INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on October 25, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, the allegations made against Gaudenzia, Inc. Harrisburg Concept 90 were partially substantiated. Gaudenzia, Inc. Concept 90 was found to be out of 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 observation during a physical plant inspection, the facility failed to maintain the second floor men's bathroom and the first floor women's bathroom in good repair for the safety and well-being of the resident's employees and visitors.
The findings include:
On October 25, 2011, the men's bathroom, located on the second floor, had a broken shower handle for shower #2. The shower handles of showers # 1 & 3 in the women's bathroom also had broken handles.
The findings were not disputed by the Program Director.
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Plan of Correction
All broken shower handles in both the men's and women's bathrooms were replaced on November 7, 2011. To ensure that the men's and womens bathroom remain in good repair for the safety and well-being of the residents, a maintenence run will be conducted on a daily basis by the House Manager assigned to facility maintenence. Any maintenence issues will be documented and reported to the Program Supervisor. The Program Supervisor will then complete the electronic work order and send it to the Gaudenzia Property Manager for execution. The Property Manager will then respond by completing the work within forty eight (48) hours. This daily maintenence run will be an ongoing solution to remain in compliance with DOH regulations |
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 observation during a physical plant inspection, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom.
The findings include:
On October 25, 2011, it was observed at approximately 9:00 AM and 1:00 PM that the men's bathroom on the second floor, which is not equipped with a mechanical dryer, lacked paper towels.
This was discussed with the Program Director and the findings were not disputed.
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Plan of Correction
All broken paper towell dispensers in both the men's and women's bathroom were replaced on November 7, 2011. To ensure that individual paper towels are available to Concept 90 residents, staff and guests, a morning maintenence run will be performen by the House manager assigned to facility maintenence. This person will ensure that an appropriate ammount of paper towels are ordered for the facility on a bi weekly basis and will stock both the men's and women's bathroom on a daily basis. This maintenence run and facility order will be reported to the Program Supervisor who will then send facility order to Program Director for approval and signature. This system will be implemented on an ongoing basis to ensure compliance with DOH standards. |
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 observation during a physical plant inspection, the facility failed to maintain the second floor men's bathroom in a clean and sanitary manner at all times.
The findings include:
On October 25, 2011, the men's bathroom, located on the second floor, had a black and green foreign substance under the faucet handles of sink #1 & 2.
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Plan of Correction
To ensure that both the men's and women's bathrooms are maintained in a clean and sanitary manner at all times, the House Manager on duty will make a run through the facility including the men's and women's bathrooms. This run will occur on all three shifts utilized at Concept 90, and will occur on a daily basis. Any sanitation issues that are discovered during these runs will be reported to the Program Supervisor who will then identify the resident(s) that the area in question is assigned to. The resident(s) will then be responsible as part of their work therapy to maintain the area under the supervision of the Program Supervisor. This system will be implemented on an ongoing basis to remain in compliance with DOH standards. |
705.9 (4) (ii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(ii) Assignments of staff during emergencies.
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Observations
Based upon a review of the policy and procedure manual, the Communication Log, and interviews with the Program Director and the Program Supervisor, the facility failed to follow the project's written policies and procedures provided for staff and residents in case of an emergency.
The findings include:
Facility policy titled: GAUDENZIA, INC. STANDARD: 705.9 &10 (709.28 1-10)
SUBJECT: Fire Drills/Evacuation under the subsection Evacuation Procedures stated the following:
"Upon notification of an impending or actual emergency or disaster either by alarm or verbally, staff on duty, or the person in charge will have all occupants vacate the premises via predetermined and posted routes and assemble in the parking lot beyond the front of the building.
Staff on duty or the person in charge will insure occupants have been evacuated. A count will be taken at the assembly area to count for the whereabouts of all persons. The staff on duty will also insure that windows and doors are secure when safe to do so. If it is determined that the facility cannot be re-entered, the person in charge will make arrangements to transport and house the people at other Gaudenzia facilities and/or alternative appropriate facilities."
On October 25, 2011 the staff Communication Log was reviewed. The log contained an entry that documented on October 15, 2011, the day following the learning experience fire drills, that the smoke detectors sounded the fire alarm on two separate occasions. The staff on duty failed to evacuate the building but in stead called the Program Director to determine the course of action. Per the entry in the Communication Log, the Program Director was called and gave instructions not to evacuate the building.
