INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 9, 2016 through May 10, 2016 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, Inc. Broad Street 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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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure the safety and well-being of clients, staff, and visitors as evidenced by the following:
1) The rear perimeter fence near the driveway entrance was deformed in a way as to possibly allow individuals to gain access or egress, in addition to safety concerns with the exposed fence top.
2) The trash dumpster, located in the rear driveway of the facility, was overflowing and was not covered - the dumpster itself was missing one of the two lids.
3) Directly next to the outside trash dumpster was a 55 gallon drum filled with the facility's waste cooking oil, which was leaking a steady stream of oil to the street.
4) A high voltage transformer, located in the rear next to the driveway, had a fence around it, but the fence was not properly secured and could allow clients/staff/visitors access.
5) The facility's front door (marked with the 3029 address) facing Broad Street had broken glass on the bottom portion of the door.
6) There was a severe water leak at the bottom of the stairwell which leads to basement level that had a puddle and water damage to the hallway door and floor tiles.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
1) This issue was corrected by Gaudenzia maintenance staff on 6/10/16 by adjusting and realigning the fence brackets.
2) Republic Trash company is scheduled to replace the trash dumpster lid on 6/16/16.
3) The drum was removed by Valley Protein on 5/26/16 and replaced with a new one. The drum will be replaced every three months. The Broad Street facility Cook is responsible for ongoing monitoring of oil build up in the drum and for contacting Valley Protein in the event the drum needs to be replaced before the 3-month interval.
4) The fence was properly secured with a lock on 5/16/16.
5) Replacement glass has been purchased and delivered to the Broad St facility. Maintenance staff will replace the glass on 6/17/16.
6) Maintenance staff will facilitate repair of the leak and water damage on 6/17/16.
All facility issues relating to the safety and well-being of clients, staff, and visitors are monitored daily by program staff and Managers. As ongoing monitoring, all facility issues will continue to be communicated to the Program Director and Mental Health Division Director within 24 hours of finding. The MH Division Director will follow up with the Maintenance Director on all Broad St facility related issues on a weekly basis until resolved. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, five of the facility's restrooms had hot water temperatures recorded above 120 degrees. Additionally, one restroom was not maintained in a safe manner.
1) 1st floor kitchen temperature was 136 degrees; 2nd floor female restroom near room #5 was 129 degrees; 2nd floor female bathroom near room #1 was 124 degrees; 2nd floor staff restroom was 122 degrees; 3rd floor restroom near room #6 was 132 degrees.
Additionally, the female restroom, located in the shared lounge on the 1st floor, had significant damage on the wall behind the toilet and the light fixture in the ceiling was improperly secured and uncovered.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Gaudenzia maintenance department adjusted the facility's hot water tank temperature on 5/11/16 to 118 degrees. The 1st floor kitchen, both 2nd floor female restrooms, 2nd floor staff restroom, and 3rd floor restroom temperatures were all checked and read at under 120 degrees. The hot water temperature will be checked ongoing at a minimum of once/week ongoing by the Broad St facility safety committee representative. Any water temperature read above 120 degrees will be reported immediately to the maintenance department. For ongoing monitoring the MH Division Director and Program Director will follow up weekly with the Maintenance Department Director on all facility related maintenance issues.
The wall and light fixture in the 1st floor female restroom will be repaired by Gaudenzia maintenance staff by 6/30/16. All facility-related maintenance issues are monitored daily by Broad Street program staff and Managers. All facility issues will continue to be communicated to the Program Director and Mental Health Division Director within 24 hours of finding. The MH Division Director will follow up with the Maintenance Director on all Broad St facility related issues on a weekly basis until resolved. |
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 May 10, 2016 at approximately 9:00 am to 10:30 am, the facility's kitchen freezer temperature was measured at 30 degrees and the basement refrigerator, located across from laundry area, was measured at 45 degrees at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MH Division Director and Program Director formally reviewed this area with the Broad St cook/safety committee representative on 6/1/16.
1) All refrigerator and freezer temperatures within the facility will be documented accurately and reviewed by the Program Director, and in his/her absence the MH Division Director, on a weekly basis.
2) In the event that a refrigerator temperature is measured above 40 degrees, or a freezer temperature measured above 0 degree, the facility staff will measure the temperature again the following morning. If the measure remains out of the required temperature range the staff, or his designee will immediately contact EcoLab to assess. All facility refrigerators/freezers are under warranty with EcoLab. |
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 the review of client records, the facility failed to document an informed and voluntary consent to release information form in client record #'s 12 and 14. Additionally, a consent to release information form in client record # 13 was missing required information.
#12 - It was documented in the client chart that the client's therapist made telephone contact on 4/27/2016 to two separate government agencies, as well as another treatment provider, without obtaining proper consent to release information forms.
#13 - A consent to release information form to a government agency, dated 3/25/2016, did not include what information was to be released and the purpose of disclosure.
