INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 28-30, 2017, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia DRC Inc., 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:
|
Plan of Correction
|
705.1 (2) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
|
Observations
During the physcial plant inspection conducted on November 30, 2017, 502's bedroom wall and window was damaged due to leaking coming in from the exterior wall of the building.
The finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The facility manager had the window and wall repaired by facility maintenance staff in room 502 the same day of the audit ? 11/30/17. The window was calked, plastered and painted. The facility manager and clinical supervisor will monitor the window condition as part of the weekly inspection by clinical and monthly by maintenance staff. |
705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
|
Observations
During the physcial plant inspection conducted on November 30, 2017, it was observed that there were no ABC fire extinguisher in the kitchen.
The finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
On the date of the inspection - 11/30/17, there was a fire extinguisher on the wall in the kitchen that is ABC rating. The fire extinguisher was removed from the area and mounted on the wall near the kitchen wall behind the serving line by the facility maintenance. The ABC fire extinguisher will continue to be monitored by facility manager as part of his monthly facility review. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
During the review of the fire drill record for period October 2016 through October 2017, the facility failed to document that the fire alarms/smoke detectors were operative during the following drills; 12/16, 1/17, 3/17, 2/17, 5/17, 6/17, 7/17, 8/17, 10/17.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The facility manager will document that the fire alarms/smoke detectors were operative prior to any and all fire drills. He will put the system on test after he has made contact with the alarm company to ensure that the alarm system is operative. Paperwork was provided at the time of the inspection from the alarm company indicating that the facility contacted the company prior to the alarm being pulled. |
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.
|
Observations
Based on the review of the facility's consent to release form, the facilty limited the client's right to revoke their consent by stating that the client can verbally or in writing revoke their consent to the to the Project Director.
Additionally, the failed failed to obtain a valid consent for the following records, #1, 2, 5 and 6.
Client record #1 - Three progress notes were reviewed documenting that A family session was conducted on the following dates; 10/29/17, 11/19/17 and 11/2617. The facility failed to obtain valid consents for the client's family and friend.
Two Continuing Care/Transition/Discharge Plan and Summaries dated 11/13/17 for two different clients were in client's file.
Client record #2 - A consent to release dated 10/6/17 for the client's wife showed that all boxes were checked for what was going to be released including the other box. The other box that was checked also included verbiage "anything released", the facility failed to expand what anything release meant. Additionally, the facility checked the following for the purposed of the release:
To provide funding for ongoing treatment effort
To obtain insurance or employment of government benefits
To enable judges, attorney, probation, parole officers to support treatment goals or to make legal decisions
To coordinate treatment efforts with my family/concerned person ' s/case manager
To coordinate treatment efforts with my employer
The wife was neither the client's employer, funding source, justice system or government agency.
Client record #5 - A Level Change Recommendations to the Department of Corrections (DOC) dated 9/18/17 exceeded 4 PA Code 255.5 by documenting in the form the client's Social History and treatment issues.
Client record #6 - Consent to Release dated 7/26/17 for the client's family failed to document the purpose of the release.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Client # 1 - The clinical supervisor will review all consent forms to ensure that the client has either verbally or in writing revoked their consent. The clinical supervisor will review all consents for any family sessions prior to any session occurring.
In addition, the Continued Care/Transition/Discharge Plan and Summaries will be reviewed by the clinical supervisor and placed in the closed file upon completion of treatment for each client to ensure that the error does not occur again in the future.
Client #2 - Clinical supervisor will have a training with the clinical staff to review the process for consent forms and monitor the completed consent forms for accuracy. The verbiage "anything released" will not be used on any consent forms.
Client # 5 - Clinical supervisor will review the Level of Change Recommendation to the Department of Corrections to ensure that the social history and treatment issues not exceed 4 PA Code 255.5
Client # 6 ? Clinical Supervisor will review consent for release to ensure that there is a clear indication of what the purpose of the release is for.
The Clinical Director will conduct at training with the clinical staff by January 31, 2018 to ensure that all staff is trained on the proper procedure of completing consent to release forms In addition, all consent forms must be reviewed by clinical supervisor to ensure that the correction is being implemented by the counselors. Clinical supervisor will review all new forms for clients listed in the citation by January 9, 2018.
|
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.
|
Observations
Based on the review of the facilty's Client Rights form failed to included the following verbiage verbatim:
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
The finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The facility Client Rights will be edited by Outpatient Director to include the verbiage, verbatim, regarding no discrimination in the provision of services. The Outpatient Intake Assessment Director will make the corrections to the Client Rights Form to ensure that the verbiage is added to assure the deficiency does not occur again. This will be implemented as of January 5, 2018. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
|
Observations
Based on the review of the facilities medication administration records, the facility failed to maintain accurate records in the individual medications
Medication record #1:
Ranitidine 150 mg 1 tab twice daily - November 29, 2017 and November 30, 2017 not marked that the client received their required medication twice on those days.
Docusate 100 mg 1 tab twice daily - The Medication record only shows that the client received their medication only once per day from November 1, 2017 through November 28, 2017.
Mirtazaphine 30 mg 1 tab once daily - November 28, 2017 not marked that the client received their required medication.
Medication record #2:
Methinazale 5 mg 1 pill in am - November 13, 29 and 30, 2017 not marked that the client received their required medication.
Benztropine 1mg 1 pill twice a day - November 13, 29 and 30, 2017 not marked that the client received their required medication in the morning and on November 13, 2017 in the evening.
