INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on January 15-16 & 28-31, 2019, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Gaudenzia Kindred House. 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 investigation.
|
Plan of Correction
|
704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
|
Observations
The facility failed to hire staff in sufficient numbers to provide consistent transportation to medical appointments, court appearances and other necessary off-site activities.
The facility ' Program Handbook for Gaudenzia Kindred House ' states, on page 5 under ' Services Offered ' , that transportation is provided; Staff and client interviews were also conducted on January 15-16, 2020 that confirmed that the facility offers transportation, if necessary, however it was reported that these services are not consistently provided due to staff shortages.
|
Plan of Correction
Effective 2/3/20, the clinical team has started to meet regularly to discuss client community service/support needs and will schedule the appropriate modes of transportation. Documentation of transportation needs will be included in staff meeting notes. The program will continue to provide transportation via program vehicles and RideShare according to the clients' schedule as indicated in the program handbook for both standard appointments and during any emergencies (i.e., COVID 19). There are no amendments or changes to the policy or to any information indicated in the handbook. Management will oversee the process of transportation coordination. If there is a need to adjust/reschedule any client appointments, they will be done in a timely manner. Any transportation interruptions or concerns will be forwarded to the Division Director for review and next steps. The Division Director is working with Human Resources to actively recruit and hire appropriate program staffing including a House Manager/Driver to ensure there is no interruption in transportation services.
|
704.3(d) LICENSURE 24 Hour Coverage
704.3. General requirements for projects.
(d) Inpatient nonhospital facilities except for transitional living facilities and licensed facilities providing halfway house services shall have awake staff coverage 24 hours a day. Halfway houses shall have at least one staff person on the premises at all times.
|
Observations
The facility failed to have staff coverage 24 hours a day.
On 9/14/2019 Facility staff left the facility unattended due to an altercation with a resident. This incident was alluded to during interviews with residents and staff and this incident was documented by the facility and submitted with the incident reports requested by DDAP staff.
|
Plan of Correction
Following the altercation between a staff member and a resident on 9/14/19, the staff member left the facility. Additional staff coverage and assistance with the incident was provided by neighboring Gaudenzia program staff on 9/14/19. The staff member who left the facility was officially terminated.
On 9/16/19 Division Director met with staff regarding appropriate coverage and de-escalation of clients.
Effective 1/21/20, program hired a Clinical Supervisor. The Clinical Supervisor with oversight from the Division Director will ensure that the program is appropriately staffed and documented on the program staffing schedule. The Clinical Supervisor with oversight from the Division Director will ensure clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the program. Every attempt will be made to ensure that more than one person is staffed at the program at all times. In the event, that there is a need for staffing, the Clinical Supervisor and/or the Division Director will make arrangements for coverage (i.e., contacting other staff members or contacting neighboring Gaudenzia program for staff support). All staffing issues will be discussed during weekly clinical team meetings.
|
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.
|
Observations
The facility failed to ensure that the exterior grounds were maintained and free from danger to health and safety.
A physical plant inspection was conducted on January 15, 2020; the following deficiencies were identified:
**the gate at the top of the stairs leading down to child area was not closed/latched.
**the transition molding on the floor between the kitchen and hall was not properly secure creating a trip hazard
**mops stored in the hallway creating an unsanitary environment.
**crack in the cement landing outside the rear exit creating a trip hazard.
**vent from heat pump is still uncovered
**sharp wires on fence surrounding outdoor play area
**rusted picnic tables in the outdoor play area
**car seats improperly stored in the stairwell from the downstairs child care area-unsafe
**light fixtures throughout the facility had broken or missing covers and some had insect carcasses
**broken ceiling tiles in rooms throughout the facility.
**railing on accessibility ramp leading to the Nelson Center building has exposed areas of wood that can produce splinters-needs paint
|
Plan of Correction
Effective 1/17/20, the Program Manager contacted the organization's Maintenance Department to review existing and to submit new facility work orders.
Gate ? Effective 1/17/20, all staff were instructed by the Deputy Director to ensure the gate at the top of the stairs remains latched at all times. On 1/17/20, the Program Director placed a sign at the top of the steps as a reminder to staff to ensure that gate remains latched at all times. Beginning 1/17/20, the House Manager, as part of daily facility rounds, will check to ensure that the gate remains latched at all times.
