INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 12-13, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Together 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.
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Plan of Correction
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document semiannual performance evaluations for counselor assistants in one of one personnel records.
The findings include:
On May 13, 2011, one personnel record identified as a counselor assistant was reviewed for documentation of semiannual performance evaluations. The facility did not document semiannual performance evaluations in personnel record # 11.
The last documented performance evaluation for personnel # 11 was dated 4/26/11.
After an interview with the facility director on May 13, 2011, a second performance evaluation for personnel # 11 was provided, but the second performance evaluation was dated 4/15/11. The facility director confirmed that semiannual performance evaluations had not been documented for counselor assistants.
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Plan of Correction
Program Director has met with the clinical supervisor to review and train on the standard for semiannual performance evaluation of a counselor assistant. This semiannual evaluation will be based on measurable performance standards. If this individual does not meet the standards at the time of the evaluation, the counselor assistant shall remain in this status until a satisfactory rating is received from the counselor assistant's supervisor. Clinical Supervisor will be responsible for supervisory follow up and Division Director will be responsible for oversight. Full compliance will be met effective 06/14/11. |
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
Based on the review of client records and an interview with the facility director, the facility failed to document a physical examination within 7 days of admission in five of eleven client records.
The findings include:
On May 13, 2011, eleven client records requiring documentation of a physical examination were reviewed. The facility did not document physical examinations within 7 days of admission, as per facility policy, in client records # 1, 2, 4, 6 and 11.
The facility ' s policy titled " PHYSICAL EXAMINATION LABORATORY STUDIES " states:
" A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend. Other exceptions are:
1.The client received a complete physical examination no longer than one month prior to admission; that the program staff can obtain the results in writing; and the nurse on duty is able to ascertain no noticeable medical problems. "
Client # 1 was admitted on 3/31/11. The physical exam for client # 1 was dated 4/8/11.
Client # 2 was admitted on 4/15/11. The physical exam for client # 2 was dated 4/29/11.
Client # 4 was admitted on 12/19/10. The physical exam for client # 4 was dated 12/27/11.
Client # 6 was admitted on 4/8/11. The physical exam for client # 6 was not signed or dated.
Client # 11 was admitted on 1/1/11. The physical exam for client # 11 was dated 1/14/11.
An interview with the facility director on May 13, 2011 confirmed the findings.
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Plan of Correction
Division Director met with the Physician to review and train on the standard for documentation of physical examination within 7 days of admission. A system has been put in place to make sure that physical examinations are completed and documented within the required time frame. Nurse Manager will be responsible for supervisory follow up and Divison Director will be responsible for ovesight. Full compliance will be met 06/14/2011. |
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 and an interview with the facility director, the facility failed to document follow-up information within one week in two of four client records.
The findings include:
On May 13, 2011, four client records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information within one week of referral appointment, as per facility policy, in client records # 8 and 9.
The facility ' s policy titled " FOLLOW UP INFORMATION " states:
When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor [sic].
Client # 8 was discharged on 3/21/11. An aftercare referral appointment was scheduled for 3/23/11, but follow-up information was not documented at the time of review on 5/13/11.
Client # 9 was discharged on 3/25/11. An aftercare referral appointment was scheduled for 3/29/11, but follow-up information was not documented at the time of review on 5/13/11.
An interview with the facility director on May 13, 2011 confirmed the findings.
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Plan of Correction
Division Director has met with clinical supervisor to review and train on the standards for documentation of follow-up information within one week from discharge. A follow-up log has been put in place as well as designated staff to complete documenation of follow-up. Clinical Supervisor will be responsible for supervisory follow-up and Division Director will be responsible for oversight. Full compliance will be met 06/14/2011. |