The Program Director and Program Supervisor were interviewed on October 25, 2011 regarding the decision to not evacuate when the reason for the alarm was unknown. the Program Director and the Program Supervisor stated that the staff on duty when the smoke detectors were sounding the alarm worked at the facility for some time and was familiar with how the smoke detectors sound before going off when it is a real alarm and when it is not. They indicated that because of the initial sound before the alarm went off that the staff person knew that the alarm was a false alarm and therefore it was decided to not evacuate the building.
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Plan of Correction
Beginning on 11/7/2011, any impending or actual emergency or disaster either sounded by alarm or verbally communicated, the staff on duty or the person in charge will have all occupants vacate the premises using the predetermined and posted routes. All occupants will then assemble in the parking lot beyond the front of the building. The staff on duty will then ensure that all occupants have been evacuated and a count will be taken to ensure that all have been evacuated and accounted for. The staff on duty will then secure the facility, (windows and doors) when it is safe to do so. If the determination is made that the facility is unsafe to re enter, the staff on duty will communicate to the Program Supervisor and Program Director and arrangements will be made to house the people at other Gaudenzia facilities and/or other appropriate alternative facilities. A staff in house training will be conducted by the Program Director on January 4, 2012 to ensure that all facility staff are familiar and versed in all Gaudenzia fire drill/evacuation procedures. All fire drills/evacuations will be monitored and documented by the Program Director on a weekly basis. All fire drill/evacuations will be communicated and entered into the QI process on a monthly basis on an ongoing basis. Any problems with fire drills/evacuations will be reported to the Central Region Director as soon as they occur. |
705.10 (b) (3) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(3) Repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperative.
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Observations
Based upon a review of the Communication Log, an interview with the Program Director and the Program Supervisor, and documentation provided by the facility on November 4, 20111, the facility failed to repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperative.
The findings include:
On October 25, 2011 the staff Communication Log was reviewed. The facility documented on October 15, 2011, the day following the learning experience fire drills, that the smoke detectors sounded the fire alarm on two separate occasions and that the Program Director was called and gave instructions not to evacuate the building.
The Program Director and Program Supervisor were interviewed on October 25, 2011 regarding the decision to not evacuate when the reason for the alarm was unknown. the Program Director and the Program Supervisor stated that the staff on duty when the smoke detectors were sounding the alarm worked at the facility for some time and was familiar with how the smoke detectors sound before going off when it is a real alarm and when it is not. They indicated that because of the initial sound before the alarm went off that the staff person knew that the alarm was a false alarm and therefore it was decided to not evacuate the building.
The Program Director and Program Supervisor were asked if the problem with the smoke detectors was addressed within 48 hours of the time the detector or alarm was found to be inoperative and if they had a report from showing that it had been from the company that worked on the system. They both indicated that they believed it had been addressed within two to three days. They did not have a copy of the report and were asked to fax it when they received the report.
On November 4, 2011 the facility faxed a letter from the inspection agency dated 10, 27, 2011 indicating that a visual inspection of the system had been conducted. There were three additional pages documenting an inspection for the building known as Anderson Hall on October 21, 2011 documenting a test of six manual pull stations, five audio/visual devices, one heat detector and one smoke detector. The smoke detector listed was located at the bottom of the stairs in the basement. The inspection was not conducted within the required 48 hours but was conducted more than five days after a problem with the system was identified and the inspection was incomplete as it did not address any of the other smoke detectors located in the building.
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Plan of Correction
A facility maintenence run will be conducted on a daily basis by the House Manager assigned to maintenence. This maintenence run will include all facility smoke detectors. If it is found that any somke detector or the smoke detector system is inoperable or in disrepair, the House Manager will immediatly report the problem to the Program Supervisor and Program Director. The Program Director will then notify the Department of General Services and Kint Corporation to arrange for immediate repair. Kint Corporation will be required to check all smoke detectors located in the building. |
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 a review of client records, the facility failed to obtain and informed and voluntary consent for specific information released from the client record and released information that exceeded 4 Pa. Code 255.5.
The findings include:
4 Pa. Code 255.4 restricts information that can be released to a government agency to the following five items:
(1) Whether or not the client is in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency
of such relapse.
