the specific information disclosed on a signed consent to release client information form, for a government agency, that was in the client record. The facility also failed to document the name of the person, agency or organization to whom disclosure is made, the specific information disclosed, and the purpose of the disclosure on two other signed consent to release client information forms contained in the record.
Client # 3 was admitted to the program on 3/10/14 and was still an active client as of 4/21/14. The record included a consent to release client information form for a government agency that was signed by the client on 4/09/14. The facility failed to adhere to the restrictions imposed at 4 Pa. Code 255.5 (b) (1-5) as the next page in the record contained documentation of a disclosure of client information to the government agency in excess of 4 Pa. Code 255.5 (b) (1-5).
Client # 7 was admitted to the program on 2/18/14. The facility failed to document the specific information disclosed on a consent to release client information form that was included in the client record.
Client # 9 was admitted to the program on 1/15/14 and was still an active client as of 4/21/14. The record included two consent to release client information forms for a government agency that were signed by the client. The facility failed to document the specific information disclosed on both consent to release client information forms. The facility also failed to obtain an informed and voluntary consent to release client information form for the disclosure of information to a government agency. Record # 9 included a progress note dated 4/4/14 that documented contact between the facility and the government agency, for which there was no voluntary and informed consent form signed by the client.
Client # 11 was admitted to the program on 3/6/14 and was still an active client as of 4/21/14. The record included a consent to release client information form for a government agency that was signed by the client on 4/21/14. The facility failed to document the specific information disclosed on the consent to release client information form.
Client # 13 was admitted to the program on 3/11/14 and was still an active client as of 4/21/14. The record included a consent to release information form signed by the client on 3/11/14. The facility failed to document the name of the person, agency or organization to whom disclosure is made, the specific information disclosed and the purpose of the disclosure on the consent to release client information form.
The findings were reviewed with the Facility Director.
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Plan of Correction
A record-keeping training will be held on June 5, 2014 will review the Division of Drug and Alcohol Licensure per DOH Policy 709.28(c)Confidentiality.
The training will include obtaining 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:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Expiration date of the consent.
All Consent Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Clinical Supervisor.
Persons Responsible:
Division Director
Together House Program Director and Clinical Supervisor
Timeframe for Completion: June 5, 2014 |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, and failed to afford the client an opportunity to request reconsideration of a decision terminating treatment in two of two client records reviewed.
The findings include:
Two client records requiring documentation of notification of termination were reviewed on April 21, 2014. The facility failed to document notification of termination in client records # 8 and 14.
Client # 8 was admitted to the program on 12/5/13 and was involuntarily terminated on 3/3/14. The facility failed to inform the client, in writing, of a decision to involuntarily terminate treatment. In addition, the client was not offered an opportunity to request reconsideration of a decision terminating treatment.
Client # 14 was admitted to the program on 11/20/13 and was involuntarily terminated on 1/2/14. The facility failed to inform the client, in writing, of a decision to involuntarily terminate treatment. In addition, the client was not offered an opportunity to request reconsideration of a decision terminating treatment.
The findings were reviewed with the Facility Director.
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Plan of Correction
A record-keeping training will be facilitated on June 5, 2014 to review how to notify the client, in writing, of a decision to involuntarily terminate their treatment at the project. The training will include the clients request reconsideration of a decision terminating treatment as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.33(a): Notification of Termination.
All discharge documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Clinical Supervisor.
Persons Responsible:
Division Director
Together House Program Director and Clinical Supervisor
Timeframe for Completion: June 5, 2014 |
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record that included documentation of a record of services provided in three of sixteen client records reviewed and verification that any work done by the client was an integral part of the treatment and rehabilitation plan in eight of sixteen client records reviewed.
The findings include:
Sixteen client records were reviewed on April 21 - 22, 2014. The facility failed to document a complete client record that included a record of services provided in client records # 1, 2 and 4. The facility also failed to document that any work done by the client was an integral part of the treatment and rehabilitation plan in client record # 1, 2, 4, 5, 12, 13, 14 and 15.
Client # 1 was admitted to the program on 1/31/14 and was still an active client as of 4/21/14. The facility failed to document a complete client record that included a record of services provided and documentation that work done by the client was an integral part of the treatment and rehabilitation plan.
Client # 2 was admitted to the program on 2/12/14 and was still an active client as of 4/21/14. The facility failed to document a complete client record that included a record of services provided and documentation that work done by the client was an integral part of the treatment and rehabilitation plan.
Client # 4 was admitted to the program on 3/11/14 and was still an active client as of 4/21/14. The facility failed to document a complete client record that included a record of services provided and documentation that work done by the client was an integral part of the treatment and rehabilitation plan.
In addition, the facility failed to document a complete client record that included documentation that work done by the client is an integral part of his treatment and rehabilitation plan in client records # 5, 12, 13, 14, and 15.
The findings were reviewed with the Facility Director.
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Plan of Correction
A record-keeping training will be facilitated on June 5, 2014 to include the Record of Service and any work done by the client to be an integral part of the treatment and rehabilitation plan as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.53(a): Complete Client Record.
All treatment planning documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Clinical Supervisor.
Persons Responsible:
Division Director
Together House Program Director and Clinical Supervisor
Timeframe for Completion: June 5, 2014 |