INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 9, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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:
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff schedules and first aid certifications provided by the facility, the facility failed to ensure that at least one person trained in first aid was onsite during the project's hours of operations. The 11:30 p.m. - 7:30 a.m. shifts between October 30, 2022 and November 10, 2022 did not have staff trained in first aid.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 1/6/23, all currently employed DRC Inpatient staff have received CPR training.
The identified staff person is no longer employed with Gaudenzia. The Program Director has amended the schedule to ensure that staff with CPR/First Aid training are available on all shifts.
The Program Director will also review training requirements monthly to ensure continued compliance.
The Director of Operations will ensure that any Residential Aide on the Inpatient floor is CPR certified.
The Division Director and Program Director will ensure that at least one CPR-trained staff person is scheduled to be onsite for all shifts.
The CQI Manager will conduct quarterly reviews of staff training records to ensure continued compliance.
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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 on December 9, 2022, the facility failed to keep the grounds of the facility in good repair at all times as bedrooms numbers 511, 509, and 504 had severely peeling and rusted window sealant.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
On 1/6/23, the Division Director submitted a work order to Gaudenzia's Corporate Maintenance Department for the necessary repairs.
The Corporate Maintenance Director and Deputy Directors will ensure that repairs are made.
The Division Director will review the requirement with the Program Director during a supervision session.
The CQI Manager will perform a quarterly inspection of the physical site.
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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
Based on a physical plant inspection on December 9, 2022, the facility failed to keep frozen food at or below 0 degrees Fahrenheit, as the freezer in the kitchen was 10 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/9/23, the Deputy Director checked the freezer temperature, which was (-10F).
Kitchen staff will check freezer temperatures daily and report the temperatures on logs.
The Facilities Director will perform monthly safety checks and report issues to the Deputy Director.
The Division Director will review the requirement with the Program Director during a supervision session.
The CQI Manager will perform a quarterly inspection of the physical site.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on December 9, 2022, the facility failed to ensure that facility heaters were permanently mounted or installed. Portable heaters were found in a counselor ' s office on the fifth floor and a staff member ' s office on the seventh floor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The space heaters were removed from the offices on 12/12/22.
The Division Director will review the requirement with the Program Director during a supervision session.
The Program Director will conduct a weekly walkthrough of the 5th and 7th floors to ensure that there are no portable heaters in offices or resident rooms.
The CQI Manager will perform a quarterly inspection of the physical site.
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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 a physical plant inspection on December 9, 2022, the facility failed to ensure that exits from the facility were unobstructed as one of the emergency exit stairwells led down to a locked door.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Maintenance Dept. will perform monthly safety checks to ensure that emergency exit stairwells are unobstructed, and doors are unlocked.
The DRC Maintenance
Department will conduct weekly safety checks to ensure that stairwells remain unobstructed.
The Division Director will review the requirement with the Program Director during a supervision session.
The CQI Manager will perform a quarterly inspection of the physical site.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from January 2022 through September 2022, the facility failed to conduct fire drills during sleeping hours at least every six months.
Based on the program schedule provided by facility staff, the unit sleeping hours are 11:00 P.M. through 06:00 A.M. No fire drills between January 2022 and September 2022 were conducted between those hours.
This is a repeat citation from December 14, 2021 annual licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Division Director will adjust the program schedule to accommodate fire drills during varied hours.
The Division Director will review the requirement with the Program Director during a supervision session.
The Program Director will review the fire drill logs monthly to ensure compliance with the requirement.
The CQI Manager will perform a quarterly inspection of the physical site.
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from January 2022 through September 2022, the facility failed to prepare alternate exit routes as the same exit route was documented in each drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Division Director will review the requirement with the Program Director during a supervision session.
The Program Director will ensure the fire drills are conducted monthly using alternate exit routes.
The CQI Manager will perform a quarterly inspection of the physical site.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records a discussion with the facility staff, and facility policies, the facility failed to follow their written procedures for the management of treatment and rehabilitation services, pertaining to case consultations in two of five applicable records, failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours in one of one applicable record, and failed to follow their policy related to psychosocial assessments being completed within 72 hours of admission in four of seven applicable records.
Client #1 was admitted on April 13, 2022 and discharged on May 2, 2022. The record contained no psychosocial assessment.
