INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from May 22-23, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Fountain Springs, 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an individual training plan in accordance with facility policy in one of four records.
The findings include:
The project policy states: "In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year."
On May 9, 2012, employee # 1's personnel record was reviewed.
The project failed to develop an individual training plan annually in accordance with policy.
Employee # 1 has been the Project Director since 1988.
Per policy, training plans will be conducted in January of each year.
The facility failed to document an individual training plan in January for employee # 1.
The findings were reviewed with the human resources staff.
The Project was previously cited for noncompliance with this standard during the 2011 licensure inspection.
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Plan of Correction
The Training Department will ensure that an individual training plan is developed and documented for all employees within required timeframes. A reminder of the January 31st deadline for completion will be forwarded to all managers during the 1st week of December. In addition, the Training Department will coordinate with the Executive Assistant to ensure that the development of an Individual Training Plan for the Project Director is a specific agenda item during the Project Director's meeting with the Chairman of the Board during the month of December. A current, signed Individual Training Plan is presently in the Project Director's file. Individual Training Plans will be completed for all employees by January 31, 2013 as per policy. A training plan was completed for the corporate employee identified as deficient and dated in May, 2012. The Director of Training and the Director of Human Resources will ensure that all corporate staff complete an annual training plan as per organization policy in January of each year and will monitor ongoing conformance. The Program Director will ensure that a training plan will be completed in January of each year per policy for each employee at the facility and will monitor ongoing conformance. Completion date - 5/9/12. |
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 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. Additionally, the facility failed to maintain the grounds to be free of hazards.
The findings include:
The physical plant inspection was conducted on May 23, 2012.
The grass located in the children's recreational space was not cut at the time of inspection. In some spots the grass and a thistle plant were approximately 24 inches high . The uncut grass and weeds created a potential haven for insects and/or animals.
The findings were confirmed by the Facility Director during the physical plant inspection.
On the following day, during the physical plant inspection of the halfway house located in the same building as Fountain Springs, the Licensing Specialist observed a child from the halfway house run across the facility's access road and then walk around a vehicle parked next to a steep grade.
An inspection of the access road and the steep grade revealed that there was no fence or natural barrier to prevent or protect an unknowing individual from falling down the steep grade.
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Plan of Correction
The building exterior and grounds should be clean, safe, and sanitary at all times for the safety and well-being of residents, employees and visitors... The grass and related weed removal will take place on a regular, contracted basis in order to maintain the outdoor play area and to control pests and/or animals and create a safer, hazard-free environment. The area was mowed on the date of the site visit (5/23/2012) and therafter, has been mowed and trimmed on a two-week contractual schedule. The Program Director will esure bi-weekly grounds maintenance occurs and will ensure contracts are completed annually.
Building exterior and grounds shall have a fence or natural barrier to protect children from all areas determined to be unsafe including steep grades, cliffs, open pits, swimming pools, high voltage boosters or roads... The Gaudenzia Physical Plant Manager will complete a feasibility study by August 15, 2012 regarding the construction of a barrier between the entrance of New Destiny and the parking lot/road to impede the exodus of children from the building. The barrier will tie into the playground. A barrier will be installed consisting of poles, chains and signage in the area of the steep grade. The project will be engaged and completed by August 31, 2012.
The Program Director will maintain communication with the Gaudenzia Physical Plant Manager throughout the work project to ensure completion. Completion date - August 31, 2012 |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based upon the physical plant inspection, the facility failed to ventilate toilet and wash rooms by exhaust fan or window.
The findings include:
The physical plant inspection was conducted on May 23, 2012.
The facility failed to ensure that one out of one staff /visitor bathrooms located on the first floor was ventilated by an exhaust fan or window.
The findings were confirmed by the Facility Director during the exit interview.