Molding ? As of 1/24/20, floor molding has been properly secured.
Mop ? As of 1/17/20, mops were removed from the hallway and are now stored in the utility closet.
Cement ? Scheduled to be repaired on 3/21/20.
Vent ? On 1/21/20 external contractor assessed vents and temperatures. Per 3/20/20 update from the organization's Maintenance Department the vent is projected to be repaired by May 1, 2020 which is also contingent on the relaxation of the current government restrictions regarding Covid-19. In the interim the vent will be protected using a mesh covering as of 4/10/20. Fence ? As of 1/22/20 fence was repaired including coverage exposed sharp wires.
Picnic Tables ? On 1/17/20, all rusted picnic tables in the play area were removed. Division Director is working with Maintenance/Operations Department to order new picnic tables
Car Seats ? On 1/17/20, all car seats were removed and are now being stored in the child care storage area and Program Director meet with staff and clients to reiterate the importance of keeping areas clean and free items that would obstruct throughways and exits.
Light Fixtures ? As of 1/22/20 broken and missing cover were replaced and fixtures were cleaned.
Ceiling Tiles ? As of 1/24/20 broken ceiling tiles throughout the facility have been repaired.
Accessibility Ramp ? Per 3/20/20 update from the organization's Maintenance Department the accessibility ramp is projected to be repaired by May 1, 2020 which is also contingent on the relaxation of the current government restrictions regarding Covid-19.
Effective 2/3/20, an assigned House Manager will conduct a monthly facility audit to ensure that there are no environmental issues that would affect the health and safety of the clients. Audits will be conducted using Monthly Division Director Safety and Sanitization Report and will be reported during monthly staff meetings. Any found issues that immediately impact the health and safety of the clients will be immediately reported to the Division Director with the appropriate work orders submitted to the Maintenance Department.
Effective 3/1/20, the facility will have at minimum quarterly onsite facility audits that will be conducted by the organization's CQI Department staff. Findings will be documented using the CQI Manager Quarterly Program Review and Audit Preparation Tool. Findings will be immediately discussed with program management onsite at the conclusion of the audit. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings. The Division Director or her designee will be responsible for ensuring that all work orders are completed in a timely manner.
|
705.2 (3) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(3) Keep exterior exits, stairs and walkways lighted at night.
|
Observations
The facility failed to keep exterior exits, stairs and walkways lighted at night.
An incident report related to a person falling outside the facility, dated 9/29/2019 at 8:20 pm, stated " the lights were not on. It was extremely dark outside. This may have contributed to (the fall) " .
|
Plan of Correction
On 1/24/20 exterior lights were replaced.
Effective 2/3/20, an assigned House Manager will conduct daily facility walkthroughs to ensure that there are no environmental issues that would affect the health and safety of the clients. Any found issues that immediately impact the health and safety of the clients will be immediately reported to the Division Director with the appropriate work orders submitted to the Maintenance Department. Management will oversee the process daily. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
The facility failed to provide privacy for counseling sessions.
*The main lounge area is used for treatment groups and does not have a door which allows counseling sessions to be heard outside of the counseling area.
|
Plan of Correction
On 1/27/20, the Maintenance Department installed a door in the main lounge areas allowing privacy during counseling sessions. Ongoing confidentiality training for staff will be offered to better ensure that confidentiality issues in general do not recur.
|
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.
|
Observations
The facility failed to ensure that bathrooms were maintained in a functional, clean and sanitary manner.
*The electrical outlets in residential bathrooms were not covered with child safety covers
|
Plan of Correction
On 1/17/20, all missing electrical outlet covers were replaced.
Beginning 2/3/20, the House Manager, as part of daily facility rounds, will check to ensure bathrooms are functional, clean and sanitary. Checks should occur a minimum twice daily, following morning and evening client use.
A Community Meeting was held on 1/27/20. Clients were reminded of the importance of electrical outlet covers; specifically following the use of the outlets the cover should be immediately replaced.
Effective 2/3/20, an assigned House Manager will conduct a monthly facility audit to ensure that there are no environmental issues that would affect the health and safety of the clients. Audits will be conducted using Monthly Division Director Safety and Sanitization Report and will be reported during monthly staff meetings. Any found issues that immediately impact the health and safety of the clients will be immediately reported to the Division Director with the appropriate work orders submitted to the Maintenance Department.
