INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 20-21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Common Ground 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 and a plan of correction is due on June 19, 2010.
|
Plan of Correction
|
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Based on a tour of the physical plant and an interview with the facility director, the facility failed to keep the grounds of the facility clean, sanitary and in good repair at all times.
A tour of the facility was conducted on May 21, 2010 at 1:00 PM. During the tour, the inspector noted the carpet in the first floor hallway was visibly stained and in need of replacement.
An interview was conducted with the facility director prior to the physical plant tour. During this interview the facility director advised they were aware that the carpet was stained and needed to be replaced. The facility director stated that the carpet was scheduled to be replaced.
|
Plan of Correction
The carpet was professionally cleaned on 6/20/10.
The Central Region Physical Plant Manager also met with the flooring vendor to secure measurements and select product style.
Installation of new flooring is expected within the next 3 months.
The Program Director will assume responsibility for following up with the Central Region Physical Plant Manager and Central Region Director regarding installation progress.
Targetd Completion Date: 9/30/10
|
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
|
Observations
Based on a tour of the physical plant and an interview with the facility director, the facility failed to keep the facility free of rodent and insect infestation.
The findings include:
A tour of the facility was conducted on May 21, 2010 at 1:00 pm. During the tour at approximately 1:30 pm, a bed bug was discovered on the underside of the mattress in bedroom # 16.
An interview was conducted with the facility director prior to the physical plant tour. During this interview the facility director advised they were aware of the bed bugs; and added the insect problem was under control but was not yet resolved.
|
Plan of Correction
Room #16 was immediately treated with an approved chemical agent while licensing specialists were on site. The Central Region Physical Plant Manager (licensed exterminator)also subsequently treated the room.
The Program Director met with all clients on May 21,2010, and received no complaints of bedbugs. No complaints or incidents have occurred since.
The program will adhere to licensing regulations around the provision of a treatment facility that is free of rodent and insect infestation.
Program staff will adhere to all agency policies and protocols associated with pest control including bed bugs.
Program Director reviewed bed bug protocols with staff including but not limited to screening of client and client belongings, laundering of all clothing/shoes at admission, confiscation and sealed plastic storage of luggage, bags, etc..., handling of linens, room inspections, and immediate chemical treatment of sited bugs.
Ongoing room inspections are conducted twice daily by designated staff on duty and findings are documented in a log book.
Any bug findings are immediately reported to the Program Director who subsequently promptly reports such to the Central Region Director. The Central Region Director directs extermination services in collaboration with the Regional Physical Plant Manager.
Ongoing monitoring of protocol conformance is reported in daily logs and monthly reports completed by designated staff on duty and the Program Director then submitted to the QI and Safety Committees.
Targeted Resolution date: 6/24/10
|
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
|
Observations
Based on a tour of the physical plant, the facility failed to light interior exits and stairs at all times.
The findings include:
A tour of the facility was conducted on May 21, 2010 at 1:00 PM. During the tour at approximately 1:45 PM, it was found the back stairway to was dimly lit; furthermore the light could be turned off.
|
Plan of Correction
The Program Director completed an acquisition request/work order requesting repairs to the back stairwell light and switch.
The request/order was submitted to the Central Region Physical Plant Manager and Central Region Director on 6/22/10.
The issue was also reported to the Safety Committee.
The Program Director will assume responsibility for following up with the Central Region Physical Plant Manager regarding progress.
Staff have been trained to conduct regular ongoing maintenance checks throughout the facility and submit documentation to the Program Director to assure ongoing conformance with all physical plant standards.
Targeted Resolution Date: 7/31/10
|
709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
|
Observations
Based on a review of client records, the facility failed to accurately document the vital signs in the physical examination in four out of four detox client records.
The findings include:
On May 20, 2010 four detox client records were reviewed. The facility neglected to record vital signs during the time of the physical examination in four client records. The vitals signs which appeared on the physical examination were not recorded the day the physical was completed, but instead the vitals were previously recorded from the nursing assessment which is completed upon the client's arrival.
Client # 6 was admitted on November 4, 2009, the nursing assessment was completed on November 5, 2009. The physical examination was completed on November 7, 2009. The vital signs on the physical exam were transposed from the previously recorded, nursing assessment.
Client # 7 was admitted on May 17, 2010, the nursing assessment was completed on May 17, 2010. The physical examination was completed on May 18, 2010. The vital signs on the physical exam were transposed from the previously recorded, nursing assessment.
Client # 8 was admitted on May 18, 2010, the nursing assessment was completed on May 18, 2010. The physical examination was completed on May 19, 2010. The vital signs on the physical exam were transposed from the previously recorded, nursing assessment.
Client # 9 was admitted on May 4, 2010, the nursing assessment was completed on May 4, 2010. The physical examination was completed on May 5, 2010. The vital signs on the physical exam were transposed from the previously recorded, nursing assessment.
|
Plan of Correction
The Nurse Manager shall assure that vital signs are accurately documented on the physical examination for all clients.
The Nurse Manager met with the Physician and Nursing Staff regarding the following protocol. The Physician or Nurse shall ascertain client vital signs at the time of the physical examination and document findings on the physical examination form.
