INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8-10, 2019, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc.-- Crossroads 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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705.4 (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.
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Observations
Based on the physical plant inspection conducted on October 10, 2019, the facility failed to ensure that counseling sessions could not be seen outside of counseling offices.
There are two counseling offices in the facility that have windows in the doors of the counseling offices that allow someone standing outside of the office to see counseling inside of the office.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Division Director will submit a work order to the Operations Manager to have the identified counselor office door windows covered to ensure privacy by 10/23/2019.
Operations Manager will have these windows covered to ensure privacy by 11/1/2019.
Program Director will complete monthly rounds to ensure privacy is continued to be provided and if any issues with privacy are noted the Program Director will submit work orders as needed. The monthly facility rounds will begin by November 15th, 2019.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection conducted on October 10, 2019, the facility failed to maintain each bathroom in a functional manner at all times.
The left faucet handle for the first shower in the second floor men's shower room was not working, and the shower head was wobbly.
The shower on the right in the second floor women's bathroom had a floor tile in front of it with a small section broken off from the floor tile.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Division Director will submit work orders to the Operations Manager to have the faucet handle in the first shower in the second floor men's shower and shower handle fixed or replaced and will also include replacing the broken tile in the women's bathroom by 10/23/2019.
Operations Manager will ensure the faucet handle, shower head and floor tile are repaired or replaced by 11/1/2019.
Program Director and Operations Manager will complete monthly facility rounds to ensure all physical plant items are operable. These monthly rounds will begin by November 15th, 2019. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the physical plant inspection conducted on October 10, 2019, the facility failed to ensure that all of its fire extinguisher had documentation that they were annually inspected.
The fire extinguisher next to the double doors in the male co-occuring area did not have a tag with the documented inspection date.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Operations Manager will replace the missing fire extinguisher tag by 11/1/2019.
Operations manager will complete monthly facility rounds to ensure all fire extinguishers are being inspected monthly and that all extinguishers have tags. These rounds will begin by November 15th, 2019. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records conducted during the on-site inspection, the facility failed to acquire documentation from clients that it informed the clients of all of their rights in two of five detoxification client records reviewed.
The clients' rights forms that were signed by clients #1 and #2 do not inform the clients of the following: That the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the clients if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Agency CQI Director will adjust the client rights form to include acknowledgement from the client that they have been informed about the fact that the facility or clinical director may temporarily remove information from the file that may be detrimental if presented to the client prior to the client reviewing their record. This will be updated by 11/22/2019.
The updated client rights form will be reviewed with all clinical staff by the Program Director by 11/22/2019.
Program Director will complete monthly chart audits starting by December 15th 2019 to ensure client rights forms are being completed and reviewed with clients as well as signed and dated about their specific rights.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records conducted during the on-site inspection, the facility failed to acquire documentation from clients that it informed the clients of all of their rights in two of five detoxification client records reviewed.
The clients' rights forms that were signed by clients #1 and #2 do not inform the clients of the following:: Clients have the right to appeal a decision limiting access to their records to the director.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Agency CQI Director will update the client rights form to include acknowledgement of the client's right to appeal a decision limiting access to their records to the director. This update will be completed by 11/22/2019.
The Program Director will review the updated client rights form with clinical staff by 11/22/2019.
The Program Director will complete monthly chart audits beginning by December 15th, 2019 to ensure that the updated client rights are being reviewed and documented appropriately including client acknowledgement of their right to appeal a decision limiting access to their records.
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records conducted during the on-site inspection, the facility failed to acquire documentation from clients that it informed the clients of all of their rights in two of five detoxification client records reviewed.
The clients' rights forms that were signed by clients #1 and #2 do not inform the clients of the following:: Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The agency CQI Director will update the client rights form to include client acknowledgement of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. This update will be completed on the client rights form by 11/22/2019.
Program Director/Nurse Manager will review the updated client rights form with all clinical staff by 11/22/2019.
Program Director/Nurse Manager will ensure client rights forms are being reviewed and completed appropriately through completing monthly chart audits starting by December 15th, 2019.
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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 on a review of client records conducted during the on-site inspection, the facility failed to update treatment plans at least once every 15 days in 2 of 4 applicable residential rehabilitation records.
A total of 11 client records were reviewed during the on-site inspection including five detoxification records, and six residential rehabilitation records. Five of the six residential records required treatment plan updates at least once every 15 days.
Client #9 was admitted to the short-term co-occuring program on September 11, 2019, and was an active client at the time of the on-site inspection. The short term co-occurring program has a treatment regimen of less than 30 days. The client's individualized treatment plan was completed on September 19, 2019, but there was no treatment plan update at the time of the inspection.
Client #10 was admitted to the short-term residential program on September 10, 2019, and was discharged on October 08, 2019. The short-term residential program has a treatment regimen of less than 30 days. The client's individualized treatment plan was completed on September 12, 2019, but was not updated until October 1, 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Program Supervisors/Director will meet with all clinical staff by 11/1/19 and review the time frames for treatment plans outlined in PA Code 28 section 709.52 b; explaining that treatment plans will be completed on the first day of admission; comprehensive treatment plans will be completed on day three of treatment; and updated treatment plans will occur every fifteen days, for individuals with a treatment stay of less than 30 days.
Program/Clinical Supervisors will complete bi-weekly audits of the charts to check for compliance with service dates for treatment plans starting 11/4/19. The results of the audits will be reviewed in the monthly program meetings with a plan being developed during the meetings to address any identified deficiencies.
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