Effective 3/1/20, the facility will have at minimum quarterly onsite facility audits that will be conducted by the organization's CQI Department staff. Findings will be documented using the CQI Manager Quarterly Program Review and Audit Preparation Tool. Findings will be immediately discussed with program management onsite at the conclusion of the audit. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings. The Division Director or her designee will be responsible for ensuring that all work orders are completed in a timely manner.
|
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.
|
Observations
The facility failed to ensure that all utensils were properly stored creating a danger to health and safety.
*serving trays were located in an open box on the floor in the kitchen.
|
Plan of Correction
Nutritional Services for the facility are provided by the neighboring Gaudenzia Program. Effective 1/17/20, the House Manager on duty will ensure that all serving trays and appropriate utensils be returned to the neighboring facility following the completion of meals. All utensils that remain onsite will be kept in a secured container.
Beginning 2/3/20, the House Manager, as part of daily facility rounds, will check to ensure that serving trays and utensils are properly stored and/or returned to neighboring Gaudenzia Program. Checks will occur at minimum three times a day; following program meal times. Management will provide oversight to this process.
Effective 3/1/20, the facility will have at minimum quarterly onsite facility audits that will be conducted by the organization's CQI Department staff. Findings will be documented using the CQI Manager Quarterly Program Review and Audit Preparation Tool. Findings will be immediately discussed with program management onsite at the conclusion of the audit. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings. The Division Director is responsible for the overall safety of the program facility.
|
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
|
Observations
The facility failed to maintain each exit in a manner that is unobstructed.
*The side exit to the play area was obstructed by a carpeted mat that was laying folded against the door. Additionally, the front exit from kitchen was obstructed by milk crates and empty boxes that had been discarded and were lying on the concrete pad.
|
Plan of Correction
As of 1/17/20, the carpeted mat that was laying folded against the door near the side exit and the milk crates and empty boxes near the kitchen exit were removed.
Effective 2/3/20, an assigned House Manager will conduct daily facility walk throughs to ensure that there are no environmental issues, including egress obstructions, that would affect the health and safety of the clients. Any found issues that immediately impact the health and safety of the clients will be immediately reported to the Division Director with the appropriate work orders submitted to the Maintenance Department. Management will oversee this process daily.
Effective 3/1/20, the facility will have at minimum quarterly onsite facility audits that will be conducted by the organization's CQI Department staff. Findings will be documented using the CQI Manager Quarterly Program Review and Audit Preparation Tool. Findings will be immediately discussed with program management onsite at the conclusion of the audit. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings. The Division Director is responsible for the overall safety of the program facility.
|
709.24 (a) LICENSURE Treatment/rehabilitation Management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
|
Observations
The facility failed to properly supervise children while the parents were attending their evening group.
Staff and client interviews were conducted on January 15-16, 2020 that confirmed that the facility staff is responsible for supervising resident ' s children during the groups that occur during the evening hours. On December 1, 2019 at approximately 9 pm two children were left unsupervised and an incident ensued that required reporting to the Department.
|
Plan of Correction
On 12/2/19, Management met with staff and residents to reiterate the procedures for supervision of children. Residents are responsible for the supervision of their own children and staff provide monitoring of residents and children.
Immediately following the incident, program staff increased facility round checks to ensure that children are properly being supervised by their parent(clients). Evidence of any unsupervised children will be addressed immediately with the client. Any found issues that immediately impact the health and safety of the children will be immediately reported to the Clinical Supervisor and Division Director accompanied by an incident report, if warranted.
|
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
|
Observations
The facility failed to ensure that medications were documented in the client Medication Administration Record (MAR).
**According to facility policy each client receiving medication, and the staff present, should each initial the MAR once a medication has been administered or dispensed; additionally, when a medication is not dispensed there should be a notation in the MAR as to the reason it was not given to the patient.
Client #2 was admitted on 8/28/19 and was an active client at the time of the investigation.
Celexa 20 mg
Not initialed by client on January 1, 2, 7, 8, 9, 2020
Not given, no documentation of reason on January 4, 10-12, 2020
Nicotine patch daily
Not initialed by client on January 1-3, 5-6, 9-12, 2020
Not given, no documentation of reason on January 10-12, 2020
Client #4 was admitted on 8/16/19 and was an active client at the time of the investigation.
