INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 28 -31, 2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site investigation, Gaudenzia DRC was found to not 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 a physical plant inspection conducted during the complaint investigation, the facility failed to maintain a safe and sanitary envirenment.
The following was observed:
- A black substance around the bathroom and common area room windows on the male floor as well as around the windows in the bathroom on the female floor.
- Peeling/chipped paint on all of the windows on the male and female floors.
-Trash bags full of water were on the floor of the first shower stall on the male floor bathroom
-Standing water on the bathroom floor from a leaking air conditioners in the male bathroom
-Shower stall floor in the male bathroom appeared to be rusting and chipping.
-Two male client bedrooms had newspapers logged inside the light fixture on the ceiling and one of them had disconnected the light bulbs in the light fixture.
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Plan of Correction
Maintenance crew and director of facility maintenance removed the black substance on the day of the audit in both the bathroom and common area room windows on the male floor as well as around the windows and the bathroom on the female floor. Residential Aide and Maintenance Crew will conduct inspections to ensure that black substance is not visible.
Maintenance crew sand and repainted the window on the male and female floors completed 6/7/19. Maintenance crew will conduct regular inspections to ensure the paint is not chipping or peeling.
Trash bags full of water were removed the day of the audit. Residential Aide will complete inspections in the bathroom as part of their hourly rounds and reports any water bags found immediately.
Standing water is from the condensation from the air conditioner, wet floor sign has moved in place, tight below the air conditioner. Periodic inspections will be conducted by the Residential Aide to ensure there is no water left on the floor and have it removed immediately.
Shower stall in the mens bathroom have all been replaced to stainless steal prior to this audit, no rusting or chipped identified.
The male clients bedrooms newspaper logged inside the light fixture, was removed on the day of the audit as well as tighten up the light bulbs, was also completed the day of the audit. This will be monitored daily as part of the Residential Aide room inspections. |
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection conducted during the complaint investigation, the facility failed to ensure that lounge furnishings were in good repair. The couches and chairs in the male day room were cracked and torn.
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Plan of Correction
The couches and chairs in the male day room that were cracked and torn. Were all replaced with new chairs and tables the day of the audit by Maintenance crew. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records during the complaint investigation, the facility failed to provide counseling on a regular and scheduled basis.
Client #1: Admitted 6/14/2018, Discharged 8/24/2018 - The client's treatment plan indicated weekly individual counseling session however, the client's chart only had documentation of three sessions (6/11/2018, 7/4/2018, 8/7/2018).
Client #2: Admitted 4/9/2019, Discharged 5/29/2019 - The client's treatment plan indicated weekly individual counseling session however, the client's chart did not contain any documentation of individual sessions.
Client #3: Admitted 3/27/2019, Discharged 5/29/2019 - The client's treatment plan indicated weekly individual counseling session however, the client's chart only had documentation of one individual session (3/31/2019).
Client #4: Admitted 7/19/2019, Discharged 10/4/2018 - The client's treatment plan indicated weekly individual counseling session however, the client's chart was missing documentation for individual sessions for the first two weeks in August 2018 and the last two weeks in September.
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Plan of Correction
Client # 1 Admitted 6/14/18 and discharged 8/24/18 - The client's treatment plan indicated weekly individual counseling session however, the client's chart only had documentation of three sessions (6/11/2018, 7/4/2018, 8/7/2018). Client has been discharged however, counselor updated all missing individual missing individual notes.
Client #2: Admitted 4/9/2019, Discharged 5/29/2019 - The client's treatment plan indicated weekly individual counseling session however, the client's chart did not contain any documentation of individual sessions. Client discharged on 5/29/19, counselor updated individual notes into the closed chart.
Client #3: Admitted 3/27/2019, Discharged 5/29/2019 - The client's treatment plan indicated weekly individual counseling session however, the client's chart only had documentation of one individual session (3/31/2019). Client discharged on 5/29/19, however, counselor updated missing individual notes into the closed chart.
Client #4: Admitted 7/19/2019, Discharged 10/4/2018 - The client's treatment plan indicated weekly individual counseling session however, the client's chart was missing documentation for individual sessions for the first two weeks in August 2018 and the last two weeks in September. Client # 4 did not get admitted on 7/19/19, client was admitted on 7/19/18 and discharged on 10/4/18.
Client was discharged on 10/4/18, however, counselor updated the chart with missing individual notes for the timeframe listed.
Program Director will review charts for missing documentation, including missing individual notes to ensure all documentation is completed prior to chart being closed out.
Clinical Supervisor and Program Director will conduct regular monthly audits of all charts to ensure that all required individual sessions are completed and documents as required. |
711.51(b)(2)(i) LICENSURE Orientation- Project Policies
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on a review of the facility's policy and procedures, the facility failed to follow their orientation process.
The policy states that a facility aide will return all personal effects to a client upon release/discharge and ensure the client signs paperwork indicating that their personal property was returned. However, the facility was unable to provide documentation to confirm that client belongings were logged during intake. In addition, the facility did not have documentation indicating that client belongings were returned to them in 2018 when discharged from the facility.
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Plan of Correction
Director of Operations will return all personal effects to a client upon release/discharge and ensure the client signs paperwork indicating that their personal property was returned. Director of Operations will keep The documentation in a Binder book for future review. |