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Plan of Correction
The staff/visitor bathroom will be ventilated by an operable exhaust fan to create a noticeable air flow. A contract is in place with a repair man to install the exhaust fan. The Program Director will follow-up as needed to ensure the work is completed. |
705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based upon a review of temperature logs, the facility failed to ensure frozen food was kept at or below 0 Fahrenheit (F).
The findings include:
Temperature logs for facility freezers and refrigerators were reviewed on May 23, 2012. The facility failed to maintain required temperatures for the Left Freezer for 34 of 34 days, from February 28, 2012 to April 1, 2012.
The following times and corresponding temperature ranges were documented on the Left Freezer Temperature Log.
9:00 AM readings - temperatures ranged from + 5 degrees F to + 25 degrees F, on 29 out of 34 days where temperatures were recorded,
2:00 PM readings - temperatures ranged from + 5 to + 30 degrees F, on 24 out of 34 days where temperatures were recorded.
7:00 PM readings - temperatures ranged from + 5 to + 30 degrees F, on 33 out of 34 days where temperatures were recorded.
12:00 AM readings - temperatures ranged from + 3 to + 35 degrees F, on 32 out of 34 days where temperatures were recorded.
The findings were confirmed by the Facility Director following the physical plant inspection.
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Plan of Correction
The Gaudenzia Physical Plant Manager inspected the freezer on July 5, 2012 and subsequently arranged for a refrigeration company to service the freezer so that the frozen food will be consistently stored at or below 0 degrees. Staff on duty will continue to monitor and document freezer temperatures and any problems with the temperature range will be reported to the Program Director who will in turn take action to secure repairs or replacement as needed. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based upon the physical plant inspection the facility failed to maintain protective caps over each electrical outlet.
The findings include:
The physical plant inspection was conducted on May 23, 2012.
Protective caps were missing over electrical outlets in the following locations:
1st Floor
The outlet located in the hallway just outside the staff / visitor's bathroom was missing one of two caps.
Basement - Children's Recreational Room
The outlet on one of the wall's was missing one of two caps.
The findings were confirmed by the Facility Director during the physical plant inspection.
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Plan of Correction
Protective caps will be maintained over each electrical outlet in the building. The two (2) missing electrical outlet covers were replaced on 5/23/2012. The regulation, as well as, the safety reasons for maintaining protective covers over each electrical outlet will be discussed with staff at a mandatory staff meeting on 7/19/2012. Staff will document in writing that they understand and will comply with the regulation. Checking for and replacing missing covers will be added to the daily house run sheet as an additional reminder for staff. The Program Director will conduct random checks to ensure compliance. |
709.24(a)(3) 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:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based upon a review of the project's Policy & Procedure (P&P) Manual, the project failed to adopt consistent policies for individualized treatment and rehabilitation plans. The facility had policies for treatment plans that were contradictory.
The findings include:
The P&P Manual was reviewed from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director(when applicable) within 3-5 client days residential..."
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service, within 3 days of admission (residential)..."
The first policy allows five days to complete the individualized treatment plan while the second policy stipulates it must be completed within three days.
Regarding outpatient facilities, the policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"An individual treatment and rehabilitation plan will be developed with each client after the completion of the client's psychosocial evaluation."
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan ..."The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) ... by the second or third counseling outpatient appointment....."
The policy titled, "Intake Process/Paperwork" Psychosocial Assessment stated:
Upon completion of the psychosocial histories...The assessment shall be submitted promptly ... to the Clinical Supervisor for review and signature ... within 3 individual sessions for outpatient.
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service,... by the third session (outpatient)..."
Each policy relating to the completion of the treatment plans for outpatient contained statements that require the treatment plan be completed in three sessions (regardless of being individual or group) while there are other statements that would indicate that the treatment plan would not be required or allowed to be completed until the third individual session based on the completion of the psychosocial assessment.