Wellbutrin XL 150 mg daily
Not given, no documentation of reason on January 3-4, 2020
Wellbutrin XL 300 mg daily
Not given, no documentation of reason on January 10, 2020
Client #5 was admitted on 9/5/19 and was an active client at the time of the investigation.
Seroquel 50 mg 9 am
Not given, no documentation of reason on January -12, 14, 15, 2020
Ser- 50 mg 1 pm
Not given, no documentation of reason on January -12-15, 2020
Seroquel 200 mg bedtime
Not given, no documentation of reason on January -12, 2020
Client #6 was admitted on 12/18/19 and was an active client at the time of the investigation.
Lidocaine patch-daily
Not initialed by client on January 1, 2, 7, 8, 9, 2020
Not given, no documentation of reason on January 13-16, 2020
Seroquel-daily 8am and 8 pm
Not initialed by client on January 16, 2020
Not given, no documentation of reason on January 4, 12-13, 2020
Client #11 was admitted on 9/6/19 and was the child of an active client at the time of the investigation.
Vyvanse 40 mg to be taken 1 capsule by mouth daily for 30 days according to " Individual resident ' s controlled substance , Record " form:
October 23-25, 2019 there is no documentation of the name, time, amount on hand, amount received, or amount given filled in or as to who passed the medication.
October 27-31, 2019 - no information documented
November 1-4, 2019 -no information documented, however the pill count goes down from 17 to 14.
Client #12 was admitted on 9/6/19 and was the child of an active client at the time of the investigation.
Trazadone 100 mg by mouth 1x/day
November 8-9, 2019 no record of med given, no documentation of reason
Celexa 20 mg by mouth daily
October 13, 15 & 19, 2019 no record of med given, no documentation of reason.
Client #13 was admitted on 8/719 and was the child of an active client at the time of the investigation.
Remeron 15 mg every night beginning October 23, 2019
October 23-28, 2019 no record of med given, no documentation of reason.
Client #14 was admitted on 6/27/19 and was the child of an active client at the time of the investigation.
Wellbutrin 150 mg daily
October 10, 14, 15, 17-21, 24-26, 2019 no record of med given, no documentation of reason.
October 12, 13, 15, 20, 2019 no record of med given, no documentation of reason.
Client #15 was admitted on 6/26/19 and was the child of an active client at the time of the investigation.
Buspirone 10 mg 2x/daily
Am med-November 2, 18, 26-27, 2019 no record of med given, no documentation of reason.
Client #16 was admitted on 9/4/19 and was the child of an active client at the time of the investigation.
Remeron 30 mg 1x/daily
October 6, 9-10, 12-15, 18-19, 26-31, 2019 no record of med given, no documentation of reason.
|
Plan of Correction
Medical services are now being provided by a registered nurse who was hired on 3/2/20 with medical support also being provided by the Nurse Manager and the Eastern Region Medical Division Director. All necessary medication information will be recorded on the client's MAR along with any other relevant documents and that any lapses in medication administration will also be appropriately documented per facility policy. On 1/21/20 registered nurse facilitated a medication monitoring seminar with the program clients. Effective 3/1/20, the organization's Nurse Manager will conduct a minimum quarterly medical services onsite audits at the facility. Findings will be documented using the CQI Department Medical Services Inspection Form. Any found issues that immediately impact the health and safety of the children will be immediately reported to the Division Director and/or the Eastern Region Medical Division Director; accompanied by an incident report if necessary. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings. The Division Director and Eastern Region Medical Division Director will be responsible for ensuring that all medical services are provided according to regulatory requirements. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
|
Observations
The facility failed to ensure that outdated drugs were removed.
*A physical plant inspection was conducted on January 15, 2019 during which the medication area was inspected; medications from two clients, discharged in September 2019, were found in the medication cart and were not discarded as per facility policy.
This was confirmed with facility staff.
|
Plan of Correction
Medical services are now being provided by a registered nurse, who was hired on 3/2/20 with medical support also being provided by the Nurse Manager and the Eastern Region Medical Division Director.
Within the next 30 days, beginning 3/16/20, the Registered nurse will conduct an audit of the program's medication room to ensure that only active medications are onsite for program clients/children. Any medications found belonging to previous clients will be disposed of according to organizational policy.
