INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 11 and 12, 2009, conducted by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Common Ground, 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 and a plan of correction is due on June 17, 2009.
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Plan of Correction
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704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of the facility's detoxification service schedule and census reports, the facility failed to ensure that the client to primary care staff ratio did not exceed 7:1.
The findings include:
The facility's schedules were reviewed during the licensing inspection of May 11 and 12, 2008 and additional clarification was received on July 27, 2009. This material was reviewed on August 17, 2009. As a result of that review, the facility was determined to exceed the the 7:1 client to primary care staff ratio on the following days:
April 23, 2009 - There was a 9:1 ratio during the 2nd and 3rd shifts.
April 24, 2009 - There was a 9:1 ratio during the 2nd and 3rd shifts.
April 26, 2009 - There was an 8:1 ratio for all three shifts.
April 27, 2009 - There was a 10:1 ratio for the 2nd and 3rd shifts.
April 30, 2009 - There was a 9:1 ratio for all three shifts.
May 1, 2009 - There was a 10:1 ratio for all three shifts.
May 5, 2009 - There was a 9:1 ratio for the 2nd and 3rd shifts.
May 6, 2009 - There was a 9:1 ratio for the 2nd and 3rd shifts.
May 10, 2009 - There was an 8:1 ratio for all three shifts.
May 12, 2009 - There was an 8:1 ratio for the 2nd and 3rd shifts.
May 13, 2009 - there was a 9:1 ratio for the 2nd and 3rd shifts.
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Plan of Correction
The Nurse Manager will assure that the staff to client ratio does not exceed one to seven in detox. Should census rise above seven, the Program Director will authorize overtime as requested by the Nurse Manager. The Nurse Manager will assume responsibility for coordinating additional staff coverage. Ongoing conformance will be monitored and reported by the Nurse Manager in her monthly Quality Improvement report.
Target Date for Resolution: 8/19/09 (Immediately) |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on a physical plant inspection, the facility failed to maintain smoke detectors and fire alarms so that persons with a hearing impairment will be alerted in the event of a fire.
Findings:
A physical plant inspection was conducted on May 12, 2009 at 09:00. The facility did not designate at least one bedroom in the residential rehabilitation component with an alarm system for hearing impaired clients. The facility only had one bedroom equipped with a strobe light, specifically bedroom #1 (one of the detox bedrooms).
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Plan of Correction
The Program Director completed an acquisition request for a strobe light to be installed in a rehab bedroom. The request has been forwarded to the Central Region Plant Manager for project coordination.
Achievement progress and continued conformance will be monitored by the Program Director and designated staff through the monthly QI and Safety Committees reports.
Targeted time frame for completion is 9/1/09.
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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records and a review of the client handbook, the facility failed to demonstrate efforts towards informing clients of their rights in nine of nine records.
Findings:
Nine client records were reviewed on May 11-12, 2009. The facility did not document a complete list of client rights in the client handbook or on a client sign-off in client records # 1, 2, 3, 4, 5, 6, 7 8 and 9.
The client handbook did not include:
1.The project director may temporarily remove portions of the (client ' s) record prior to the inspection by the client if he/she determines that the information may be detrimental if presented to the client.
2.The client shall have the right to appeal a decision limiting access to his/her records to the project director.
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Plan of Correction
In addition to the currently used Gaudenzia, Inc. Client Bill of Rights document, information will be revised and included in the Client Orientation Handbook and/or posted on the client bulletin board. This revision will clarify that the Project Director may temporarily remove portions of the (client ' s) record prior to the inspection by the client if he/she determines that the information may be detrimental if presented to the client and that the client shall have the right to appeal a decision limiting access to his/her records to the Project Director.
Achievement progress and continued conformance will be monitored by the Program Director and Program Supervisor.
Targeted time frame for completion is 7/1/09.
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709.32(c)(2) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(2) Drug storage areas.
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Observations
Based on a physical plant inspection, the facility failed to maintain all drugs, stored for clients, in locked containers.
Findings:
An inspection of the nursing office and medication room was conducted on May 12, 2009 at 13:30. The facility did not store all medications in locked cabinets, as stated in the projects policy and procedures manual.
The lock on one of the cabinets, used for medication storage, in the medication room was broken. The cabinet would not stay locked after the nurse attempted to do so.
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Plan of Correction
The program will continue to store medications under double lock. A faulty cabinet hinge which impeded the cabinet's locking mechanism was immediately repaired on the day of the site visit when the problem was discovered.
Achievement and continued conformance will be monitored by the Nurse Manager and documented via the monthly Medical QI report.
Targeted time frame for completion is RESOLVED.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in one of one client records.
Nine client records were reviewed on May 11-12, 2009. Of those nine records, three were detoxification client records. Follow-up information was required in one detoxification client record. The facility did not document follow-up information within seven days from discharge as per facility policy in client record # 9.
Client record # 9 was discharged on 2/1/2009, but follow-up information was not documented at the time of this inspection.
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Plan of Correction
The facility will document follow up information on clients within 7 days of a referral appointment or within 30 days of discharge if no appointment was scheduled. The Nurse Manager shall review the policy with Nursing staff to assure timeliness and completion of documentation as required.
Achievement and continued conformance will be monitored by the Nurse Manager and documented via the monthly Detox QI report.
Targeted time frame for completion is 7/1/09.
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709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan developed with the client in three of four client records.
Findings:
Nine client records were reviewed on May 11-12, 2009. Individual treatment plans were reviewed in four client records. The facility did not document an individual treatment plan developed with the client in records # 2, 3 and 4.
The individual treatment plans were not signed by the clients, and there was not documentation, in the clients' progress notes, to indicate the clients participated in the development of the treatment plans.
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Plan of Correction
The program will continue to have clients sign their initial treatment plan within 24 hours of admit. Upon individualization of the plan by the counselor and client, the plan will be signed again to verify collaboration on the plan. The Program Supervisor has reviewed this protocol with clinical personnel and provided training.
Achievement and continued conformance will be monitored by the Program Supervisor and documented via the monthly QI report.
Targeted time frame for completion is 7/1/09.
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709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document progress notes to include Data, Assessment and Plans relative to treatment in six of six client records.
Findings:
Nine client records were reviewed on May 11-12, 2009. Progress notes were reviewed in six client records. The facility did not document progress notes to include Data (information presented by the client during the counseling session, counselor observations and information about the client from other sources) in client records # 1, 2, 3, 4, 7 and 8.
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Plan of Correction
Counselors will continue to document individual progress notes using the data-assessment-plan format relative to treatment. The Program Supervisor provided training/reviewed with counselors the importance of including information presented by the client during the counseling session, counselor observations and information about the client from other sources in the data section of the note. The Supervisor also stressed using the data-assessment-plan format in the documentation of group progress notes as well.
Achievement and continued conformance will be monitored by the Program Supervisor and documented via the monthly QI report.
Targeted time frame for completion is 7/1/09.
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