INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 2016 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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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
A physical plant inspection was conducted on May 16, 2016. The bathroom in resident bedroom #5 was observed to have a leaking bathtub faucet with steady dripping of water.
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Plan of Correction
The part for the leaky faucet came in on 5/18/16 and was fixed on 5/18/16 by the maintenance man, overseen by Program Director. The Program Director will assure that daily runs are made on the facility to assure safety and cleanliness. All maintenance issues will be documented by the house manager making the facility runs, and the maintenance issues will be entered into the maintenance system immediately by the administrative coordinator to get any/all maintenance issues resolved by Gaudenzia Maintenance department. |
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.
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Observations
Six client records were reviewed on May 16, 2016. The facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in client records # 1, 5, and 6.
Client # 1 was admitted into treatment on 2/1/16 and was still active at the time of the inspection. The client's comprehensive treatment plan, dated 2/10/16, indicated that the client was to receive individual counseling sessions once a week. The client's last treatment plan update, dated 4/29/16, also indicated that the client was to receive individual counseling sessions once a week. The client did not receive an individual counseling session for the week of 5/8/16 - 5/13/16.
Client # 5 was admitted into treatment on 11/17/15 and was discharged on 4/5/16. The client's last treatment plan update, dated 2/11/16, indicated that the client was to receive individual counseling sessions once a week. The last documented individual counseling session attended by the client occurred on 2/15/16.
Client # 6 was admitted into treatment on 9/3/15 and was discharged on 3/11/16. The client's comprehensive treatment plan, dated 9/11/15, indicated that the client was to receive individual counseling sessions once a week. The last documented individual counseling session attended by the client occurred on 2/4/16.
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Plan of Correction
The Program Director will conduct a training with the clinical staff on clinical paperwork and documentation. The director will review clinical files weekly to assure that treatment plans are being followed through as indicated on the treatment plans. The director will review clinical files to assure individual sessions are happening weekly per policy and procedure manual. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Six client records were reviewed on May 16, 2016. The facility failed to ensure that a complete record was documented in client records # 2, 3, 4, 5, and 6.
Client # 2 was admitted into treatment on 3/31/16 and was still active at the time of the inspection. The client's record of service indicated that the client attended individual counseling sessions on the following dates: 4/21/16, 4/30/16, 5/6/16, and 5/13/16. Progress notes for these individual counseling sessions were not documented in the client's record.
Client # 3 was admitted into treatment on 1/4/16 and was still active at the time of the inspection. Progress notes in the client's record indicated that the client attended individual counseling sessions on the following dates: 2/24/16, 3/9/16, 3/16/16, and 3/23/16. These individual counseling sessions were not documented on the client's record of service. Additionally, the client's record of service indicated that the client attended an individual counseling session on 3/17/16. A progress note for this individual counseling session was not documented in the client's record.
Client # 4 was admitted into treatment on 8/1/15 and was discharged on 12/5/15. Progress notes in the client's record indicated that the client attended group counseling sessions on the following dates: 10/14/15, 10/30/15, 11/2/15, 11/4/15, 11/18/15, and 11/25/15. These group counseling sessions were not documented on the client's record of service. Additionally, the client's record of service indicated that the client attended group counseling sessions on 10/3/15 and 10/1/15. Progress notes for these group counseling sessions were not documented in the client's record.
Client # 5 was admitted into treatment on 11/17/15 and was discharged on 4/5/16. Progress notes in the client's record indicated that the client attended individual counseling sessions on 12/28/15, 1/5/16, and 1/13/1. Progress notes in the client's record also indicated that the client attended group counseling sessions on the following dates: 2/9/16, 2/12/16, 2/18/16, and 2/22/16. These individual and group counseling sessions were not documented on the client's record of service. Additionally, the client's record indicated that the client attended an individual counseling session on 2/15/16 and a group counseling session on 3/25/16. Progress notes for both the individual and group counseling sessions were not documented in the client's record.
Client # 6 was admitted into treatment on 9/3/15 and was discharged on 3/11/16. Progress notes in the client's record indicated that the client attended individual counseling sessions on the following dates: 10/3/15, 1/7/16, 1/14/16, 1/21/16, 1/28/16, and 2/4/16. Progress notes in the client's record also indicated that the client attended group counseling sessions on 1/26/16, 2/8/16, and 2/18/16. These individual and group counseling sessions were not documented on the client's record of service. Additionally, the client's record of service indicated that the client attended group counseling sessions on 12/17/15 and 1/22/16. Progress notes for these group counseling sessions were not documented in the client's record.
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Plan of Correction
The program director did a training with the overnight house managers on 5/17/16 to assure there was an understanding on the proper procedure is being followed for filing documents and recording on the record of service within the client chart accurately. The clinical staff checked all the clinical files to assure the documents that are on the record of service are in the file, the deadline was 5/30/16, the program checked all files for accuracy
The program will do a training with clinical staff/all staff on 7/7/16 on the standard for the record of service and the documents that should match the record of service in the client file.
Program Director will review client files record of service weekly to assure the information if filed accurately. |