INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 19 - 20, 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 June 24, 2008.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based upon a review of seven personnel training records, the facility failed to ensure that all employees completed a minimum of 6 hours of HIV/AIDS training using a Department approved curriculum within the regulatory time frame of one year for counselors and counselor assistants and two years for all other staff and volunteers. One of six clinical staff due for the training had not completed the training within the mandatory time frame. Employee #7, originally hired in February of 2007 and then rehired on 4/27/2007 had not yet completed the mandatory training as of May 20, 2008.
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Plan of Correction
1. Employee 7# will be trained in HIV/AIDs by 8-31-08. All newly hired Staff will be monitored and scheduled to attend training in HIV/AIDS and TB according to Pa Department of Health reglations within a year of their hire date.
Staff responsible: Program Director |
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 freezer temperature logs, the facility failed to ensure that frozen foods were kept at or below 0 Fahrenheit. Temperatures for freezer #1 exceeded 0 Fahrenheit daily throughout the months of March, April and May with the exception of March 8, 2008. The temperatures ranged from 4 F to 10 F. Temperatures for freezer #2 exceeded 0 Fahrenheit daily throughout the months of March, April and May with the exception of March 1 - 8, 2008; March 17, 2008 and May 1, 2, 4 & 5, 2008. Temperatures ranged anywhere from 2 up to 42 Fahrenheit during those three months.
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Plan of Correction
1. Steps have been taken to get freezers repaired to ensure that freezers register at or below 0degrees F.
2. If freezers continue to register inconsitantly to appropiate temperatures, Concept 90 will purchase a new freezer.
Persons responsible: Program Director
Cook Manager |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based upon a review of eleven client records, the facility failed to provide individualized treatment plans in two of eleven records reviewed. Client records #4 and 11 contained treatment plans that had been completed prior to the completion of the psychosocial histories and the psychosocial evaluations.
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Plan of Correction
1. Program Supervisor will review all clinical charts (ie biopsychosocials, evaluations and individual treatment plans) with counselors on a weekly basis for the next 3 months(6/18 to 9-18-08) to ensure continued compliance with BDAP.
Persons responsible: Program Director
Program Supervisor |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based upon a review of eleven client records, the facility failed to ensure that discharge summaries were completed within seven days from the date of discharge. Two of five closed client records reviewed contained discharge summaries that were completed more than seven days after the date of discharge, specifically client records #9 & 10.
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Plan of Correction
1. All clinical staff will be trained in proper documentation of Client Discharge Summaries by 7-31-2008.
2. Program Supervisor will review and monitor all closed client charts to ensure that all discharge summaries are completed in accordance to Department of Health standards from 6-18 to 9-18-2008.
Persons responsible: Program Director
Program supervisor |
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 upon a review of eleven client records, the facility failed to ensure that follow-up contact attempts were completed within seven days from the date of the referral appointment. Documentation was missing for 3 of 5 clients requiring them, specifically client records #7, 8 and 11.
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Plan of Correction
1. Program Supervisor will review all closed client charts from 6-18 to 9-19-08 to ensure that follow-ups are being conducted and documented according to Gaudenzia Inc. policy and Pa Department of Health standards.
Persons responsible: Program Director
Program Supervisor |