INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 4, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection,Gaudenzia Inc. Harrisburg Concept 90 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 the physical plant inspection the facility failed to ensure that grounds remained clean, sanitary and in good repair.
The blue paint on the wall both under and next to the window of the air conditioner in office 114 was bubbling up in several places from water and condensation. Some of the water damage to the paint is near the power outlet for the air conditioner.
The wall under the window of the air conditioner in room 211 has numerous cracks in it.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Physical Plant Manager began repair of Office 114 on 6/5/18. DGS is responsible for exterior repair to prevent water seepage prior to completion of interior office repair. All work is scheduled to be completed by 7/31/18.
The Physical Plant Manager addressed the cracking wall in room 211 on 6/13/18. The Program Director verified completion on 6/13/18.
The Physical Plant Manager and Program Director will continue to monitor the facility grounds during monthly inspections to ensure cleanliness, sanitation, and good repair. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection the facility failed to ensure that the bathrooms remained functional at all times.
The toilet stall on the far right of the men's bathroom is missing the door jam, and the lock on the door is broken.
The toilet stall on the far left of the men's bathroom has a broken handle and broken lock.
On the far right side of the men's bathroom both of the lights near the window were missing light covers, and one of the two lights had no light bulbs.
On the far left side of the men's bathroom, both of the lights near the door were missing covers, and one of the two lights had no light bulbs.
Both the lights in the women's bathroom room next to the window were missing light covers, and one of the two lights had no light bulbs.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Physical Plant Manager ordered new bathroom partitions in March 2018. The Program Director reported the findings to the Physical Plant Manager on 6/5/18. New partitions with fully functioning locks and doors are expected to be installed by 7/31/18.
The Physical Plant Manager had all new lighting fixtures with covers and new light bulbs installed in both the men's and women's bathrooms on 6/11/18.
The Physical Plant Manager and Program Director will monitor the physical plant, including bathrooms, during monthly inspections to ensure the bathrooms are fully functioning at all times. |
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 conducted during the on-site inspection, the facility failed to properly document the frequency of services in 3 of 5 applicable client records reviewed.
Client #3 was admitted for treatment on 09/29/2017, and was discharged on 01/03/2018. The client's individualized treatment plan dated 10/27/2017, does not indicate any counseling frequency at all.
Client #4 was admitted for treatment on 11/01/2017, and was discharged on 01/09/2018. The client's individualized treatment plan dated 12/01/2017, and treatment plan update dated 01/01/2018, do not indicate any counseling frequency at all.
Client #6 was admitted for treatment on 03/19/2018, and was an active client at the time of the onsite inspection. The client's individualized treatment plan dated 04/20/2018, and treatment plan update dated 05/20/2018, do not indicate any counseling frequency at all.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Effective April 1, 2018, clinical documents are contained in an electronic health record. The electronic treatment plan form is currently undergoing revision to provide space to specify both type and frequency of interventions as well as prompts to remind the clinician to address this area. These revisions will be completed by the CQI Director, and fully implemented by 7/31/18.
Client #6 completed treatment and was discharged. Prior to discharge, the treatment plans were corrected to include counseling frequency.
The Program Supervisor will ensure that treatment plans are properly utilized through ongoing regular chart audits. The Program Director will review progress during monthly CQI. |
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 conducted during the on-site inspection, the facility failed to ensure that it updated client treatment plans at least once every 30 days in 4 of 5 applicable client records.
Client #1 was admitted for treatment on 12/04/2017, and was discharged on 03/19/2018. The client's individualized treatment plan was dated 12/04/2017, but the client's treatment plan was not updated until 02/04/2018.
Client #2 was admitted for treatment on 12/08/2017, and was discharged on 03/08/2018. The client's individualized treatment plan was last updated on 01/11/2018.
Client #3 was admitted for treatment on 09/29/2017, and was discharged on 01/03/2018. The client's individualized treatment plan was dated 10/27/2018, but the client's treatment plan was never updated.
Client #4 was admitted for treatment on 11/01/2017, and was discharged on 01/09/2018. The client's individualized treatment plan was dated 12/01/2017. The client's treatment plan update dated 01/01/2018, gave no information about the progress of the client.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Program Director reviewed the requirements for documentation of updated treatment plans on 6/20/18, with the Program Supervisor and clinical team. The Program Director revised a documentation tracking grid to assist the Program Supervisor in tracking the due dates and status of all treatment plans. The Program Supervisor will monitor treatment plan completion during weekly chart audits, and during weekly clinical team meetings. The Program Director will review progress monthly through CQI. |
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:
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Observations
Based on a review of client records conducted during the on-site inspection, the facility failed to document a complete client record in 2 of 6 client records reviewed.
Client #1 was admitted for treatment on 12/04/2017, and was discharged on 03/19/2018. The client's individualized treatment plan dated 12/04/2017, and treatment plan updates dated 02/04/2018, and 03/01/2018, indicated that there were to be 7 clinical group counseling sessions per week, but there were progress notes for an average of less than two clinical group counseling sessions per week.
Client #2 was admitted for treatment on 12/08/2017, and was discharged on 03/08/2018. The client's individualized treatment plan dated 12/11/2017, and treatment plan update dated 01/11/2018, indicated that the there were to be 4 clinical group counseling sessions per week, but there were progress notes for an average two clinical group counseling sessions per week.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Program Director reviewed the requirements for documentation of a complete client record, including treatment plans, individual counseling, and group counseling, on 6/20/18, with the Program Supervisor and clinical team. The Program Director revised a documentation tracking grid to assist the Program Supervisor in tracking the due dates and status of all required clinical documentation. The Program Supervisor will monitor documentation completion during weekly chart audits, and during weekly clinical team meetings. The Program Director will review progress monthly through CQI. |