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Plan of Correction
The relevant policies in the Gaudenzia Policy & Procedure Manual will be revised by the Quality Improvement Director to ensure consistency and clarity, and to meet all relevant State, Accreditation, and Funding requirements. Changes to these policies will be reviewed and approved by the Board of Directors. These changes will be reviewed with clinicians at each facility's staff meetings by the Program Director and/or Program Supervisor in order to ensure full understanding and ongoing compliance. Program Supervisors will monitor timely completion of Initial Treatment Plans as part of regular clinical chart reviews, and the findings of these reviews will be discussed in regular clinical supervision as well as staff meetings and monthly CQI analysis. These policies will be revised and approved by July 31, 2012. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based upon the review of Administrative documentation, the project failed to have an annual audit of financial activities associated with the project's drug/alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
Licensing Staff conducted an Administrative Review from May 7 - 9, 2012.
Administrative documentation specified that the fiscal year runs from July 1 to June 30. However, the project's annual fiscal audit was late as it was completed February 20, 2012.
The findings were reviewed during the exit interview for the Administrative Review and were not disputed.
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Plan of Correction
At the most recent Audit Committee meeting, the necessity that all future financial audits must be completed within required timeframes was reinforced with the external independent public accountant. These timeframes were acknowledged by the independent public accountant and recorded in the meeting minutes. The Director of Finance and Accounting will maintain oversight throughout the auditing process to ensure completion in a timely manner. The Financial Audit for Fiscal Year 2011 - 2012 will be completed within six (6) months after June 30th close of Gaudenzia's fiscal year (by December 31, 2012) as per Chapter 709.25(a). Completion date - 4/30/12. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to document physical examinations as per facility policy.
The P&P Manual was reviewed from May 1-2, 2012.
The facility policy titled, "Physical Exams - Labs" with the subtitle, "Physical Examination Laboratory Studies" included the following language:
"A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend. Other exceptions are:
1. The client received a complete physical examination no longer than one month prior to
admission; that the program staff can obtain the results in writing; and the nurse on duty is able to ascertain no noticeable medical problems.
2. Any physical examination not performed by the Gaudenzia physician will be reviewed and signed off by him/her as soon as possible following receipt of such documentation."
Nine records requiring documentation of physical examinations were reviewed from May 22-23, 2012. Nine of nine records, specifically # ' s 1, 2, 3, 4, 5, 6, 7, 8, and 9, either contained physical exams that were not completed in accordance with facility policy, or did not contain a physical exam.
Client # 1 was admitted on February 7, 2012, and the physical exam was due by February 14, 2012. The record contained a copy of a physical exam that was completed September 29, 2011, while the client was at another facility. No other documentation of a physical exam was contained in the file.
Client # 2 was admitted on February 13, 2012, and the physical exam was due by February 20, 2012. The record contained a physical exam that was late as it was dated March 15, 2012. In addition, the physical exam was documented by a physician's assistant but never countersigned by a supervising physician.
Client # 3 was admitted on February 22, 2012, and the physical exam was due by February 29, 2012. The record contained a physical exam that was dated February 24, 2012; however, it could not be determined if a qualified physician signed the physical as the signature was not legible and there were no apparent credentials following the signature.
Client # 4 was admitted on April 4, 2012, and the physical exam was due by April 11, 2012. The record contained a physical exam that was late as it was dated April 30, 2012. In addition, it could not be determined if a qualified physician signed the physical as the signature was not legible and there were no apparent credentials following the signature.
Client # 5 was admitted on April 9, 2012, and the physical exam was due by April 16, 2012. The record contained a physical exam that was late as it was dated April 30, 2012.
Client # 6 was admitted on November 18, 2011, and was discharged on April 26, 2012. The record contained a physical exam that was completed on November 2, 2011, while the client was at another facility. However, the physical exam was not reviewed and signed off by the Gaudenzia physician.
Client # 7 was admitted on September 7, 2011, and was discharged on December 2, 2011. The physical exam was due by September 14, 2011; however, as of the date of inspection, the record did not contain documentation of a physical exam.