On October 25, 2011, four client records requiring consents to release information were reviewed. Two of four client records contained documentation showing that the facility released information to a government agency that exceeded what was permissible under 4 Pa. Code 255.5. The facility released the client's Discharge Summary which included private health information about the client.
The findings were confirmed by the Program Supervisor.
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Plan of Correction
A chart audit reviewing both client consents and discharge summaries will be conducted by the Program Supervisor on a weekly basis. This audit will occur for three months. The audit, will determine that Concept 90 does not exceed 4 Pa. Code 255.5, which restricts information that can be released to a government agency to the five items: (1) Whether or not the client is in treatment. (2) Client's prognosis.(3) The nature of the project. (4) A brief description of the client's progress. (5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse. The audit will insure that private health information or any other information that exceeds 4 Pa. Code 255.4 will not be included in information that is released. If after three months of weekly chart audits it is determined by the Program Supervisor that innappropriate information is not bening released, the chart audits will occur on a monthly basis and reported to the Gaudenzia QI process.
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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 the facility Policy and Procedures Manual, the staff Communication Log, the facility Fire Drill Log, client records, and a document with the subject listed as Learning Experience, the facility failed to ensure that client rights were upheld.
The findings include:
On October 25, 2011, a complaint investigation was conducted in reference to allegations that between October 13 - 14, 2011, the facility punished the entire community due to some clients smoking in their rooms. The claimant alleged that on October 13, 2011, the facility director instructed staff to conduct hourly fire drills from 3:00 PM to 11:00 PM and that the drills took place in the pouring down rain. The claimant also alleged that the facility deprived him of sleep by conducting fire drills every 2 hours during the overnight, starting at midnight on October 14, 2011.
Gaudenzia policy titled, "Client Rights Punishment," dated January 2009, stated:
"Gaudenzia, Inc. strictly prohibits all corporal and unusual punishment, humiliation, mental abuse and punitive interference with the daily functions of living, such as eating or sleeping.
1. All clients have the right to humane discipline;
2. Clients are assured freedom from physical abuse, corporal punishment, denial of food or
clothing, or unusual punishment;
3. If discipline is necessary as a result of the client not following program rules, then the
discipline is designed as an integral part of the individual's treatment (us (sic) of the
Learning Experience or LE is strongly encouraged);
4. All discipline and /or disciplinary procedures are authorized solely by the program
supervisor based upon clinical staffing of the client;
5. A client may appeal any discipline procedure either verbally or in writing to the primary
counselor, and is entitled to a review with other staff and clients present. Clients will not
be disciplined for this or any their (sic) appeal of their treatment."
The staff Communication Log was then reviewed and it documented the following entry on October 13, 2011: "(Redacted Facility Director name) addressed (redacted client name) and (redacted client name) for smoking in their rooms. The learning experience is a 48 hour smoking ban. In addition, they were to present a fire drill every hour on the hour. This experience is to continue for 24 hours starting at 2:00 pm 10-13-11 until 10-14-11."
Subsequent Communication Log notes, regarding fire drills and entered from October 13 - 14, 2011, are as follows:
"Per (redacted Program Director name). The fire drills are to be ran (sic) every 2 hrs, in the womens (sic) hall."
"Staff All fire drills were done every 2 hrs throughout the night. Last one for 3rd shift was
at 6 oclock (sic) am."
The Fire Drill Log documented that on October 13, 2011, a fire drill was conducted at 3:00 PM and that 41 clients and 11 staff members participated. No other fire drills were documented for October 13, 2011.
A review of the Communication Log and client record # 2 confirmed that client # 2 left ASA (Against Staff Advice) at approximately 9:45 PM on October 13, 2011. No reason for leaving was provided.
A further review of client record # 2 revealed that the facility documented two (2) phone complaints that were received from a male who identified himself as the client's brother. The complaints were dated October 14, 2011, and October 17, 2011. The complaint dated October 14, 2011, stated: "Client's brother called extremely angry that his brother had left treatment ASA and was filing a verbal complaint regarding our fire drill procedure last night in the rain. I informed his brother that I could not confirm or deny the client's presence in treatment nor discuss this matter with him as there was no release for him. Program Director informed of this complaint." The complaint dated October 17, 2011, stated: "Client's brother called again to file a complaint with Program Director (sic) regarding events that transpired the day his brother left ASA. I again reminded him that there was no release in the chart. I encouraged him to place a complaint in writing and mail it in to the Program Director for review, as Program Director (sic) was out of the office today. He adamantly demanded that Program Director (redacted name) return his call." The Program Supervisor confirmed that she documented the calls.
