INITIAL COMMENTS
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This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 5, 2021 by staff from the Bureau of Program Licensure. Part 2 consisted of a physical plant inspection and client record reviews.
Based on the findings of Part 2, an on-site licensure renewal inspection, Ambrosia of Philadelphia was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection conducted on February 09, 2021, the facility failed to ensure the building was safe and in good repair.
The following bedrooms had burnt outlets in restrooms located in the following resident bedrooms: 710, 709, 707, 706, 705, 704, 601, 410 and 412.
The following bedrooms missing and/or broken window shades in the following resident bedrooms: 712, 708, 705, 701, 610, 605, 603, 404 and 709.
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Plan of Correction
Ambrosia of Philadelphia has collaborated with our property manager and organized to have the outlets in rooms 710, 709, 707, 706, 705, 704, 601, 410, and 412 replaced. This has been completed as of 4/6/2021. Our Operations Department is conducting weekly room inspections of all client rooms moving forward to ensure all items required are present, operable, and safe.
Ambrosia of Philadelphia has ordered the shade replacements for 712, 709, 708, 705, 701, 610, 605, 603, and 404. This update will be completed no later than April 30, 2021. Our Operations Department is conducting weekly room inspections of all client rooms moving forward to ensure all items required are present, operable, and safe.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on the physical plant inspection conducted on February 09, 2021 , the facility failed to provide a wall mirror in the public bathroom located on the seventh floor.
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Plan of Correction
Ambrosia of Philadelphia has remounted this wall mirror on 4/1/2021 and is conducting weekly room inspections of all client rooms moving forward to ensure all items required are present, operable, and safe. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on the physical plant inspection conducted on February 09, 2021, the facility failed to ensure that all showers had slip resistant surfaces.
The bedrooms; 608, 610 and 613. Additionally, in the bedroom 611, the bathroom shower curtain appeared to have mold along the side and bottom of the curtain.
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Plan of Correction
Ambrosia of Philadelphia has purchased slip-resistant strips to add to the showers located in 608, 610, and 613 which have been installed as of 4/6/2021. Our Operations Department is conducting weekly room inspections of all client rooms moving forward to ensure all items required are present, operable, and safe.
Ambrosia of Philadelphia has purchased a shower curtain replacement for 611. This was replaced on 4/6/2021 and our Operations Department is conducting weekly room inspections moving forward to ensure all required items are present, operable, and safe.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on the physical plant inspection conducted on February 09, 2021, the facility failed to properly secure placement of an exhaust fan in room 610 ' s bathroom.
Exhaust fan was observed hanging loosely off a ceiling tiles.
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Plan of Correction
Ambrosia of Philadelphia has remounted the exhaust fan in 610 after discovering a client tampered with it in order to try to hide contraband. Our Operations Department is conducting weekly room inspections moving forward to ensure all required items are present, operable, and safe. |
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 conducted on February 09, 2021, the facility failed to display proper temperature reading within refrigerators located on the sixth and seventh floor conference rooms.
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Plan of Correction
Ambrosia of Philadelphia has since replaced the thermometers which were missing from the refrigerators located in the 6th and 7th floor conference rooms. Our Operations Department is conducting weekly facility inspections moving forward to ensure all required items are present, operable, and safe. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on the physical plant inspection conducted on February 09, 2021, the facility failed to ensure that all emergency exit was unobstructed
The emergency exit located on the six-floor eastside could not be opened unless the emergency exit on the westside was opened at the same time.
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Plan of Correction
Ambrosia of Philadelphia is working closely with our Information Technology department to address the obstruction noted. We have hired an electrician to come on-site to address the panel/controller having the issue. It is anticipated this repair will be completed no later than April 30, 2021.
It is noted, however, if an emergency occurs and our alarms are triggered, all electronically sealed doors immediately release to allow for safe evacuation.
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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.
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Observations
Based on the review of client record on March 05, 202, the facility failed to document when the witnessed signed or when the client signed the release form in 3 of 15 records. The form only had one spot for a date to cover both signatures. Additionally, the facility failed to provide written acknowledgement that all clients are able to verbally revoke consent in 15 of 15 records and releases for funding sources were not documented in 2 of 15 records.
The consents in the following records were observed to have only one spot for date and signature:
Client #01 admitted 12/04/2019
Client #03 admitted 06/08 2020
Client #10 admitted 03/02/2021
The following records did not have releases for the funding source:
Client #6 admitted 03/01/2021
Client #12 admitted 03/03/2021
The findings were discussed with facility staff.
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Plan of Correction
Since the date of our record inspection, Ambrosia of Philadelphia's Director of Compliance has added a witness and/or staff signature to all consents which are signed by our clients. This revision became effective and was placed in rotation as of 2/11/2021. Both signatures present on the form have their own timestamps in place. Due to client's discharging from our program, new forms cannot be obtained in all cited instances, however, should a request for records come in for any client with the outdated consent in their chart, Ambrosia of Philadelphia will request the updated consent be completed prior to any disclosures taking place. These forms, once edited in our EMR system, automatically populate for all clients as of the effective date of the revision.