Client #2 was admitted on April 20, 2022 and was discharged on June 20, 2022. The psychosocial assessment was not completed until May 6, 2022. Additionally, staff names and titles were not included as part of the case consultation documentation, per the facility policy.
Client #3 was admitted on January 6, 2022 and was discharged ASA (Against Staff Advice) on February 10, 2022. The psychosocial assessment was not completed until January 18, 2022. Additionally, there was no documentation in the client record that the emergency contact was called.
Client #4 was admitted on September 27, 2022 and was discharged on October 18, 2022. Staff names and titles were not included as part of the case consultation documentation, per the facility policy.
Client #6 was admitted on October 19, 2022 and was active at the time of the inspection. The psychosocial assessment was not completed until October 25, 2022.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Client 6: 82964
Client was discharged 12/19/22
The Division Director will review the requirements with the Program Director during a supervision session.
The Program Director will conduct in-service training related to required documentation for client contact after ASA discharges, and documentation of case consultations and biopsychosocial using the established auditing tool.
The Program Director will conduct biweekly clinical chart audits.
The Division Director will conduct monthly clinical chart audits.
The CQI Manager will conduct quarterly clinical chart audits.
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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 a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client #5 was admitted on October 19, 2022 and was active at the time of the inspection. The record did not contain a client signed consent to release information form to the funding source; however, the record contained evidence of billing.
Client #6 was admitted on October 19, 2022 and was active at the time of the inspection. The record did not contain a client signed consent to release information form to the funding source; however, the record contained evidence of billing. Additionally, the record contained documentation that identifying information and lab work were sent to a laboratory, however, the record did not contain a client signed consent to release information form.
This is a repeat citation from December 14, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client 5: 82962
Client was discharged 12/19/22
Client 6: 82964
Client was discharged 12/19/22
The Program Director will review the proper completion of consents with the Intake Coordinator.
The Intake Coordinator will complete all required consents, particularly for funding sources and labs within the established timeframe.
The Program Director will conduct biweekly clinical chart audits.
The Division Director will conduct monthly clinical chart audits.
The CQI Manager will conduct quarterly clinical chart audits.
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709.52(a)(3) LICENSURE Support service type
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to ensure that individual treatment and rehabilitation plans included documentation of the proposed type of support services in two of six applicable records reviewed.
Client #6 was admitted on October 19, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan signed by the client on October 25, 2022, did not include the proposed type of support services.
Client # 7 was admitted on November 2, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan signed by the client on November 7, 2022, did not include the proposed type of support services.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client 6: 82964
Discharged 12/19/22
Client 7: 83477
Discharged 1/2/23
The Division Director will review the required components for a treatment plan with the Program Director during a supervision session.
The Program Director will conduct an in-service training with Counselors to review required components for treatment plans.
The Program Director will review all treatment plans for compliance.
The Program Director will conduct biweekly clinical chart audits.
The Division Director will conduct monthly clinical chart audits.
The CQI Manager will conduct quarterly clinical chart audits.
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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.
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Observations
Based on a review of seven client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 30 days in two of five applicable records reviewed.
Client #2 was admitted on April 20, 2022 and was discharged on June 20, 2022. The individual treatment and rehabilitation plan was completed on May 6, 2022 and a treatment plan update was due to be completed by June 6, 2022; however, the treatment plan update was not completed until June 16, 2022.
Client #6 was admitted on October 19, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 27, 2022 and a treatment plan update was due to be completed by November 27, 2022; however, the treatment plan update was not completed until December 7, 2022.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Client #6 was discharged on 12/19/22.
The Division Director will review the established timeline for treatment plan completion with the Program Director during a supervision session.
The Program Director will conduct an in-service training with Counselors to review the timeliness of treatment plan completion.
The Program Director will review all treatment plans for compliance.
The Program Director will conduct bi-weekly clinical chart audits and utilize the Forms Audit Report from our EHR to confirm presence of Tx plans.
The Division Director will conduct monthly clinical chart audits.
The CQI Manager will conduct quarterly clinical chart audits.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in six of six applicable records reviewed.
Client #2 was admitted on April 20, 2022 and was discharged on June 20, 2022. The treatment plan completed on May 6, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions the weeks of May 9, 2022, May 23, 2022, and June 16, 2022.
Client #3 was admitted on January 6, 2022 and was discharged on February 10, 2022. The treatment plan completed on January 10, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the week of January 24, 2022.