Following effective 3/1/20, the organization's Nurse Manager will conduct at minimum quarterly medical services onsite audits at the facility. Findings will be documented using the CQI Department Medical Services Inspection Form. Any found issues that immediately impact the health and safety of the children will be immediately reported to the Division Director and/or the Eastern Region Medical Division Director; accompanied by an incident report if necessary. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings. The Division Director or Eastern Region Medical Division Director will be responsible for ensuring that all medical services are provided according to regulatory requirements.
|
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
|
Observations
On February 13, 2020 the facility unusual incidents were submitted by the facility and reviewed.
**Upon review of incidents submitted by the facility on January 21,2020, for the period from June through December, 2019, the facility failed to report the following incident to The Department within three business days:
8/13/2019-
911 was called because of a child injury-child seen at hospital
9/6/2019-
Ambulance called for transporting child to ER
9/14/2019-(2 incidents)
-Police called due to alleged assault; police being on-site mentioned in the report.
-Ambulance called for transport of child to the ER
9/28/19-
911 was called and EMT transported resident to hospital
10/1/19-
EMT was called and EMT transported resident to hospital
11/7/19-
EMT was called and EMT transported resident to hospital
12/4/19-
EMT was called and EMT transported resident to hospital
|
Plan of Correction
Effective 2/3/20 program incident management procedures were posted in the staff office. Effective 1/21/20, the program hired a Clinical Supervisor. Effective 2/3/20, as part of the weekly clinical team meetings all incidents will be reviewed and discussed, including timely submission of reports. The Clinical Supervisor will ensure that all reportable incidents will be submitted to DDAP within the regulatory timeframe.
All program staff are required to take the Incident Management Refresher Course using the organization's online training system beginning 3/16/20. All training must be completed within 30 days. The Clinical Supervisor will ensure that all staff training will be completed as indicated and will ensure that all incidents reports are completed and submitted according to regulatory guidelines. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings.
|
709.51(a)(1) LICENSURE Criteria for Admission
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
|
Observations
The facility failed to adhere to the policy for the maximum age for admitting children to the program.
On page 5 of the "Program Handbook for Gaudenzia Kindred House" the section entitled 'Special Services' lists the age for admitting children "from birth to age 10". It was discovered that a child was admitted who was 11 years old at the time of admission, and who turned age 12 within a short time after admittance, was involved in an incident with a younger child. Ona n incudent report dated 12/1/2019 this child's age is listed as 12 years old.
|
Plan of Correction
On 12/2/20, the over-age child was removed from the program (i.e., went to another family member's home).
Effective 1/21/20, the program hired a Clinical Supervisor. Effective immediately, all program admissions will be reviewed by the Clinical Supervisor to ensure that program criteria for admission is being met. No children over the age of 10 years of age will be admitted to the facility. Admission and/or intake procedures will be documented in the client's electronic health record. All new admissions will be reviewed and discussed during the weekly clinical team meetings. Any admission criteria concerns will be addressed by the Clinical Supervisor and reported to the Division Director for guidance and/or support as necessary.
Effective 3/1/20, the facility will have at minimum quarterly onsite facility audits that will be conducted by the organization's CQI Department staff, which includes random quantitative and qualitative clinical documentation audits. Findings will be documented using the Clinical Compliance Residential Audit Tool. Clinical documentation findings will be reported to the Clinical Supervisor and/or Division Director. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings. The Division Director is responsible for ensuring the overall compliance with clinical documentation requirements.
|
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
The facility failed to document a physical examination in one of five records reviewed.
Client #3 was admitted on 12/9/19 and was an active client at the time of the investigation. No physical examination was documented at the time of the record review.
|
Plan of Correction
Program nurse was terminated on 1/30/20. Medical services are now being provided by a registered nurse, who was hired on 3/2/20 with medical support also being provided by the Nurse Manager and the Eastern Region Medical Division Director.
Effective 1/21/20, the program hired a Clinical Supervisor. Effective immediately, all program admissions, including intake requirements, will be reviewed by the Clinical Supervisor. All clients will have a physical examination within three days following admission to the program completed by the registered nurse or other qualified medical personnel. All new admissions will be reviewed and discussed during the weekly clinical team meetings. Client #3 had a physical examination on 12/27/19.