Divalprocx 500 mg 1 pill twice a day - November 30, 2017 not marked that the client received their required medication in the morning.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Policy for medication control has been developed by the facility director and located in the policy and procedure book. It includes all medications used by clients which shall include, but not be limited to: (1) Administration of medication, including the documentation of the administration of medication: (i) By individuals permitted to administer by Pennsylvania law. (ii) When self - administered by the client.
The nurse manager will review the medication log book daily to ensure that records are accurate for individuals medications to be administered daily.
|
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client's 12 records, the facility failed to document psychosocial evaluations that included the counselor's clinical impressions for all records reviewed.
Client #1's psychosocial evaluation was completed on 10/20/17.
Client #2's psychosocial evaluation was completed on 10/5/17.
Client #3's psychosocial evaluation was completed on 10/18/17.
Client #4's psychosocial evaluation was completed on 10/17/17.
Client #5's psychosocial evaluation was completed on 7/21/17.
Client #6's psychosocial evaluation was completed on 7/30/17.
Client #7's psychosocial evaluation was completed on 9/27/17.
Client #8's psychosocial evaluation was completed on7/5/17.
Client #9's psychosocial evaluation was completed on 7/3/17.
Client #11's psychosocial evaluation was completed on 10/24/17.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Clinical supervisor will review all psychosocial evaluations for the counselor's clinical impressions. Clinical supervisor will also schedule training for clinical staff on clinical impressions being documented correctly |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates in four of eleven records reviewed, #5, 6, 7 and 9.
Client #5 - The treatment plan update was not documented as of the date of the licensing inspection. The comprehensive treatment plan was documented on 7/24/17.
Client #6 - The facility failed to document an update to the stated goals for treatment plan updates 8/24/17 and 9/6/17.
Client #7 - The facility failed to document an update to the stated goals for treatment plan updates 10/27/17 and 11/24/17.
Client #9 - The facility failed to document an update to the stated goals for treatment plan update 8/2/617. Additionally, the treatment plan update was documented late from the date of the comprehensive treatment plan dated 7/3/17.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The clinical supervisor will review all treatment plans during supervision bi-weekly and or monthly. The charts listed at the time of the audit 11/28 ? 12/1/17, numbers 5, 6, 7 & 9 have all been discharged from treatment. In addition a random audit of charts will be conducted for accuracy and signed within the timeframe of thirty days. |
709.53(a) LICENSURE Complete Client Record
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:
|
Observations
Based on a review of client records, the facility failed to document a complete client record in seven of twelve client records reviewed, 5, 6, 7, 8, 9, 11 and 12.
Client record #5 - Record of Service not documented and client was seen for an individual session dated 8/16/17 and the client's history/evaluation documented on 7/21/17.
Client record #6 - The client was admitted on 7/24/17 and discharged on 9/25/17. The facility failed to document a follow-up as of the date of the licensing inspection.
Client record #7 - Progress notes reviewed, but services not documented on the client's record of service - (Individual sessions) 11/15/17, 11/22/17, 11/26/17 and (Group sessions) 10/13/17 and 11/30/17.
Record of service - services rendered documented on the record of service, but no progress notes provided for review - 9/28/17, 9/27/17, 9/25/17, 10/3/17, 10/2/17, 11/3/17, 11/1/17, 10/31/17, 11/19/17, 11/8/17, 11/7/17, 11/16/17, 11/15/17, 11/23/17, 11/22/17, 11/21/17 and 11/20/17.
Client record #8 - The client was admitted on 6/29/17 and discharged on 8/21/17. The facility failed to document a follow-up as of the date of the licensing inspection.
Progress notes reviewed, but services not documented on the client's record of service - (Individual sessions) 7/30/17 and 7/5/17 (Group sessions) 7/3/17, 7/5/1, 7/7/17, 7/13/17, 7/14/17, 7/21/17, 8/2/17, 8/8/17, 8/11/17, 8/18/17
Client record #9 - Progress notes reviewed, but services not documented on the client's record of service - (Individual sessions) 8/4/17, 8/7/17 (2 notes), 8/28/17 and 9/4/17.
Record of Service - no record of services documented after 7/30/17.
Marked on the client's record of service, but no progress notes reviewed - (Group sessions) 7/25/17, 7/26/17, 7/27/17, 7/18/17, 7/19/17, 7/20/17, 7/11/17, 7/12/17, 7/13/17, 7/10/17, 7/3/17, 7/4/17, 7/5/17, 7/6/17, 6/27/17, 6/28/17 and 6/29/17.
Client record #11 - Progress notes reviewed, but services not documented on the client's record of service - (Individual sessions) 10/27/17, 11/3/17, 11/10/17, 11/19/17 (Group sessions) 10/26/17, 10/27/17, 10/30/17, 10/31/17, 11/2/17, 11/7/17, 11/15/17, 11/16, 11/17/17, 11/20/17, 11/21/17, 11/24/17 and 11/27/17.
Client record #12 - Record of Service - services rendered documented on the record of service, but no progress notes provided for review - (Individual sessions) 11/13/17 and 11/16/16 and (Group sessions) 10/31/17, 11/1/17, 11/3/17, 11/8/17, 11/9/17, 11/14/17, 11/15/17 and 11/16/17.
Progress notes reviewed, but services not documented on the client ' s record of service - (Individual sessions) 11/8/17 and 11/15/17.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Clinical supervisor will review all client records to ensure all records of service reflect treatment documentation and individual sessions.
A review of the charts listed at the time of the inspection # 5, 6, 7, 8, 9 & 11 have all been discharged. Client # 12 clinical chart for record of service has been updated for missing record of service. Each counselor will be required to provide clinical tracking sheets weekly to the clinical supervisor supporting that all documentation has been completed to reflect these required documents.
|