INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15 and 15, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Kindred House 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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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records on May 15 and 16, 2013 the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment.
Findings: Based on a review of eight client records, one record was required to have a notification of termination. The notification of termination was missing in one of one client record reviewed.
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Plan of Correction
The Program Director will do a training on Policy of Client Notification of Termination and Client Right to Appeal Treatment Termination with the entire staff. The Treatment Notice will be given to each client that does not complete the program. A file folder will be kept in the Administrative office of the Notification of Termination so that all staff have access to the form. The Program will monitor this system monthly. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records the facility failed to meet this requirement. The client was not informed of the right to appeal the decision to involuntarily terminate treatment in of record(s).
The findings include:
Eight client records were reviewed on May 15, 2013. Client record #2 required to include on the termination letter the opportunity to have the client request reconsideration of a decision to terminate treatment.
Client #2 was admitted on 10-31-2012 and terminated 12-28-2013.
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Plan of Correction
There will be documentation on the initial/intake DAP note stating that a review have been done with each client entering Kindred House/ Gaudenzia on the Orientation Handbook information with great emphasis on notification of termination and client rights to appeal treatment termination.
Program director will meet with clinical staff on this process. Program director will monitor process and sign off on DAP note. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document a follow up attempt in three of four client records.
The findings include:
Eight client records were reviewed on May 15, 2013. The facility policy states that clinical staff must contact each discharged client by phone one month after discharge unless they have been referred to another agency and their arrival at that agency is confirmed. Follow up to other agencies will be conducted within one week following their discharge date for referrals. A follow-up attempt was required in three of the client records. The facility did not document a follow-up in client record # 2, # 4, and # 5.
Client record #2 was admitted on October 31, 2012 and discharged on December 28, 2012. The client was referred to another program and needed to have a one week discharge documented in the client chart. Documentation of follow-up phone call was due by November 7, 2012. The facility failed to document a follow-up in this client record as of the date of the inspection.
Client #4 was admitted on September 28, 2012 and discharged on April 3, 2013. A follow-up was due one month after the discharge date. The facility failed to have a follow-up completed by May 3, 2013 as required.
Client #5 was admitted on March 11, 2013 and discharged to another program. There was no documentation of a follow-up contact within seven days of the client's discharge.
The director confirmed this finding.
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Plan of Correction
A follow up process is established for discharged clients. The Administrative Coordinator will contact all discharged clients within 7 days then 30 days. This log will be maintained by the Administrative Coordinator and reviewed weekly by the program director. |
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 on the review of client records, the facility failed to document that work done by the client at the project as an integral part of the treatment and rehabilitation plan in eight of eight client records.
The findings include:
Eight records were reviewed on May 15, 2013. Verification of work as an integral part of the treatment and rehabilitation plan was required in eight client records. The facility did not document work as an integral part of the treatment and rehabilitation plan in client records.
Client #1 was admitted on November 16, 2012 and discharged on April 17, 2013. Client record # 1 failed to document the work done by the client at the project as an integral part of the treatment and rehabilitation plan.
Client #2 was admitted on October 31, 2012 and discharged on December 28, 2012. Client record # 2 failed to document the work done by the client at the project as an integral part of the treatment and rehabilitation plan.
Client #3 was admitted on November 28, 2012 and discharged on April 13, 2013. Client record # 3 failed to document the work done by the client at the project as an integral part of the treatment and rehabilitation plan.
Client #4 was admitted on September 28, 2012 and discharged on April 3, 2013. Client record # 4 failed to document the work done by the client at the project as an integral part of the treatment and rehabilitation plan.
Client #5 was admitted on March 11, 2013 and discharged on April 1, 2013. Client record # 5 failed to document the work done by the client at the project as an integral part of the treatment and rehabilitation plan.
Client # 6 was admitted March 12, 2013. Client record # 6 failed to document the work done by the client at the project as an integral part of the treatment and rehabilitation plan.
Client #7 was admitted on February 12, 2013. Client record # 7 failed to document the work done by the client at the project as an integral part of the treatment and rehabilitation plan.
Client #8 was admitted on April 23, 2013. Client record # 8 failed to document the work done by the client at the project as an integral part of the treatment and rehabilitation plan.
This was discussed with and confirmed by the director on May 15, 2013.
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Plan of Correction
Each client treatment plan will reflect a goal on the work therapy they are participating in at that particular time. An addendum will be made to treatment plans if the work therapy changes within the the time frame of the 30day treatment plan.
Program director will sign off on all treatment plans and initial addendums |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the staffing requirements facility summary report and active client list, the facility failed to notify the Department of a change in authorized maximum capacity.
The findings include:
The fire drill record was reviewed on May 15, 2013 for May 2012 through May 2013. The census for the March 19, 2013 fire drill had a count of seventeen woman - sixteen children and one staff member. When checked against the census, the facility had one more client making the total number of women of eighteen. The capacity approval is sixteen.
On December 23, 2012 the fire log had documentation stating the client count was eighteen woman- fourteen children and one staff member. This count was two clients over capacity.
The Facility Director acknowledged the facility's over capacity.
No documentation was presented that there was a discharge occurring on those days.
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Plan of Correction
The program director will assure that the census of 16 is abheld. Weekly administrative meetings are conducted which review discharge(dates) and admissions(dates). Program will monitor census. |