Client #4 was admitted on September 27, 2022 and was discharged on October 18, 2022. The treatment plan completed on September 27, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the weeks of September 26, 2022, and October 3, 2022.
Client #5 was admitted on October 19, 2022 and was active at the time of the inspection. The treatment plan completed on October 19, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the week of November 28, 2022.
Client #6 was admitted on October 19, 2022 and was active at the time of the inspection. The treatment plan completed on October 19, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the week of November 28, 2022.
Client #7 was admitted on November 2, 2022 and was active at the time of the inspection. The treatment plan completed on November 2, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the week of November 28, 2022.
This is a repeat citation from the December 14, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Division Director will review the established requirements for service delivery according to treatment plan with the Program Director during a supervision session.
The Program Director will conduct in-service training with Counselors to review established policy.
Counselors will document missed individual and groups sessions on Independent Notes to include the reason for the missed session(s).
The Program Director will conduct bi-weekly clinical chart audits.
The Division Director will conduct monthly clinical chart audits.
The CQI Manager will conduct quarterly clinical chart audits
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709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include medication records in three of four applicable records reviewed.
Client #1 was admitted on April 13, 2022 and discharged on May 2, 2022. The client record did not contain complete documentation of medication records.
Client #3 was admitted on January 6, 2022 and was discharged on February 10, 2022. The client record did not contain complete documentation of medication records.
Client #6 was admitted on October 19, 2022 and was active at the time of the inspection. The client record did not contain complete documentation of medication records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client 1: Discharged 5/2/22 medical record was not found on this client.
Client 3: Discharged 2/10/22 medical record was not found on this client.
Client 6: Discharged 12/19/22
This standard has been reviewed with the Charge Nurse.
The Charge Nurse will conduct an in-service with medical staff to review the requirement.
The Charge Nurse will conduct monthly medical chart audits.
The Deputy Director will ensure ongoing compliance through monthly supervision sessions with the Charge Nurse.
The CQI Manager will conduct quarterly reviews of medical charts.
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709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary in two of four applicable records reviewed.
Client #1 was admitted on April 13, 2022 and discharged on May 2, 2022. The client record did not contain a discharge summary.
Client #4 was admitted on September 27, 2022 and was discharged on October 18, 2022.The client record did not contain a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Discharge Summaries have been added to the client records #1 and #4.
The Division Director will review the established requirements for Cont. Care Plan completion with the Program Director during a supervision session.
The Program Director will conduct in-service training with Counselors to review established policy.
The Program Director will conduct bi-weekly clinical chart audits.
The Division Director will conduct monthly clinical chart audits.
The CQI Manager will conduct quarterly clinical chart audits
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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 a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information in two of three records reviewed.
Client #1 was admitted on April 13, 2022 and discharged on May 2, 2022. The client record did not contain documentation of follow-up information.
Client #3 was admitted on January 6, 2022 and was discharged on February 10, 2022. The client record did not contain documentation of follow-up information.
This is a repeat citation from December 14, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Division Director will review the requirement for client follow-up after discharge with the Program Director during a supervision session.
The Program Director will conduct in-service training related to required documentation for client contact after discharge.
The Program Director will conduct biweekly clinical chart audits.
The Division Director will conduct monthly clinical chart audits.
The CQI Manager will conduct quarterly clinical chart audits.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of six applicable client records, the facility failed to document, in the client's complete record, verification that any work done by the client at the project is an integral part of his/her treatment and rehabilitation plan in any of the applicable records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
All client records that were reviewed for this standard have been discharged.
The Program Director will conduct in-service training related to required components for treatment plans.
The Program Director will conduct biweekly clinical chart audits.
The Division Director will conduct monthly clinical chart audits.
The CQI Manager will conduct quarterly clinical chart audits.
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709.54(a)(2) LICENSURE Receiving/storing/preserving
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(2) Receiving, storing and preserving of food stuff.
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Observations
Based on a physical plant inspection on December 9, 2022, the facility failed to follow their written policies and procedures related to receiving, storing and preserving food stuff, as the walk-in fridge contained meat that was date stamped October 11, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Food Services Supervisor will conduct weekly audits to ensure that all food items have not expired.
Expired food items will be immediately discarded.
The CQI Manager will conduct quarterly reviews of the physical site.
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