INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 21-22, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection,Treatment Trends, Inc. - Half-way Home of The Lehigh Valley 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
One personnel record was reviewed for the clinical supervisor position on May 21, 2018. The facility failed to fully document monthly supervision meetings for the first 6 months of employment in the clinical supervisor position for employee record # 3. Employee # 3 was hired by the project on 5/20/15 and began employment in the clinical supervisor position on 9/11/17. Monthly supervision meetings were required to be documented for the months of October 2017 - March 2018. A monthly supervision meeting was not documented for the month of January 2018. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director will create a process by which to document supervision regularly. Program Director will document clinical supervision at the end of each supervision session to ensure documentation has occurred. |
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
A physical plant inspection was conducted on May 22, 2018. A walk-in freezer in the kitchen was observed to have a temperature of 10F. A temperature log for the period of 4/16/18 - 5/22/18 indicated that the freezer had a recorded daily temperature of 10F, which is above the required temperature of 0F or below. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director has worked with HVAC vendor to replace exterior temp gauges. Additionally walk in refrigerator and freezer received new hang on thermometers. Clinical techs will receive training on 6/20/18 on how to proper monitor, log, and report temperatures as a part of their supervision. Program Director,in concert with House manager and Quality assurance department, will monitor temp log book for a period of the next 3 months. Spot checks will occur randomly following the 3 month evaluation period. |
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.
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Observations
Seven client records were reviewed on May 21-22, 2018. The facility failed to obtain an informed and voluntary consent to release information, where consent was applicable, for client record # 7. Client # 7 was admitted into treatment on 8/14/17 and was discharged on 11/19/17. Documentation in the client's record indicated that the facility faxed a prescription authorization request to a health insurance company, on the client's behalf, on 10/11/17. A consent to release information to this insurance company was not documented in the record. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director met with service coordinator on 5/22/18 and provided training/supervision to ensure proper releases of information are in place prior to conducting medical appointments and/or other various health insurance resourcing for residents. The Program Director in concert with the Clinical supervisor reviewed all current charts to ensure releases are on record and in compliance with confidentiality. The Program Director, Quality assurance department, and/or delegate will be conducting random spot checks to insure confidentiality is being upheld. |