#14 - It was documented in several progress notes that the client's therapist made separate contacts with a government agency and several of the client's family members without obtaining a proper consent to release information form.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Mental Health Division Director completed an in-service on Consents for Releases of Information on 5/19/16. All Counselors, the Intake Specialist, Program Supervisors, and Psychiatrist were in attendance. Bi-weekly chart reviews will be conducted by each Clinical Supervisor as part of ongoing monitoring for this issue. The RINT Program Director will conduct a random review of 20% of open charts on a monthly basis to monitor compliance.
The Mental Health Division Director will conduct a random review of 20% of open charts on a quarterly basis to monitor compliance.
#12 The Release of Information for indicated treatment provider was signed by the resident on 5/16/16.
#13 Two Releases of Information dated 3/25/16 in resident's chart indicated the purpose of the disclosure.
#14 Resident discharged prior to 5/9/16.
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709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, client record #'s 6, 11, 12, and 13 did not have preliminary treatment plans documented in the client records.
#6 was admitted on 08/26/2015 and was discharged on 10/10/2015.
#11 was admitted on 03/23/2016 and was still an active client at the time of the inspection.
#12 was admitted on 03/18/2016 and was still an active client at the time of the inspection.
#13 was admitted on 03/25/2016 and was still an active client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Initial/Preliminary Treatment plans for residential programs are due within 5 days of admission. An in-service to review due date time frames for documentation was facilitated by the Mental Health Division Director with Broad Street clinical staff, Supervisors, and the Intake Specialist on 5/19/16.
Completion of Initial Treatment Plans, including all required signatures by the due date will be monitored ongoing by the Program/Clinical Supervisors. The RINT Program Director will conduct a random review of 20% of open charts on a monthly basis to monitor compliance. The Mental Health Division Director will conduct a random review of 20% of open charts on a quarterly basis to monitor compliance.
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709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, client record #'s 4, 7, 11, 12, and 15 were missing either the type and/or frequency of treatment and rehabilitation services on the documented comprehensive treatment plan.
#4 - The comprehensive treatment plan, dated 4/29/2016, was missing the type and frequency.
#7 - The comprehensive treatment plan, dated 12/09/2015, was missing the type and frequency.
#11 - The comprehensive treatment plan, dated 4/11/2016, was missing the type and frequency.
#12 - The comprehensive treatment plan, dated 3/23/2016, was missing the frequency.
#15 - The comprehensive treatment plan, dated 12/22/2015, was missing the frequency.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The Mental Health Division Director will complete an in-service mandatory for all Broad St clinical staff and Supervisors by 6/30/16 on comprehensive completion of treatment plans.
All current Broad St Counselors have completed the 12-hour Clinical Record Keeping and Current Standards Training offered through the Gaudenzia Training Institute, which includes review of completion of Treatment plans.
All clinical documentation, including treatment plans, will be reviewed and approved by the Supervisor prior to being submitted for inclusion in the clinical chart.
Supervisors will review clinical documentation as part of ongoing individual supervisions with staff. Additionally, Bi-weekly chart compliance reviews will be conducted by each Clinical Supervisor.
The RINT Program Director will conduct a random review of 20% of open charts on a monthly basis to monitor compliance.
The Mental Health Division Director will conduct a random review of 20% of open charts on a quarterly basis to monitor compliance.
#4 The type and frequency on treatment plan dated 4/29/16 was updated on 5/31/16 and reviewed with resident.
#7 Resident discharged prior to 5/9/16.
#11 Type and frequency on treatment plan dated 4/11/16 was updated on 5/31/16 and reviewed with resident.
#12 Frequency on treatment plan dated 3/23/16 was updated on 6/3/16.
#15 Resident discharged prior to 5/9/16.
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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, client record #'s 1, 3, and 5 did not receive individual counseling sessions according to the individual's comprehensive treatment plan.
#1 - The treatment plan, dated 12/15/2015, indicated one individual session per week; however, only nine individual counseling sessions were documented from 12/3/2015 (date of admit) through the date of the inspection.
#3 - The treatment plan, dated 2/23/2016, indicated one individual session per week; however, only two individual sessions were documented from 02/22/2016 (date of admit) through the date of the inspection.
#5 - The treatment plan, dated 10/16/2015, indicated one individual session per week; however, only four individual sessions were conducted from 10/14/2015 (date of admit) through 02/24/2016 (date of discharge).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisors will review clinical documentation as part of individual supervisions with staff. This will include ensuring that counseling services are provided according to the individual treatment plan. Additionally, Bi-weekly chart compliance reviews will be conducted by each Clinical Supervisor. The Program Director will also conduct a random review of 20% of open charts on a monthly basis.
#1 All missing progress notes will be completed, signed, and included in the resident's clinical chart by 06/30/16.
#3 All individual progress notes required as indicated on the 2/23/16 treatment plan have been completed, signed and filed into the resident's chart.
#5 All missing progress notes will be completed, signed, and included in the resident's chart by 6/10/16. |