INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on September 17, 2020 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation, Snug Harbor Rehabilitation and Recovery LLC was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
705.1 (3) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(3) Comply with applicable Federal, State and local laws and ordinances.
|
Observations
Based on a physical plant inspection and a review of the items in the refrigerator on September 17, 2020, the facility failed to use only food products within the recommended dates of use. The commercial size ranch dressing container expired June 2020. The findings have been reviewed with the facility staff during the inspection.
|
Plan of Correction
Staff has been re-educated on food item rotation and disposal of outdated food items.
The House Monitors will manage this duty and ensure food items are rotated oldest to newest and that dates are monitored to dispose of outdated items properly. This task will be completed by first shift House Monitors checked weekly. If an item is found to be outdated it will be disposed of immediately.
The log will be reviewed by the House Monitors Supervisor and routinely reviewed with Senior Management to ensure outdated items are removed and that this deficiency will not reoccur.
This process will be implemented on or before 10/21/2020. |
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.
|
Observations
Based on a physical plant inspection on September 17, 2020, the facility failed keep cold food at or below 40F, and frozen food at or below 0 F. there were no thermometers in the refrigerator and the freezer in the residential kitchen. The findings have been reviewed with the facility staff during the inspection.
|
Plan of Correction
New thermometers were purchased for the staff refrigerator which can be used for overflow of food items for clients. The log book that is kept on top of the microwave is used daily to record temperatures of refrigerator and freezer.
The House Monitors will ensure temperatures for cold food are at 40 degrees or less and the freezer is maintained at 0 degrees or less. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
|
Observations
Based on client interviews and a review of client records on September 17, 2020, the facility failed to provide orientation of the project policies to clients at admission. There was no documentation that clients received an orientation with facility staff or that they received a client handbook showing that the project's policies were reviewed with them. The findings have been reviewed with the facility staff during the inspection.
|
Plan of Correction
A new client orientation schedule has been implemented to ensure all clients are oriented to their new surroundings and staff.
The client handbook is reviewed upon admission to the detoxification unit and clients are asked to sign receipt of this handbook. Intake Staff has been re-educated to the importance of reviewing the client handbook with new clients in more detail. However, taking into consideration the condition of new clients arriving in detox the client handbook is reviewed again in the residential unit and clients are asked to sign again their receipt and understanding of the rules and expectations of each client.
Intake is responsible for the initial review and Clinical Supervisor assumes responsibility for the second review. Clients are asked to sign again acknowledging receipt and understanding of this handbook.
The new orientation schedule will be used by or before 10/21/2020. This orientation will begin in INTAKE and be retained within the client medical record.
|
709.52(e)(6) LICENSURE Vocational Support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(6) Vocational.
|
Observations
Based on review of client record and interviews with staff and residents on September 17, 2020, the facility failed to document on treatment plans a vocational goal for work being done at the facility. Clients were assigned to cook for both the rehabilitation and detoxification clients, but those goals were not documented on the treatment plan as work therapy. The findings have been reviewed with the facility staff during the inspection.
|
Plan of Correction
All counselors have been re-educated on the need to document in the client's treatment plan all duties/chores that clients perform within the residential unit.
A chore assignment board is under development to ensure not one client is doing the same chore all the time. This schedule will be for a period of one week. This schedule is prepared by the House Monitor.
This work therapy documentation is an example of life skill education used as an aid to assist clients once they graduate from the program.
Program Manager will ensure this documentation is correctly entered into the treatment plan.
This procedure will be implemented on or before 10/21/2020. |