INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on observations on June 10, 2011 the facility failed to ensure that the water temperature did not exceed 120 F in the sole bathroom in the facility.
The findings include:
The physical plant inspection was conducted on June 10, 2011 at 2:30pm. During the tour temperatures were taken in shared staff/client bathroom, the hot water measured over 120 degrees.
The hot water temperature was 137 F in the bathroom sink.
A clinician and the facility director confirmed the temperatures.
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Plan of Correction
On June 13, 2011 the property manager was contacted regarding the excessive hot water situation. On June 17, 2011 the property maintenance manager assessed the hot water system and it was determined that the system needed to be updated/replaced. The landlord was notified of the need for the update. An anticipated replacement/repair date is September 20, 2011.
A sign has been posted by staff on duty warning client of the potential hot water.
Follow up calls will be made monthly to the landlord to ensure compliancy.
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709.93(a)(11) LICENSURE Client records
709.93. 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's policy and procedure manual, and a conversation with a counselor, the facility failed to document follow-ups in accordance with the facility's policies and procedures in one of three client records.
The findings include:
Six client records were reviewed on June 10, 2011. Documentation of a follow-up was required in three of those records. The facility failed to document follow-up information in accordance with the facility's policies and procedures in client record # 4.
The facility's policy titled, FOLLOW UP INFORMATION states:
In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are not referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder.
Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder.
Client # 4 was admitted on December 30, 2010 and discharged on April 19, 2011. The client was not referred to an outside source. A follow up attempt should have been made to the client by May 19, 2011, there was no documentation of a follow-up at the time of inspection.
The lack of follow-up documentation was confirmed by the counselor.
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Plan of Correction
The facility's policy and procedure manual was reviewed May 9 ? 12, 2011 at Gaudenzia's Corporate Office. According to corporate guidelines, no individual facility may change any policy or form to suit facility needs. The CQI Director revised the follow up policy on June 15, 2011. All Gaudenzia policies are now updated on the Gaudenzia website forms page. All updates will be discussed monthly in the CQI meeting and clarified by the CQI Director.
On June 20, 2011 a meeting was held with the Division Director and Administrative Coordinator to review the policy on follow up procedures Gaudenzia developed. A memo was distributed to all staff on June 29, 2011 explaining the procedure to be used effective immediately.
The new policy states; the first follow up will be completed no later than 7 days of discharge on all referred clients who have given written consent. Follow ups will be completed on all other discharged clients within 30 days regardless of discharge status.
Both follow ups will be documented on the same form.
Forms will be forwarded monthly to the Administrative Coordinator to be filed in the proper follow up log/binder. All forms will be reviewed monthly during the administrative meeting with the Clinical Supervisor, Administrative Coordinator and the Division Director. Follow up will be discussed during both clinical meetings and supervisory sessions. Follow up will be completed by designated clinical staff.
To ensure compliancy 100% of the facility closed charts will be monitored through the administrative utilization process by the Administrative staff. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a written client follow-up policy that accurately reflects their follow-up process.
The findings include:
From May 9, 2011 through May 11, 2011, the facility's policy and procedure manual was reviewed. The facility had two conflicting procedures regarding attempts to follow up on clients.
The facility's policy titled: "Follow Up Information," states:
" All clients are followed up after discharge.
Follow up information shall be conducted for each client after discharge from the program, unless there is specific client refusal for follow up. Each program will maintain a follow up policy outlining the specific steps taken. The follow up log binder will house the documentation of each follow up attempt.
Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow up.
In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder.
In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note [remember to state the reason for the refusal in the note and on the form].
Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder.
.Follow up information shall include the client's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals. "
The facility ' s policy and procedure manual contained a second written policy titled: " FOLLOW UP INFORMATION. " This second policy states: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor's designee, to follow-up the discharged client's progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
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Plan of Correction
The facility's policy and procedure manual was reviewed May 9 ? 12, 2011 at Gaudenzia's Corporate Office. According to corporate guidelines, no individual facility may change any policy or form to suit facility needs. This citation regarding conflicting policies was reported to the Central Region Director and the CQI Director by the facility Division Director. The CQI Director revised the follow up policy on June 15, 2011. All Gaudenzia policies are now updated on the Gaudenzia website forms page. All updates will be discussed monthly in the CQI meeting and clarified by the CQI Director.
On June 20, 2011 a meeting was held with the Division Director and Administrative Coordinator to review the policy on follow up procedures Gaudenzia developed. A memo was distributed to all staff on June 29, 2011 explaining the procedure to be used effective immediately.
The new policy states; the first follow up will be completed no later than 7 days of discharge on all referred clients who have given written consent. Follow ups will be completed on all other discharged clients within 30 days regardless of discharge status.
Both follow ups will be documented on the same form.
Forms will be forwarded monthly to the Administrative Coordinator to be filed in the proper follow up log/binder. All forms will be reviewed monthly during the administrative meeting with the Clinical Supervisor, Administrative Coordinator and the Division Director. Follow up will be discussed during both clinical meetings and supervisory sessions. Follow up will be completed by designated clinical staff.
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