A document with the subject listed as Learning Experience and dated October 21, 2011, was presented to Licensing staff by the PD. The PD confirmed that he produced the document and he said that it provided the facility's account of the fire drills / Learning Experience that took place from October 13 - 14, 2011. The document provided the following information:
1) on October 13, 2011, clients in room # 215 admitted to smoking in their room
2) clients in room # 215 claimed that other clients were smoking inside their room too
3) on October 13, 2011, the PD questioned the community about smoking in their rooms
during the Morning Meeting and 18 out of 32 residents present raised their hand, admitting
that they too had smoked in the facility
5) the document cited the facility's Smoking Policy as well as the Department of Health
licensing and the accrediting agency's credentialing standards as the basis for conducting a
Learning Experience (LE)
6) the LE consisted of a series of fire drills to be conducted throughout the day
7) fire drills were called hourly and reportedly began at 12:00 PM, with the clients reporting
outside
8) at 11:00 PM on October 13, 2011, it was decided to conduct the remaining fire drills
inside due to inclement weather and it was also decided to conduct them every 2 hours
9) at 12:00 AM the PD conducted the fire drill in the women's hall, reiterated the facility's
smoking policy, went over the importance of not smoking inside the facility, and processed
the client's feelings in regard to the LE
10) the LE ended at 8:00 AM the following morning
The PD and Program Supervisor (PS), were interviewed and asked to confirm and / or clarify the details listed above. Both the PD and PS confirmed that numerous clients admitted to smoking in the facility and that as a result staff members were instructed to conduct fire drills every hour, on the hour, for a period of 24 hours. The drills began at 3:00 PM on October 13, 2011 and were run every hour on the hour until 11:00 PM that same night. The PD admitted that there was some rain in the area and that he modified his directive at 11:00 PM because the rain was heavier. He stated that the overnight staff conducted fire drills, inside the facility, every 2 two hours beginning at 12:00 AM on October 14, 2011. Drills were conducted at 12:00, 2:00, 4:00 and 6:00 AM. He he stated that the fire drills ended at 8:00 AM on October 14, 2011.
Based on the interviews with the PD and PS, as well as a review of the Communication Log and the Learning Experience memo, it has been determined that the facility violated their own Policy in regard to client rights. This violation took place in three ways. First and foremost, the Gaudenzia Policy titled Client Rights Punishment states that interference with a daily function of living, such as sleeping, is "strictly prohibited." The statements of the PD and PS, along with the documentation in the Communication Log, and the Learning Experience memo confirm that clients were deprived of their sleep by having to respond to fire drills every two hours (four total) during the overnight. Second, the policy states that "if discipline is necessary...then the discipline is designed as an integral part of the individual's treatment." Therefore, those individuals responsible for smoking in the facility should have been been disciplined on an individual basis. However, the statements of the PD, and documentation in the Communication Log and the Learning Experience memo confirm that all clients responsible for smoking in the facility were subjected to the same Learning Experience and not an individualized disciplinary response. Third, the policy provides for utilizing the Learning Experience as a disciplinary measure for dealing with a client's rule(s) violation. However, the statements of the PD and PS, as well as the documentation in the Communication Log and the Learning Experience memo confirm that all clients, including non-smokers, were subjected to the disciplinary action regardless of their involvement or lack there of, in violating the smoking policy.
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Plan of Correction
Concept 90 will refrain from utilizing any Learning Experience that inteferes with the daily function of living, which includes sleeping. All Learning experiences will occur during the first and second shifts of the facility which are the hours between 8:00 am. and 11:00 pm. The program Supervisor will review all learning Experience contracts by counselors as they are submitted to ensure that no Learning Experience disrupts the daily functioning of the facility and that all Learning experiences address individual client needs for rule violation or behavioral issues Additionally the community as a whole will not held accountable for any member or members of the community violating facility rules or engaged in behavioral issues. All serious behavioral issues or violation of program or facility rules will be reviewed by the Program Director who will ensure that Gaudenzia policy and procedures are not violated when Learning Experiences are deemed appropriate. |