Ambrosia of Philadelphia's Director of Compliance has added verbiage to all applicable consent forms notifying clients they are able to revoke any signed consent either in writing or verbally at any time after the document has been signed. This document update became effective 3/29/2021. Due to client's discharging from our program, new forms cannot be obtained in all cited instances, however, should a request for records be received for any client with the outdated consent in their chart, Ambrosia of Philadelphia will request the updated consent be completed prior to any disclosures taking place. These forms, once edited in our EMR system, automatically populate for all clients as of the effective date of the revision.
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709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records March 5, 2021, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information for funding sources in 13 out of 15 records and for parole in 2 out of 15 records.
The consents in the following records failed to comply with 4 Pa. Code 255.5 by allowing the release of the following infromation:
Biophysical assessment, psychiatric evaluation, laboratory reports, urine analysis, progress notes, medical history, staff conference/ treatment plan and review, intake evaluation, discharge summary, telephone calls, others and letters,
Client 1 consent dated 12/4/19
Client 2 consents dated 3/2/21
Client 3 consent dated 6/8/20
Client 4 consent dated 3/3/21
Client 5 consent dated 1/21/21
Client 7 consent dated 2/13/21
Client 8 consent dated 11/23/20
Client 9 consent dated 9/4/20
Client 10 consent dated 3/2/21
Client 11 consent dated 3/2/21
Client 13 consent dated 2/27/21
Client 14 consents dated 2/28/21
Client 15 consent dated 2/18/21
These findings were discussed with the facility.
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Plan of Correction
Ambrosia of Philadelphia's Director of Compliance has reviewed the applicable statute and has adjusted all of the consents signed by our clients. The information to be disclosed has been limited to comply with 4 Pa. Code 255.5 (b). This revision is effective and in rotation as of 3/29/2021. Due to client's discharging from our program, new forms cannot be obtained in all cited instances, however, should a request for records come in for any client with the outdated consent in their chart, Ambrosia of Philadelphia will request the updated consent be completed prior to any disclosures taking place. The signed updated consent will be uploaded to the client's chart for retention purposes. These forms, once edited in our EMR system, automatically populate for all clients as of the effective date of the revision. All consents are discussed and signed during our Admissions process. All of the above will be monitored by the Director of Compliance moving forward. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of the facility's client records on March 5, 2021, the facility failed to include the following verbiage on the client rights form that the client receives.
A client receiving care or treatment under section 7 of the act (71 P.S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
This finding was discussed with the facility.
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Plan of Correction
Ambrosia of Philadelphia's Director of Compliance has updated the Client's Rights form signed by our clients upon admission to include the verbiage below. This revision is effective and in rotation as of 3/29/2021. These forms, once edited in our EMR system, automatically populate for all clients as of the effective date of the revision.
Verbiage added to the Client's Rights form signed by every client upon admission now includes:
"A client receiving care or treatment under section 7 of the act (71 P.S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment."
Due to client's continuously discharging from our program, new forms cannot be obtained in all cited instances, however, all clients who were part of our active census on the date this revision was effective have been asked to review and sign the updated version. All of the above will be monitored by the Director of Compliance moving forward to ensure we remain in line with all applicable regulations. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the facility's client records on March 5, 2021, the facility failed to include the following verbiage on the client rights form that the client receives.
The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
This finding was discussed with the facility.
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Plan of Correction
Ambrosia of Philadelphia's Director of Compliance has updated the Client's Rights form signed by our clients upon admission to reflect the verbiage below. This revision is effective and in rotation as of 3/29/2021. These forms, once edited in our EMR system, automatically populate for all clients as of the effective date of the revision.
Verbiage added to the Client's Rights form signed by every client upon admission now includes:
"The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion."
Due to client's continuously discharging from our program, new forms cannot be obtained in all cited instances, however, all clients who were part of our active census on the date this revision was effective have been asked to review and sign the updated version. All of the above will be monitored by the Director of Compliance moving forward to ensure we remain in line with all applicable regulations.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of the facility's client records on March 5, 2021, the facility failed to include the following verbiage on the client rights form that the client receives.
Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
This finding was discussed with the facility.
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Plan of Correction
Ambrosia of Philadelphia's Director of Compliance has updated the Client's Rights form signed by our clients upon admission to reflect the verbiage below. This revision is effective and in rotation as of 3/29/2021. These forms, once edited in our EMR system, automatically populate for all clients as of the effective date of the revision.
Verbiage added to the Client's Rights form signed by every client upon admission now includes:
"Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record."
