INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19-20, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc., West Chester was found to be not 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 conducted on December 19, 2017, the facility failed to keep the facility in good repair at all times.
A section of the wall behind the door in bathroom #2, on the male floor, had been broken tile leaving several sharp tile edges exposed and creating a safety hazard.
Additionally, the plaster on the ceiling, in the women's bathroom #1, above the shower stalls were water damaged and cracked; the vent cover in room #9 on the male floor was not properly secured; the vent cover in room #7 on the male floor was missing; and the ADA strobe for the fire alarm in room #5, on the male floor, was not secured to the wall.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
On 1/4/2018, Director contacted the maintenance department to ensure that the showers in bathroom #1 in the women's dorm have been re-plastered. On 1/4/2018, Director ensure that the maintenance department installed a new vent covers to room number 7 & 9 in the men's dorm. On 1/4/2018, Director ensure that the ADA fire alarm located in room #5 in the men's dorm was secured. On 1/4/2018, Director ensured that the broken tiles in the men's bathroom were repaired. Maintenance department removed all broken tiles and replaced them with new tiles. Director and Maintenance Superisor tour the facility monthly to address any repairs that are needed within the facility. Director generated a maintenance grid to keep track of any issues that have been identified during the tour and to keep track of the date that the issue was resolved. |
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 a physical plant inspection conducted on December 19, 2017, the facility failed to maintain each bathroom in a clean functional and sanitary manner at all times.
A toilet in bathroom #2 on the first-floor women's hall was not properly secured to the floor. Additionally, a sink in this bathroom was not draining and was approximately half-full with water.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
As of 12/19/2017, Director ensure that the maintenance department secured the toilet in bathroom #2 in the women's dorm. On 12/19/2017, Director ensured that the maintenance department repaired the sink in the women's dorm to allow the water to easily flow. Director and Maintenance Supervisor tour the facility monthly to address any repairs that are needed within the facility. Director generated a maintenance grid to keep track of any issues that have been identified during the tour and to keep track of the date that the issue was resolved. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Seven inpatient client records were reviewed on December 20, 2017. The facility failed to document whether a copy of a consent to release information was offered to the client in two of seven client records reviewed.
Client # 1 was admitted on 10/16/17 and was an active client at the time of the licensing inspection. The consent to a funding source was dated 10/16/17.
Client # 4 was admitted on 9/25/17 and was discharged on 11/14/17. The consent to a funding source was dated 9/25/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 12/20/2017, Clinical Supervisors will review charts weekly to ensure all documents are in the chart and are completed in its entirety. Director will review charts randomly to ensure the same. In-service training has been scheduled by the Director for Thursday, January 25, 2018 at 3:00pm for all staff. All consents to the funding source are signed by the client during the intake process at the time of admission. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Facility policy and procedure manual was reviewed on December 19, 2017. The facility's policy failed to include the following elements with regard to client rights:
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/20/2017, Director submitted the Client Rights form to the Eastern Divisional Drug & Alcohol Director so that it can be modified and included in the clinical chart. The revised form should be implemented and given to all clients no later than 1/31/2018. |
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
Seven inpatient client records were reviewed on December 20, 2017. The facility failed to provide counseling according to the treatment plan in three of seven client records reviewed.
Client # 1 was admitted on 10/16/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan, dated 10/26/17 and a treatment plan update, dated 11/26/17 indicated that group counseling would be provided 3 times per week, however group sessions were documented on 10/23, 11/14, 11/17, 11/20, 12/5, 12/6, 12/12, 12/13 and 12/18/17.
Client # 5 was admitted on 8/2/17 and was discharged on 10/30/17. All documented treatment plans indicated that group counseling would be provided 3 times per week, however group sessions were documented on 8/14, 8/28, 9/7, 9/14, 9/15, 9/22, 9/26, 9/29 and 9/30/17.
Client # 7 was admitted on 2/29/17 and was discharged on 6/13/17. All documented treatment plans indicated that group counseling would be provided 3 times per week, however group sessions were documented on 4/3, 4/4, 4/17, 4/19, 4/21, 4/24-25, 4/27-28, 5/1-5, 5/10, 5/12, 5/15-16, 5/19, 5/22, 5/25 and 6/6/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
As of 12/20/2017, Director or designee will review all new admission charts within 14 days of admission to ensure that all documentation is completed in a timely manner. Charts will be reviewed every 30 days thereafter. Effective 12/26/2017, all group notes are submitted to the Clinical Supervisor to ensure that clients are attending the required groups and the group note is placed in the client's chart. |
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
Seven inpatient client records were reviewed on December 20, 2017. The facility failed to document a complete client record in two of seven client records reviewed.
Client # 4 was admitted on 9/25/17 and was discharged on 11/14/17. The record of service for November 2017 was missing.
Client # 5 was admitted on 8/2/17 and was discharged on 10/30/17. The discharge summary was dated 10/30/17, however the record of service indicated a group session on 11/16/17 for which there was no corresponding progress note, and a progress note for a group session on 11/6/17 was documented in the client record.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
As of 12/20/2017, Director and designee will review all charts every 30 days to ensure that all documentation is completed in the chart in a timely manner. On 12/26/2017, Director and Clinical Supervisor held a clinical training for all clinical staff. In this training Director and Clinical Supervisor reviewed all clinical documentation that go in the chart and how to accurately complete each form. Record of service was one of the forms that was reviewed in detailed. |