INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 14, 2011 through June 15, 2011 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:
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Plan of Correction
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on observations on June 14, 2011 the facility failed to ensure that the water temperature did not exceed 120 F in the two bathrooms in the facility.
The findings include:
The physical plant inspection was conducted on June 14, 2011 at 2:50pm. During the tour temperatures were taken in shared staff/client female bathrooms, the hot water measured over 120 degrees.
The hot water temperature was 130 F in the bathroom sink.
The facility director was present during the tour and confirmed the temperatures.
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Plan of Correction
On Monday 6-27-11 the Central Region Physical Plant Manager was called to adjust the water temperature at the Cncept 90 facility. The water temperature was adjusted and is now in compliance with the standard. To ensure that the temperature remains within the standard, beginning 6-27-11, a weekly run on all facility faucets and showers will be conducted by the House Manager designated for facility maintenence. The House Manager will take all water temperatures and report findings to the Program Supervisor. If at any time the water temperatures are found to be out of compliance, the Physical Plant Manager will be called to make adjustments accordingly. |
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 an inspection of the physical plant, the facility failed to provide documentation that cold food is kept at or below 40 degrees Fahrenheit
The findings include:
The physical plant was inspected on June 14, 2011 at approximately 3:15pm. The thermometer on the refrigerator read 50 degrees Fahrenheit. The refrigerator was revisited on June 15, 2011 at approximately 8:50am, at this time the refrigerator read 48 degrees Fahrenheit.
The facility director was present during both tours and was able to confirm the findings.
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Plan of Correction
The refrigerator in question was not maintaining a temperature at or below 40 degrees Farenheit. This was due to the refrigerator needing to be serviced. The refrigerator was serviced on June 16th, 2011. All refrigerator temperatures will be taken and logged on a daily basis. This will be done two times per day, during first shift (8-4) and second shift (3-11). The temperatures will be taken and logged by the Cook Manager who will report any temperature problems to the Program Supervisor. In addition to the temperature check all refrigerators will be checked to make sure that they are plugged in and that the on/off switch is in the on position. This will occur during the temperature check. If it is found that a refrigerator temperature falls below 40 degrees Farenheit for a period of eight hours the Cook Manager will report this to the Program Supervisor who will then call a service technician to address the problem. |
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 on the review of client records, the facility's policy and procedure manual, and a conversation with the clinical director, the facility failed to document follow-ups in accordance with the facility's policies and procedures in three of three client records.
The findings include:
Nine client records were reviewed on June 14, 2011. Documentation of a follow-up was required in three of those records. The facility failed to document follow-up information in accordance with the facility's policies and procedures in client records # 6,7, and 8. Follow-up forms were documented for each client however the forms were predated for 30, 60, and 90 day follow ups and had no other date to indicate when the actual follow-up attempt was made.
The facility's policy titled, FOLLOW UP INFORMATION states:
In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are not referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder.
Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder.
Client # 6 was admitted on January 18, 2011 and discharged on April 18, 2011. The follow up form reads: "30 Day Follow Up should be done on______", "60 Day Follow Up should be done on______", "90 Day Follow Up should be done on______", the dates were filled in before the follow ups took place and the inspector was unable to determine when the follow ups had actually been completed. Dates of 5/18/11, 6/18/11 and 7/18/11 were entered at the time of the inspection on 6/14/11.
Client # 7 was admitted on January 7, 2011 and discharged on April 11, 2011. The follow up form reads: "30 Day Follow Up should be done on______", "60 Day Follow Up should be done on______", "90 Day Follow Up should be done on______", the dates were filled in before the follow ups took place and the inspector was unable to determine when the follow ups had actually been completed. Dates of 5/11/11, 6/11/11 and 7/11/11 were entered at the time of the inspection on 6/14/11.
Client # 8 was admitted on January 25, 2011 and discharged on April 25, 2011. The follow up form reads: "30 Day Follow Up should be done on______", "60 Day Follow Up should be done on______", "90 Day Follow Up should be done on______", the dates were filled in before the follow ups took place and the inspector was unable to determine when the follow ups had actually been completed. Dates of 5/25/11, 6/25/11 and 7/25/11 were entered at the time of the inspection on 6/14/11.
On June 14, 2011 an interview was held with the program supervisor in which she confirmed the follow-up forms were pre-dated for when the follow-ups were due and that there was no other date to confirm when the follow-ups were actually completed..
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Plan of Correction
On 06/29/2011, Program Supervisor trained Intake Specialist (follow-up designee) on follow up procedures in accordance with Agency policy, indicating that when clients are referred to another program or service a follow up will occur within 7 days after the referral appointment. Furthermore, a follow up must be attempted in instances where the client left for any other reason by contacting the client within 30 days of the date of discharge. Attention was given to not predate any follow up in any circumstance but rather document the actual date of the attempt within the time frame outlined in the policy. To ensure compliance, Program Supervisor will audit the Follow Up Binder on a biweekly basis for a period of 6 months. At the end of the 6 month period, or 01/29/2012, if follow ups remain in compliance with the policy then the Follow Up Binder will be audited on a monthly basis by the Program Supervisor. |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a written client follow-up policy that accurately reflects their follow-up process.
The findings include:
From May 9, 2011 through May 11, 2011, the facility's policy and procedure manual was reviewed. The facility had two conflicting procedures regarding attempts to follow up on clients.
The facility's policy titled: "Follow Up Information," states:
" All clients are followed up after discharge.
Follow up information shall be conducted for each client after discharge from the program, unless there is specific client refusal for follow up. Each program will maintain a follow up policy outlining the specific steps taken. The follow up log binder will house the documentation of each follow up attempt.
Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow up.
In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder.
In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note [remember to state the reason for the refusal in the note and on the form].
Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder.
.Follow up information shall include the client's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals. "
The facility ' s policy and procedure manual contained a second written policy titled: " FOLLOW UP INFORMATION. " This second policy states: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor's designee, to follow-up the discharged client's progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
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Plan of Correction
The facility's policy and procedure manual was reviewed May 9 ? 12, 2011 at Gaudenzia's Corporate Office. According to corporate guidelines, no individual facility may change any policy or form to suit facility needs. This citation regarding conflicting policies was reported to the Central Region Director and the CQI Director by the facility Program Director. The CQI Director revised the follow up policy on June 15, 2011. All Gaudenzia policies are now updated on the Gaudenzia website forms page. All updates will be discussed monthly in the CQI meeting and clarified by the CQI Director.
On July 5, 2011 a meeting was held with the Program Director, Program Supervisor and Administrative Coordinator to review the policy on follow up procedures that Gaudenzia developed. A memo was distributed to all staff on July 7, 2011 explaining the procedure to be used effective immediately.
The new policy states; the first follow up will be completed no later than 7 days of discharge on all referred clients who have given written consent. Follow ups will be completed on all other discharged clients within 30 days regardless of discharge status.
Both follow ups will be documented on the same form.
Forms will be forwarded monthly to the Administrative Coordinator to be filed in the proper follow up log/binder. All forms will be reviewed monthly during the administrative meeting with the Program Supervisor, Administrative Coordinator and the Program Director. Follow up will be discussed during both clinical meetings and supervisory sessions. Follow up will be completed by designated clinical staff.
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