INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Winner Co-Occurring Women and Children Program 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 (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 and an interview with the facility director, the facility failed to 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 findings include:
An inspection of the facility's physical plant was conducted on June 1, 2011 between approximately 11:00 AM and 12:00 Noon. The grounds of the facility were not clean and in good repair at the time of inspection.
The carpets were soiled in client bedrooms # 0, 1, 2, 4, 6, 7, 8, 10, 11 and 12.
The ceiling tiles were stained in client bedrooms # 1 and 2.
The ceiling tiles were stained in the large group room on the first floor.
An interview with the Facility Director on June 1, 2011 confirmed the findings.
This is a repeat citation.
The facility was previously cited on March 4, 2011 for failing to keep the grounds of the facility clean, safe, sanitary and in good repair.
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Plan of Correction
As of 7/11/2011, the Program Director has been given a projected date of completion for carpet replacement of 8/31/2011.
Ceiling tiles are being replaced and work will be completed by 8/31/2011.
Director has a daily inspection log where problems are indicated by house managers. Director will inspect the faciity weekly and file maitenance requests. requests will be followed up on weekly by the administrative coordinator. Requests not completed within 30 days will be reported to the Division Director. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom.
The findings include:
An inspection of the facility's physical plant was conducted on June 1, 2011 between approximately 11:00 AM and 12:00 Noon. The facility did not provide either individual paper towels or a mechanical dryer in each bathroom.
The women's bathroom on the second floor, next to bedroom # 2, did not have individual paper towels or a mechanical dryer at the time of inspection.
The women's bathroom on the third floor, next to bedroom # 11, did not have individual paper towels or a mechanical dryer at the time of inspection.
An interview with the Facility Director on June 1, 2011 confirmed the findings.
This is a repeat citation.
The facility was previously cited on March 4, 2011 for failing to provide either individual paper towels or a mechanical dryer in each bathroom.
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Plan of Correction
Director has developed a check list for each room of the facility to be examined by each chift (3x per day) for papertowels in bathroom.
Director will do random weekly inspections to insure compliance with the checklist being completed.
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705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to store all eating, drinking and cooking utensils in a clean enclosed area.
The findings include:
An inspection of the facility's physical plant was conducted on June 1, 2011 between approximately 11:00 AM and 12:00 Noon. The facility did not store all eating utensils in a clean enclosed area.
Plates were stored in an enclosed cupboard, but food particles and dust were observed in this storage area.
An interview with the Facility Director on June 1, 2011 confirmed the findings.
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Plan of Correction
The house managers will do runs on the storage areas for cleanliness daily. The cook will follow behind to inspect that the cabinent will be wiped out daily. Director will do random checks weekly and hold staff responsible for doing the chore. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection and an interview with the Facility Director, the facility failed to maintain protective caps over each electrical outlet in all areas designated for children.
The findings include:
An inspection of the facility's physical plant was conducted on June 1, 2011 between approximately 11:00 AM and 12:00 Noon. The facility did not maintain protective caps over each electrical outlet in areas designated for children.
In client bedroom # 11, one of the electrical outlets did not have protective caps.
In client bedroom # 12, one of the electrical outlets did not have protective caps.
An interview with the Facility Director on June 1, 2011 confirmed the findings.
This is a repeat citation.
The facility was previously cited on March 4, 2011 for failing to maintain protective caps over each electrical outlet in areas designated for children.
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Plan of Correction
As in P0057, the checklist has been implemented to insure that the facility is check on each shift for electrical outlet covers.
Director will do random weekly checks to insure compliance |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records and an interview with the Facility Director, the facility failed to comply with 4 Pa. Code relating to projects and coordinating bodies: disclosure of client-oriented information.
The findings include:
On June 1, 2011, five client records were reviewed for documentation of informed and voluntary consent. The facility's consent to release information forms permitted the facility to act in reliance on a client's verbal consent to release information. This is in violation of 709.28 (c):
The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(1)Name of the person, agency or organization to whom disclosure is made.
(2)Specific information disclosed.
(3)Purpose of disclosure.
(4)Dated signature of client or guardian.
(5)Dated signature of witness.
(6) Expiration date of the consent.
Client records # 1, 2 and 3 contained consent to release information forms that stated:
" I understand that my records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written or verbal consent unless otherwise provided for in the regulations. "
Client record #1 contained three consent forms releasing information to government agencies and third party funding sources, but the consent forms allowed the facility to act in reliance on the client's verbal consent to release information.
Client record # 2 contained a consent form releasing information to a family member, but the consent form allowed the facility to act in reliance on the client's verbal consent to release information.