Client # 8 was admitted on December 7, 2011, and was discharged on April 28, 2012. The physical exam was due by December 14, 2011; however, the physical exam was late as it was dated April 18, 2012.
Client # 9 was admitted on November 11, 2011, and discharged on April 25, 2012. The physical exam was due by November 18, 2011; however, the physical exam was late as it was dated March 30, 2012.
The findings were reviewed with the Clinical Supervisor during the record review.
This is a repeat citation from the 2011 annual inspection.
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Plan of Correction
Clients entering Gaudenzia Fountain Springs shall receive a complete physical examination by a qualified physician within seven (7) days of admission. If an exception is made and the results of a physical examination performed by an outside provider is obtained, this physical examination will have been completed no longer than one (1) month prior to admission and will be reviewed and signed off by the Gaudenzia physician as soon as possible following receipt of such documentation. The Program Director will review, with nursing and clinical staff, the facility policy on physical examinations including documentations needed in an in-service meeting on July 12, 2012. The Program Director will obtain written verification that the policy was reveiwed and understood. The Clinical Supervisor will review new clinical charts during weekly clinical meetings to ensure compliance with the physical exam policy. In regards to the client records reviewed from May 22-23, 2012, a physical examination with a qualified physician for Client #1 has been scheduled for July 31, 2012. The physical examination documentations for Client #2, Client #3, and Client #4, will be reviewed and signed-off on by a qualified physician, including credentials, on July 31, 2012. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to document preliminary treatment plans as per facility policy.
The findings include:
The P&P Manual was reviewed from May 1-2, 2012.
The policy titled, "Clinical Level System - Women with Children" included the following language:
"12. Complete the screening/bio-psycho-social/client list and initial treatment plan by day 3."
A discussion between the Licensing Specialist and the Facility Director confirmed that the" initial treatment plan" is also known as the preliminary treatment plan.
Nine records requiring documentation of initial treatment plans were reviewed from May 22-23, 2012. Two of nine records, specifically #'s 6 and 7, did not contain documentation of initial treatment plans as per facility policy.
Client # 6 was admitted on November 18, 2011, and was discharged on April 26, 2012. The initial treatment plan was due no later than November 21, 2011; however, the record did not contain documentation of an initial treatment plan as of the date of inspection.
Client # 7 was admitted on September 7, 2011, and was discharged on December 2, 2011. The initial treatment plan was due no later than December 5, 2011; however, the record did not contain documentation of an initial treatment plan as of the date of inspection.
The findings were confirmed by the Clinical Supervisor during the record review.
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Plan of Correction
Per the Gaudenzia Policy titled, "Clinical Level System - Women with Children", counselors will complete the screening/bio-psychosocial/client list and initial treatment plan by day 3. The initial treatment plan will be signed by the client, counselor, and supervisor and filed promptly in the client case file. In addition, an Individual Counseling Session will document the completion of the bio-psychosocial and intial treatment plan. The Program Director will review this policy with clinical staff in an in-service meeting on July 12, 2012 and will obtain written verification from counselors that the policy was reviewed and understood. The Program Director and Clinical Supervisor will ensure compliance through monthly CQI case audits and ongoing staff supervision. |
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 upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to develop individual treatment and rehabilitation plans as per facility policy.
The findings include:
The P&P Manual was reviewed from May 1-2, 2012.
The policy titled, "Intake Process/Paperwork" and subtitled, "Treatment Plan" included the following language:
".....The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) within 3-5 client days residential ..."
Nine records requiring documentation of individualized treatment plans were reviewed from May 22-23, 2012. Nine of nine records, specifically #'s 1, 2, 3, 4, 5, 6, 7, 8, and 9, either did not contain an individualized treatment plan, or contained individual treatment plans that were late.
Client # 1 was admitted on February 7, 2012, and the treatment plan was due by February 12, 2012. The record contained a treatment plan that was late as it was completed on February 21, 2012.
