INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on 02/22/2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Gaudenzia, Inc. West Chester was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 client and staff interviews it was discovered that client individual sessions were being conducted in offices in which other staff members and, at times, other clients were present.
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Plan of Correction
Director has identified four offices that are being transformed into meetings areas. These offices will be available to any Counselor for any private sessions with any member. The office will be equipped with an operable phone, walls from the floor to the ceiling and door. On the door there will be a sign that will indicate if the office is in-use to prevent any distribution. The offices will ready by May 1, 2019. Director will ensure that the offices remain as meeting rooms moving forward, this will prevent any further re-occurrences to occur in the future. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to ensure that each bathroom had hot water and that water temperature was below 120 degrees.*First-floor east bathroom water temperature was 141 degrees. This is a repeat citation.
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Plan of Correction
Director and Maintenance worker adjusted the temperature on the boilers to reduce the temperature reading in all the sinks. The temperature to all sinks including the bathrooms have been checked daily and have been reading below 120 degrees to date. Director has been keeping track of all sinks including the bathrooms temperature and logging them. Director will continue to have the temperature logged and recorded in the binder to assure that the temperature continues to read less than 120 degrees. The binder will be reviewed weekly by Director or Designee to assure continued compliance. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to ensure the confidentiality of client records. A facility nursing assistant gave two boxes of client records to a resident of the facility and directed him to dispose of the records in the facility dumpster. The staff member admitted to this and was terminated according to interviews with the nurse manager and the facility director.
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Plan of Correction
As soon as the Director was made aware of the incident of client medical records wrongly being disposed, a facility search and investigation began immediately. Director was able to retrieve medical records in a common area in the facility. Medical Director along with the Division Director began investigating the incident. They interviewed the Medical Assistant who confirmed violating company policy by wrongly disposing the client medical records. The Medical Assistant was terminated immediately on 2/19/2019. Since then, all staff have attended several in-service training, last training will be held on April 18, 2019. Health Nurse Coordinator keeps track of all medical documentation that needs to be shredded. All documentation is shredded by the end of the Medical Assistant's shift, this will prevent any pile up of shredding later.
The system does not allow the termination date 2/19/2019 to be entered in the corrective action box because it occurred before the survey exit date of 2/22/2019. |