Client record # 3 contained a consent form releasing information to a friend, but the release form allowed the facility to act in reliance on the client's verbal consent to release information.
An interview with the Facility Director on June 1, 2011 confirmed the findings.
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Plan of Correction
Gaudenzia has revised its Release of Information form to come into compliance and all staff have the new form.
Director had staff meeting with staff to go over what information can and can not be requested. Clinical Supervisor will review charts monthly for compliance. |
709.28(c)(2) 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. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document the specific client information to be disclosed on a release of information form in three of five client records.
The findings include:
On June 1, 2011, consent to release information forms were reviewed in five client records, specifically client records # 1, 2, 3, 4 and 5. The facility did not document the specific information to be disclosed on release of information forms in client records # 1, 2 and 3.
Client record # 1 contained two consent forms releasing information to government agencies, but the consent forms did not include the specific information that was disclosed.
Client record # 2 contained a consent form releasing information to a probation officer, but the consent form did not include the specific information that was disclosed.
Client record # 3 contained a consent form releasing information to a government agency, but the consent form did not include the specific information that was disclosed.
An interview with the Facility Director on June 1, 2011 confirmed the findings.
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Plan of Correction
Gaudenzia has revised its Release of Information form and all staff have new form.
Staff meeting done to review with staff how to complete form and what can/can't be released. Clinical Supervisor will review charts monthly for compliance. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records and an interview with the clinical supervisor, the facility failed to inform a client of the right to request reconsideration of the decision to terminate her treatment in one of one records.
The findings include:
On June 1, 2011, one involuntarily terminated client's record was reviewed for documentation of the client being given the opportunity for reconsideration of the facility's decision to terminate her treatment. The facility failed to inform the client of her right to request reconsideration of the facility's decision to terminate her treatment, as per facility policy, in client record #6.
The facility's policy titled "POLICY & PROCEDURE FOR CLIENT NOTIFICATION OF TERMINATION & CLIENT RIGHT TO APPEAL TREATMENT TERMINATION" states: "Clients shall be informed of their right to appeal any therapeutic discharge, in writing, to the Program Director within fifteen days of the notice. The right to appeal statement shall be noted on the Therapeutic Discharge Notice."
In client record # 6, the Therapeutic Discharge Notice dated 4/27/11 informed the client of the reason for her termination, but the notice did not inform the client of her right to appeal the facility's decision to terminate her treatment.
An interview with the Clinical Supervisor on June 1, 2011 confirmed the findings.
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Plan of Correction
The Program Director is responsible for sending the termination letters to the client. In the record reviewed, the Director did not address the right to appeal. This has been changed in the form letter to insure that the following statement is included:
"You have the right to appeal this decision. Appeals must be made within ten days from the date of this letter. Appeals must be directed to:
(Name), Division Director
3025 N. Broad Street
Philadelphia, PA 19140"
Program Director will have the Administrative Coordinator read all out going termination letters to insure compliance. |
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 to include the physician's overall impression of the client, as per facility policy, in six of six client records.
The findings include:
On June 1, 2011, physical examinations were reviewed in six client records, specifically client records # 1, 2, 3, 4, 5 and 6. The facility did not document physical examinations to include the physician's overall impression in client records # 1, 2, 3, 4, 5 and 6.
The facility's policy titled "PHYSICAL EXAMINATION LABORATORY STUDIES" states: "Documentation of the results of the physical examination shall include but not be limited to: evidence of injury, neurological findings, investigation of the organ systems for potential infectious disease, pulmonary, liver and cardiac abnormalities, dermatological sequelae of addiction, vital signs, examination of general appearance, head, ears, eyes, nose, throat, chest, abdomen, extremities, skin assessment, concurrent problems and the physician's overall impression of the client. "
In client record # 1, the physical examination dated 3/22/11 did not include the physician's overall impression of the client.
In client record # 2, the physical examination dated 4/19/11 did not include the physician's overall impression of the client.
In client record # 3, the physical examination dated 4/5/11 did not include the physician's overall impression of the client.
In client record # 4, the physical examination dated 11/16/10 did not include the physician's overall impression of the client.
In client record # 5, the physical examination dated 8/25/10 did not include the physician's overall impression of the client.
In client record # 6, the physical examination dated 11/30/10 did not include the physician's overall impression of the client.
An interview with the facility director on June 1, 2011 confirmed the findings.
This is a repeat citation.
The facility was previously cited on March 4, 2011 and June 2, 2010 for failing to document physical examinations in accordance with facility policy.