Due to client's continuously discharging from our program, new forms cannot be obtained in all cited instances, however, all clients who were part of our active census on the date this revision was effective have been asked to review and sign the updated version. All of the above will be monitored by the Director of Compliance moving forward to ensure we remain in line with all applicable regulations.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of the facility's client records on March 5, 2021, the facility failed to include the following verbiage on the client rights form that the client receives.
Clients have the right to appeal a decision limiting access to their records to the director.
This finding was discussed with the facility.
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Plan of Correction
Ambrosia of Philadelphia's Director of Compliance has updated the Client's Rights form signed by our clients upon admission to reflect the verbiage below. This revision is effective and in rotation as of 3/29/2021. These forms, once edited in our EMR system, automatically populate for all clients as of the effective date of the revision.
Verbiage added to the Client's Rights form signed by every client upon admission now includes:
"Clients have the right to appeal a decision limiting access to their records to the director."
Due to client's continuously discharging from our program, new forms cannot be obtained in all cited instances, however, all clients who were part of our active census on the date this revision was effective have been asked to review and sign the updated version. All of the above will be monitored by the Director of Compliance moving forward to ensure we remain in line with all applicable regulations. All of the above will be monitored by the Director of Compliance moving forward to ensure we remain in line with all applicable regulations.
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of the facility's client records on March 5, 2021, the facility failed to include the following verbiage on the client rights form that the client receives.
Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
This finding was discussed with the facility.
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Plan of Correction
Ambrosia of Philadelphia's Director of Compliance has updated the Client's Rights form signed by our clients upon admission to reflect the verbiage below. This revision is effective and in rotation as of 3/29/2021. These forms, once edited in our EMR system, automatically populate for all clients as of the effective date of the revision.
Verbiage added to the Client's Rights form signed by every client upon admission now includes:
"Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records."
Due to client's continuously discharging from our program, new forms cannot be obtained in all cited instances, however, all clients who were part of our active census on the date this revision was effective have been asked to review and sign the updated version. All of the above will be monitored by the Director of Compliance moving forward to ensure we remain in line with all applicable regulations.
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of the facility's client records on March 5, 2021, the facility failed to include the following verbiage on the client rights form that the client receives.
Clients have the right to submit rebuttal data or memoranda to their own records.
This finding was discussed with the facility.
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Plan of Correction
Ambrosia of Philadelphia's Director of Compliance has updated the Client's Rights form signed by our clients upon admission to reflect the verbiage below. This revision is effective and in rotation as of 3/29/2021. These forms, once edited in our EMR system, automatically populate for all clients as of the effective date of the revision.
Verbiage added to the Client's Rights form signed by every client upon admission now includes:
"Clients have the right to submit rebuttal data or memoranda to their own records."
Due to client's continuously discharging from our program, new forms cannot be obtained in all cited instances, however, all clients who were part of our active census on the date this revision was effective have been asked to review and sign the updated version. All of the above will be monitored by the Director of Compliance moving forward to ensure we remain in line with all applicable regulations.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on the review of client records on March 05, 2021, the facility failed to document follow up as stated in their P&P in three of three records. The policy states that follow-ups will be completed within 7days after discharge.
Client #1 admitted 12/04/2019 discharged 12/09/2019
Client #3 admitted 06/08/2020discharged 06/13/2020
Client #5 admitted 01/21/2020 discharged 01/22/2020
The findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
Ambrosia of Philadelphia has conducted an additional training for our clinical staff on the post discharge follow up process and what the expectation is moving forward. This training was facilitated by Ambrosia of Philadelphia's Clinical Director and was presented to staff on 3/22/2021. Effective 3/25/2021, post discharge follow ups will be documented in all client charts as a Case Management note. Our Clinical Director and Compliance Officer will be conducting weekly chart audits until 100% efficiency is achieved. Discharge client charts with dates 120 days prior to 3/25/2021 will be contacted by Case Management on a rolling basis and reports will be given weekly to Director of Compliance until all clients have a follow-up documented. All cited records will have a follow-up documented by 4/23/21. |
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 on March 05, 2021, the facility failed to document follow up as stated in their P&P in two of two records. The policy states that follow-ups will be completed within 7days after discharge.
Client #8 admitted 11/23/2020 discharge date 12/18/2020
Client #9 admitted 09/04/2020 discharge date 10/09/2020
The findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
Ambrosia of Philadelphia has conducted an additional training for our clinical staff on the post discharge follow up process and what the expectation is moving forward. This training was facilitated by Ambrosia of Philadelphia's Clinical Director and was presented to staff on 3/22/2021. Effective 3/25/2021, post discharge follow ups will be documented in all client charts as a Case Management note. Our Clinical Director and Compliance Officer will be conducting weekly chart audits until 100% efficiency is achieved. Discharge client charts with dates 120 days prior to 3/25/2021 will be contacted by Case Management on a rolling basis and reports will be given weekly to Director of Compliance until all clients have a follow-up documented. All cited records will have a follow-up documented by 4/23/21. |