INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 4, 208 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Re-Entry House 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 July 3, 2008.
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Plan of Correction
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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
The non-hospital treatment and rehabilitation facility failed to keep frozen food below zero degrees Fahrenheit.
Findings: An inspection of the basement area on June 4, 2008 , where a walk -in freezer is located, verified freezer check logs with freezer internal temperatures in excess of zero degrees Fahrenheit consistently since May 22, 2008. Temperatures ranged from 8 degrees to 15 degrees Fahrenheit above zero for that thirteen day period.
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Plan of Correction
Plan of Action will be as follows:
Director of Maintenance for Gaudenzia's Eastern Region Division was immediately notified on 5th June 2008 about the freezer and a call to Service Port Refrigeration Co. was made on 10th June 2008 to which they immediately responded to the problems at hand. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
The non-hospital treatment and rehabilitation facility failed to maintain two exterior exits with handrails.
Findings: During a physical plant inspection on June 4, 2008, two exterior stairways did not have handrails installed. The exit from the basement level with seven steps was missing a handrail and the exit from the main level with five steps was missing a handrail.
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Plan of Correction
The Plan of Correction will be as follows:
Director of Maintenance of Gaudenzia's Eastern Region Division was also immediately notified about the issue at and responded on 5th June 2008. Handrails were placed in the areas of concern. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
The governing body failed to establish a treatment and rehabilitation plan that includes a written letter of agreement for 24-hour emergency psychiatric and medical coverage.
Findings:
Based on a review of the facility letters of agreement , a review of the treatment and rehabilitation procedure manual and an interview with the facility director on June 4, 2008, a written letter of agreement for 24 hour emergency medical and psychiatric care could not be presented for verification of coverage.
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Plan of Correction
The Plan of Correction will be as follows:
Letters of Agreement were drawn up for the following Referral Sources of Care extended to our Residents:
* Germantown Hospital and Northwestern Human Services for Psychatric Care
* Temple Hospital and Einstein for Emergency Services.
Program Director will be responsible in making sure that all Letters of Agreement will be signed, sent out, and placed back into Letter of Agreement Book. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Three of six client records failed to document a physical examination within seven days of the date of admission. .
Findings:
Client Record #1 - Admitted March 25, 2008. The physical examination was completed on January 9, 2008, but was not signed or dated by a physician.
Client Record #5 - Admitted March 14, 2008 and discharged on April 12, 2008. There was no documentation of a physical examination.
Client Record #6 - Admitted January 18, 2008 and discharged April 17, 2008. There was no documentation of a physical examination.
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Plan of Correction
Plan of Correction will be as follows:
All Clients will have updated psych-socials and physicals upon interview and will not be Admitted until all requested documentation is received by Clinical Staff.
Counselor III will monitor compliance for physical examinations documents and report findings for three months in CQI.
Program Director will oversse this Plan of Correction |
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
Three of three client records, where the client had been discharged, failed to document follow-up information.
Findings:
Client Record #4 - Admitted January 1, 2008, discharged on April 8, 2008 failed to document follow-up within seven days of scheduled appointment on April 14, 2008. follow-up was documented on May 8, 2008.
Client Record #5 - Admitted March 13, 2008, discharged April 12, 2008 with scheduled follow-up appointment on April 16, 2008. There was no documentation of a follow up attempt.
Client Record #6 - Admitted January 18, 2008 ,discharged April 14, 2008 with a scheduled appointment on April 18, 2008. There was no documentation of a follow up attempt.
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Plan of Correction
Plan of Correction will be as follows:
All Clinical Staff will follow-up on all Discharged Clients within seven days of Discharge.
Counselor III will admit all charts and report findings for three months in CQI. |