The Nurse Manager will monitor ongoing conformance in accordance with her monthly QI report and record audits.
Targeted Resoultion Date: 6/24/10 |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document treatment plans to include frequency of treatment and rehabilitation services in six out of six client records.
The findings include:
The facility ' s policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
" Included in the action plan will be a statement of the type (individual / group / family therapy, health education, etc.) and frequency (daily, 2-3 x weekly, once, ongoing, etc.) of service in which the client will be involved. "
Six client records were reviewed on May 20, 2010. Treatment plans including the type and frequency of treatment and rehabilitation services were required in six client records. The facility did not document treatment plans to include the type and frequency of treatment and rehabilitation services in client records # 1, 2, 3, 4, 5, and 6.
|
Plan of Correction
The Program Director and Senior/Lead Counselor met with counseling staff regarding clear documentation of the type and frequency of treatment and rehabilitation services on treatment plans.
The Program Director and Senior/Lead Counselor will monitor ongoing conformance by conducting monthly client record audits and reporting findings in a monthly QI report.
A revised treatment plan form has been developed and will be instituted upon corporate approval.
Targeted Resolution Date: 6/31/10
Targeted New Form Institution: 8/31/10
|
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.
|
Observations
Based on a review of client records, the treatment plan updates failed to include the client's progress as it relates to the goals identified on the individual treatment plan. The treatment plan updates indicated only if the goals had been met or not and lacked detail on the clients' progress in four of five inpatient client records reviewed.
Findings:
The facility's policy states:
Treatment Plan Reviews: The Counselor shall complete a treatment plan review and update 30 days after the date of the original individual treatment plan for residential, (and every 30 days thereafter), 14 days after the date of the original individual treatment plan for short-term (and every 14 days thereafter) and 60 days after for outpatient and every 60 days thereafter. This review shall include an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal has been impacted. Any goal or action step additions, revisions and deletions shall also be reflected. Goal and action step changes shall also be reflected on the treatment plan. The update shall be signed by the Counselor and submitted to the Clinical Supervisor for review and signature.
Six client records were reviewed on May 20, 2010. A treatment plan update was required in five of those client records. The facility did not document the progress on the goals stated in the individual treatment plans in client records # 1, 2, 3 and 4.
Client record #1 admission date 04/23/2010; treatment plan documented 04/23/2010; treatment plan update documented 05/07/2010.
Client record #2 admission date 05/01/2010; treatment plan documented 05/01/2010; treatment plan update documented 05/17/2010.
Client record # 4 admission date 12/31/2009; treatment plan documented 12/31/2009; treatment plan update documented 01/18/2010.
|
Plan of Correction
The Program Director and Senior/Lead Counselor met with counseling staff regarding clear documentation of the client's progress as it relates to the goals identified on the individual treatment plan.
The Program Director and Senior/Lead Counselor will monitor ongoing conformance by conducting monthly client record audits and reporting findings in a monthly QI report.
A revised treatment plan form has been developed and will be instituted upon corporate approval.
Targeted Resolution Date: 6/31/10
Targeted New Form Institution: 8/31/10
|
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
|
Observations
Based on a review of outpatient client records, the facility failed to provide an assessment for the individual client following their group counseling in six out of six outpatient client records.
The findings include:
Six outpatient client records were reviewed on May 20, 2010. All of the client records required documentation of group progress notes. The form for completing group notes included one-word adjectives describing the individuals' demeanor, in which the clinicians' could select. Underneath the adjectives were several lines for comments or elaboration. The counselors did not complete an adequate assessment as the spaces were left blank.
|
Plan of Correction
Gaudenzia Common Ground does not provide outpatient treatment services. All Common Ground services are on an inpatient basis.
The Program Director and Senior/Lead Counselor will meet with all Counselors and Counselor Assitants to review the standard, policies, and protocols for documentation of group progress notes. The Program Director and Senior/Lead Counselor will assure that all staff are using and completing the corporate approved form for group progress notes including a narrative assessment of progress.
Targeted Resolution Date: 7/1/10 |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
|
Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a discharge summary within 7 days of discharge in three of three inpatient client records.
The findings include:
On May 20, 2010 six inpatient records were reviewed. A discharge summary was required in three of those records, specifically records # 4, 5, and 6. The facility's policy states that a discharge summary is to be completed within seven days of discharge.
Client record # 4 was admitted on December 31, 2009 and discharged on January 28, 2010. The discharge summary was due by February 4, 2010. The discharge summary had not been completed until February 9, 2010.
Client record # 5 was admitted on December 14, 2009 and discharged on December 28, 2009. The discharge summary was due by January 4, 2010. The discharge summary had not been completed until May 4, 2010.
Client record # 6 was admitted on November 9, 2009 and discharged on December 7, 2009. The discharge summary was due by December 14, 2009. The discharge summary had not been completed until January 23, 2010.
|
Plan of Correction
The Program Director and Senior/Lead Counselor met with the counseling staff regarding completion of discharge summaries within seven days of a client's discharge.
The Program Director and Senior/Lead Counselor will monitor ongoing conformance via monthly chart audits and QI reporting.
Targeted Resolution Date: 6/24/10 |