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Plan of Correction
As per the Division Director of Women and Children Services: After each exam, the facility nurse will review for completeness. Any exam without a physician's impression will be immediately sent back to the physician. The Division Director is to also be immediately contacted by either the facility nurse or the program director. The Division Director will report to the Executive Director the number of times that the exams lacked a physician's impressions. |
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 client records and an interview with the clinical supervisor, the facility failed to document treatment plan updates to include an assessment of the client's progress, as per facility policy, in four of five client records.
The findings include:
On June 1, 2011, five client records requiring treatment plan updates were reviewed, specifically client records # 1, 2, 3, 4 and 5. The treatment plan updates did not include an assessment of progress, as per facility policy, in client records #1, 2, 4 and 5.
The facility's policy titled "Treatment Plan Reviews" states: "The Counselor shall complete a treatment plan review and update 30 days after the date of the original individual treatment plan for residential, (and every 30 days thereafter), 14 days after the date of the original individual treatment plan for short-term (and every 14 days thereafter) and 60 days after for outpatient and every 60 days thereafter. This review shall include an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal has been impacted. Any goal or action step additions, revisions and deletions shall also be reflected. Goal and action step changes shall also be reflected on the treatment plan. The update shall be signed by the Counselor and submitted to the Clinical Supervisor for review and signature."
In client record # 1, the treatment plan update documented on 5/19/11 did not include an assessment of progress.
In client record # 2, the treatment plan update documented on 5/16/11 did not include an assessment of progress.
In client record # 4, the treatment plan update documented on 5/12/11 did not include an assessment of progress.
In client record # 5, the treatment plan updates documented on 9/19/10, 10/19/10, 11/19/10, 12/19/10 and 2/19/11 did not include an assessment of progress.
An interview with the Clinical Supervisor on June 1, 2011 confirmed the findings.
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Plan of Correction
On June 2, 2011, the Clinical Supervisor met with the counselors to review how to do an assessment of progress on the treatment plan updates. Clinical upervisor will review monthly and not sign off on the treatment plan unless the assessment is properly assessed. |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop a written client follow-up policy that accurately reflects their follow-up process.
The findings include:
From May 9, 2011 through May 11, 2011, the facility's policy and procedure manual was reviewed. The facility had two conflicting procedures regarding attempts to follow up on clients.
The facility's policy titled: "Follow Up Information," states: "All clients are followed up after discharge. Follow up information shall be conducted for each client after discharge from the program, unless there is specific client refusal for follow up. Each program will maintain a follow up policy outlining the specific steps taken. The follow up log binder will house the documentation of each follow up attempt. Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow up.
In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder. In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note [remember to state the reason for the refusal in the note and on the form]. Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder. .Follow up information shall include the client's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals."
The facility's policy and procedure manual contained a second written policy titled: "FOLLOW UP INFORMATION." This second policy states: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. 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. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor's designee, to follow-up the discharged client's progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
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Plan of Correction
Gaudenzia's follow up policy has been revised and now states: Follow Up - within seven days of the date of a referral appointment made for a client leaving treatment, the referral shall be contacted by the counselor to determine if the client kept the initial appt. and if the referral was appropriate. In the case of a client ending treatment without a referral appt. (asa, therapeutic discharge, completion who refuses further treatment), the client shall be contacted within thirty days directly by the counselor or supervisor's designee to determine the client's well being and to maintain the opportunity for re-admission should circumstances warrent it as necessary and appropriate. Information shall be kept in the follow up log binder.
The Winner program is following this policy and program director will review log monthly for compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On June 1, 2011, the facility was again found to be out of compliance with the following standards:
705.2(2) - Building exterior and grounds: 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. This area of noncompliance was also identified during the licensing inspection conducted on March 4, 2011.
1. 705.6(2) - Bathrooms: Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom. This area of noncompliance was also identified during the licensing inspection conducted on March 4, 2011.
2. 705.11(2)(iii) - Child care: Maintain protective caps over each electrical outlet.
This area of noncompliance was also identified during the licensing inspection conducted on March 4, 2011.
3. 709.51(b)(5) - Intake and Admission: Physical Examinations. This area of noncompliance was also identified during the licensing inspections conducted on March 4, 2011 and June 2, 2010.
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Plan of Correction
As of 7/11/2011, Program Director has been given a completion date for carpet replacement of 8/31/2011.
Outlet covers are checked throughout the facility 3x per day by staff on duty on each shift. A log is kept that the outlets have been checked and for general maitenance in all rooms. The log also indicated a run on soap and paper towels in all bathrooms.
Physical exams will be reviewed for compliance by the facility nurse and program director. Any missing physicial impressions will be taken through the chain of command to the Executive Director for action. |