Effective 3/1/20, the facility will have at minimum quarterly onsite facility audits that will be conducted by the organization's CQI Department staff, which includes random quantitative and qualitative clinical documentation audits. Findings will be documented using the Clinical Compliance Residential Audit Tool. Clinical documentation findings will be reported to the Clinical Supervisor and/or Division Director. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings. The Division Director is responsible for ensuring the overall compliance with clinical documentation requirements.
|
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.
|
Observations
The facility failed to update the treatment plans every 30 days in 3 of 5 records reviewed.
Client #2 was admitted on 8/28/19 and was an active client at the time of the investigation. The comprehensive treatment plan dated 8/30/19; a treatment plan update was due by 9/30/19 but was not documented until 10/5/19; another update was due by 11/5/19 but was not documented until 11/7/19 and another update was due by 12/7/19 but was not documented until 12/28/19.
Client #4 was admitted on 8/16/19 and was an active client at the time of the investigation. The comprehensive treatment plan dated 8/23/19; a treatment plan update was due by 9/23/19 but was not documented until 9/26/19; another update was due by 10/26/19 but was not documented until 11/4/19.
Client #5 was admitted on 9/5/19 and was an active client at the time of the investigation. A treatment plan update was documented 10/9/19; a treatment plan update was due by 11/9/19 but was not documented until 11/13/19; another update was due by 12/13/19 but was not documented until 12/28/19.
|
Plan of Correction
Effective 1/21/20, the program hired a Clinical Supervisor. Effective 2/3/20, as part of weekly clinical supervisions all client treatment plans are reviewed and discussed, including upcoming treatment plan reviews. Clinical Supervisor is responsible for ensuring that treatment plans will be updated at least every 30 days. The Clinical Supervisor will review all active client treatment plans to ensure and plans are being revised according to regulatory guidelines. Any noncompliance treatment plans will be reviewed and appropriately revised by the Clinical Supervisor.
The Division Director is responsible for ensuring the overall compliance with clinical documentation requirements.
Effective 3/1/20, the facility will have at minimum quarterly onsite facility audits that will be conducted by the organization's CQI Department staff, which includes random quantitative and qualitative clinical documentation audits. Findings will be documented using the Clinical Compliance Residential Audit Tool. Clinical documentation findings will be reported to the Clinical Supervisor and/or Division Director. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings.
|
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.
|
Observations
The facility failed to provide counseling sessions according to the treatment plan in 3 of 5 records reviewed.
Client #1 was admitted on 11/25/19 and was an active client at the time of the investigation. The comprehensive treatment plan, dated 12/7/19, and a treatment plan update, dated 1/3/2020 stipulate 1 individual session and 3 group sessions per week.
Week of 12/15-12/21/19- missing two groups
Week of 12/29/19-1/4/2020- no individual session documented
Week of 1/12-1/18/2020- no individual session documented
Week of 1/19-1/25/2020- no individual session documented, missing 1 group session
Client #4 was admitted on 8/16/19 and was an active client at the time of the investigation. The comprehensive treatment plan, dated 8/23/19, and a treatment plan updates, dated 9/29, 11/4 and 12/19, stipulate 1 individual session and 3 group sessions per week.
Week of 11/24/19-11/30/19- no individual session documented; missing 1 group
Week of 12/1/19-12/7/19- no individual session documented; missing 2 group
Week of 12/8/19-12/14/19- no individual session documented; missing 1 group
Week of 12/15/19-12/21/19- no individual session documented; missing 2 group
Week of 12/22/19-12/28/19- missing 1 group
Week of 12/29/19-1/4/2020- missing 1 group
Week of 1/5-1/11/2020- missing 2 group session
Week of 1/12-1/18/2020- no individual session documented
Week of 1/19-1/25/2020- no individual session documented; missing 3 group
Client #5 was admitted on 9/5/19 and was an active client at the time of the investigation. The comprehensive treatment plan, dated 9/10/19, and a treatment plan updates, dated 10/9, 11/13 and 12/28, stipulate 1 individual session and 3 group sessions per week.