Client # 2 was admitted on February 13, 2012, and the treatment plan was due by February 18, 2012. The record contained a treatment plan that was late as it was completed on February 27, 2012.
Client # 3 was admitted on February 22, 2012, and the treatment plan was due by February 27, 2012. The record contained a treatment plan that was late as it was completed on March 8, 2012.
Client # 4 was admitted on April 4, 2012, and the treatment plan was due by April 11, 2012. The record contained a treatment plan that was late as it was completed on April 18, 2012.
Client # 5 was admitted on April 9, 2012, and the treatment plan was due by April 14, 2012. The record contained a treatment plan that was late as it was completed on April 23, 2012.
Client # 6 was admitted on November 18, 2011, and was discharged on April 26, 2012. The treatment plan was due by November 23, 2011; however, it was late as it was completed on December 2, 2011.
Client # 7 was admitted on September 7, 2011, and was discharged on December 2, 2011. The treatment plan was due by September 12, 2011; however, as of the date of inspection, the record did not contain documentation of a treatment plan.
Client # 8 was admitted on December 7, 2011, and was discharged on April 28, 2012. The treatment plan was due by December 12, 2011; however, it was late as it was completed on December 21, 2011.
Client # 9 was admitted on November 11, 2011, and discharged on April 25, 2012. The treatment plan was due by November 16, 2011; however, it was late as it was completed on November 25, 2011.
The findings were confirmed by the Facility Director and Clinical Supervisor during the record review.
This is a repeat citation from the 2011 annual inspection.
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Plan of Correction
Per the Gaudenzia Policy titled, "Intake Process/Paperwork" and subtitled, "Treatment Plan", and individualized treatment plan will be completed, approved, and signed by the counselor, Clinical Supervisor and Program Director (when applicable) within 3-5 client days. The Program Director will review this policy with the clinical staff in an in-service meeting on July 12, 2012 and will obtain written verification that the policy was reviewed and understood. The Program Director and Clinical Supervisor will ensure compliance through monthly CQI case audits and ongoing staff supervision. |
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 upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to update treatment and rehabilitation plans as per facility policy.
The findings include:
The P&P Manual was reviewed from May 1-2, 2012.
The policy titled, "Intake Process/Paperwork" and subtitled, "Treatment Plan Reviews" included the following language:
"The Counselor shall complete a treatment plan review and update 30 days after the date of the original individual treatment plan for residential, (and every 30 days thereafter) ... ...This review shall include an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal has been impacted. Any goal or action step additions, revisions and deletions shall also be reflected. Goal and action step changes shall also be reflected on the treatment plan."
Nine records requiring documentation of treatment plan updates were reviewed from May 22-23, 2012. Three of nine records, specifically #'s 1, 3, and 6, either contained treatment plan updates that did not include assessments of client's progress, or were missing treatment plan updates.
Client # 1 was admitted on February 7, 2012, and was still an active client on the date of inspection. The record contained a treatment plan dated February 21, 2012, and updated treatment plans dated March 8, 2012, April 8, 2012, and May 8, 2012. None of the updates contained an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal had been impacted.
Client # 3 was admitted on February 22, 2012, and was still an active client on the date of inspection. The record contained a treatment plan dated March 8, 2012, and updated treatment plans dated March 22, 2012, April 19, 2012, and May 17, 2012. None of the updates contained an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal had been impacted.
Client # 6 was admitted on November 18, 2011, and was discharged on April 26, 2012. The record contained a treatment plan that was dated December 2, 2011, and updated treatment plans dated January 18, 2012, February 18, 2012, and April 18, 2012. The record was missing an updated treatment plan that was due on or by March 19, 2012.
The findings were confirmed by the Clinical Supervisor during the record review.
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Plan of Correction
Counselors will complete a treatment plan review and update thirty (30) days after the date of the original individual treatment plan and every thirty (30) days thereafter. Counselors will document on each treatment plan update an assessment of the client's progress with the goals identified along with a specific indication how each goal has been impacted. Any goal or acction step addition, revision, or deletion will also be reflected on the treatment plan update. The Program Director will review this policy and procedure with clinical staff in an in-service meeting on July 12, 2012 and will obtain written verification from counselors that the policy was received and understood. The Program Director and Clinical Supervisor will ensure continued compliance through monthly CQI case audits and on-going staff supervision. |
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.
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Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to document that work done by the client at the project is an integral part of his treatment and rehabilitation plan, as per facility policy.
The findings include:
The P&P Manual was reviewed from May 1-2, 2012.
The policy titled, "Therapeutic Chores" and subtitled, "Verification of Client Activities of Daily Living and Chores" included the following language:
"Gaudenzia programs function as a modified therapeutic community, and as such, clients may be assigned specific roles or chore functions to foster their commitment to the communal therapeutic process as an integral part of his/her treatment and rehabilitation plan."
"All clients, unless medically restricted, share responsibility for maintaining the organization and cleanliness of their personal space."
"Counselors/Nurses shall document general and specific job assignments on the Job Function Diary form. The therapeutic purpose or rationale for the assignment shall be documented in the "remarks" section."
Nine client records requiring documentation of work as therapy were reviewed from May 22-23, 2012. Eight of nine records, specifically #'s 1, 2, 3, 4, 5, 6, 8, and 9, did not contain documentation of work as therapy.
Client # 1 was admitted on February 7, 2012, and was still an active client as of the date of inspection. Neither the Individual Treatment Plan nor the Job Function Diary contained documentation that demonstrated the therapeutic nature of work completed by the client.
Client # 2 was admitted on February 13, 2012, and was still an active client as of the date of inspection. Neither the Individual Treatment Plan nor the Job Function Diary contained documentation that demonstrated the therapeutic nature of work completed by the client.
Client # 3 was admitted on February 22, 2012, and was still an active client as of the date of inspection. Neither the Individual Treatment Plan nor the Job Function Diary contained documentation that demonstrated the therapeutic nature of work completed by the client.
Client # 4 was admitted on April 4, 2012, and was still an active client as of the date of the inspection. Neither the Individual Treatment Plan nor the Job Function Diary contained documentation that demonstrated the therapeutic nature of work completed by the client.
Client # 5 was admitted on April 9, 2012, and was still an active client as of the date of the inspection. Neither the Individual Treatment Plan nor the Job Function Diary contained documentation that demonstrated the therapeutic nature of work completed by the client.
Client # 6 was admitted on November 18, 2011 and was discharged on April 26, 2012. Neither the Individual Treatment Plan nor the Job Function Diary contained documentation that demonstrated the therapeutic nature of work completed by the client.
Client # 8 was admitted on December 7, 2011, and was discharged on April 28, 2012. Neither the Individual Treatment Plan nor the Job Function Diary contained documentation that demonstrated the therapeutic nature of work completed by the client.
Client # 9 was admitted on November 11, 2011, and was discharged on April 25, 2011. Neither the Individual Treatment Plan nor the Job Function Diary contained documentation that demonstrated the therapeutic nature of work completed by the client.
The findings were reviewed with the Facility Director during the record review.
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Plan of Correction
All general or specific roles or chore functions assigned to a client at Gaudenzia Fountain Springs will be documented on the Job Function Diary form. The therapeutic purpose or rationale for the assignment will be documented in the "remarks" section on the form. The Job Function Diary form will be maintained in each client case file. The Program Director will review the policy pertaining to "Therapeutic Chores" and necessary documentations with clinical staff in an in-service meeting on July 12, 2012 and will obtain written verification that the policy was reviewed and understood. The Program Director and Clinical Supervisor will ensure compliance through monthly CQI case audits and ongoing supervision. |