Week of 11/24/19-11/30/19- no individual session documented; missing 3 group
Week of 12/1/19-12/7/19- no individual session documented; missing 1 group
Week of 12/8/19-12/14/19- no individual session documented; missing 1 group
Week of 12/15/19-12/21/19- no individual session documented; missing 3 group
Week of 12/22/19-12/28/19- missing 3 group
Week of 12/29/19-1/4/2020- - no individual session documented; missing 1 group
Week of 1/5-1/11/2020- - no individual session documented; missing 2 group
Week of 1/12-1/18/2020- no individual session documented
|
Plan of Correction
Effective 1/21/20, the program hired a Clinical Supervisor. Effective 2/3/20, as part of weekly clinical supervisions all client counseling sessions are reviewed and discussed. Clinical Supervisor is responsible for ensuring that counseling sessions are occurring according to the client's treatment plan. The Division Director is responsible for ensuring the overall compliance with clinical documentation requirements.
Effective 3/1/20, the facility will have at minimum quarterly onsite facility audits that will be conducted by the organization's CQI Department staff, which includes random quantitative and qualitative clinical documentation audits. Findings will be documented using the Clinical Compliance Residential Audit Tool. Clinical documentation findings will be reported to the Clinical Supervisor and/or Division Director. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings.
|
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
|
Observations
The facility failed to include verification that work performed by the client is an integral part of the treatment and rehabilitation plans in 5 of 5 records reviewed.
Client #1 was admitted on 11/25/19 and was an active client at the time of the investigation.
Client #2 was admitted on 8/28/19 and was an active client at the time of the investigation.
Client #3 was admitted on 12/9/19 and was an active client at the time of the investigation.
Client #4 was admitted on 8/16/19 and was an active client at the time of the investigation.
Client #5 was admitted on 9/5/19 and was an active client at the time of the investigation.
|
Plan of Correction
Effective 1/21/20, the program hired a Clinical Supervisor. Effective 2/3/20, as part of weekly clinical supervisions all client treatment plans are reviewed and discussed, including the inclusion of work therapy. The Clinical Supervisor will review all active client treatment plans to ensure and plans are being revised according to regulatory guidelines. Any noncompliance treatment plans will be reviewed and appropriately revised by the Clinical Supervisor.
The Division Director is responsible for ensuring the overall compliance with clinical documentation requirements.
Effective 3/1/20, the facility will have at minimum quarterly onsite facility audits that will be conducted by the organization's CQI Department staff, which includes random quantitative and qualitative clinical documentation audits. Findings will be documented using the Clinical Compliance Residential Audit Tool. Clinical documentation findings will be reported to the Clinical Supervisor and/or Division Director. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings.
|
709.54(a)(4) LICENSURE Safety/sanitation
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(4) Safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area.
|
Observations
The facility failed to ensure that all food items were properly stored creating a danger to health and safety.
*food items in the refrigerator were not properly labeled with the date.
*food items in the refrigerator were not covered.
|
Plan of Correction
On 1/17/20, all food items that were improperly labeled with dates and uncovered were discarded. Effective immediately, House Managers conduct daily kitchen and refrigerator checks to ensure compliance with all health and safety regulatory requirements including the appropriate storage and labeling of food. Any food items found to be stored and/or labeled improperly will be immediately discarded. Management will provide oversight to this process.
Effective 3/1/20, the facility will have at minimum quarterly onsite facility audits that will be conducted by the organization's CQI Department staff. Findings will be documented using the CQI Manager Quarterly Program Review and Audit Preparation Tool. Findings will be immediately discussed with program management onsite at the conclusion of the audit. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings. The Division Director or her designee will be responsible for ensuring that all work orders are completed in a timely manner.
|
709.17(a)(1) 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:
(1) Failure to comply with a directive issued by the Department.
|
Observations
The facility failed to comply with a directive issued by the department.
On January 17, 2020 the facility was asked to remove all residents prior to and during all planned facility cleaning and renovation due to the potential presence of toxic fumes. On January 28, 2020 DDAP staff returned to the facility to find that renovations were being conducted while the residents were still on-site and the facility was permeated with fumes. A review of the hazardous materials labels confirmed that at least one of the products being used in the facility was unsuitable for pregnant women to be exposed to.
Due to the severity of the fumes, DDAP staff directed the facility to relocate the residents to another building to decrease the potential safety risks to residents, and children housed at the facility.
|
Plan of Correction
Because the directives of 1/17/20 and 1/28/20 to relocate the clients during program cleaning and renovations were not followed Program Managers were terminated.
Effective 1/29/20, all facility cleanings and renovations will be scheduled and confirmed with the Division Director/upper management and the organization's Maintenance Department. This communication will allow for the appropriate planning for client activities for the day and/or length of renovations
|