INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 19-20, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedure manual on May 21-24, 2019, the facility failed to follow their policy in regards to completion of the assessment of staff training needs. The Plan for Assessing Staff Training Needs policy stated "The training plan shall be ready for implementation effective Jan. 31st of each year." The overall training plan for the project was not completed until May 16, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The relevant Gaudenzia Policy has been revised to state that, "Program-level training needs assessments are due to the Training department by the end of January of each year. Upon receipt of the program-level annual assessments of staff training needs, the Director of Training and Education, in collaboration with the Project Director, will review the assessments in detail and develop a plan to address the training needs of the agency. The annual agency-wide training plan shall be ready for implementation no later than April 30th of each year." The Gaudenzia Director of Training and Education will ensure that this is completed within the designated timeframe each year. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on June 19, 2019, it was observed the facility failed to maintain trash dumpsters in a manner to prevent the penetration of insects and rodents. The lids to the dumpsters were observed open with trash protruding out of the top.
The findings were reviewed with facility staff at the time of the inspection.
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Plan of Correction
As of June 19, 2019, the trash dumpsters were emptied and the lids were secured to prevent the penetration of insects and rodents.
Program management will ensure that dumpsters are emptied bi-weekly or as needed.
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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 a physical site inspection on June 19-20, 2019, the facility failed to maintain inspection tags on all fire extinguishers. A fire extinguisher in the downstairs infant room did not have a tag, therefore the last date of inspection could not be verified.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 20, 2019 the fire extinguisher was inspected and the inspection tag was replaced.
House Managers will check fire extinguishers weekly to ensure that inspection tags are attached. Program management will monitor the fire extinguisher and tags monthly.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel record on June 3, 2019, employee #1 was not trained in fire extinguisher use upon hire. Employee #1 was hired on March 4, 2019 and was still employed at the time of the inspection. There was no documentation the employee received the training as of the date of this inspection June 19-20, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (c) (4) - 705.28 (c) (4) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required fire extinguisher training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based upon a review of personnel records on June 3, 2019, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies. Employee #1 was hired on March 4, 2019 and was still employed at the time of the inspection. There was no documentation in employee #1 ' s personnel record indicating the employee had been trained on what to do during emergencies as of the date of this inspection on June 19-20, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (d) (3) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required emergency procedure training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
A review of the July 2018 through May 2019 fire drill logs was conducted during the onsite inspection on June 19-20, 2019. The facility failed to conduct unannounced drills during sleeping hours at least every six months. The only documented sleeping fire drill during that timeframe was on May 9, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 24, 2019, the program management met with the staff to inform them that an unannounced fire drill must be conducted during sleeping hours at least every 6 months.
Program management will monitor the fire drills to ensure that a fire drill is completed at least every 6 months during sleeping hours.
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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
Based on the review of seven client records on June 19-20, 2019, the facility failed to document an informed and voluntary consent to release information prior to disclosure of information in client records #1, 2, 4, 5 and 7.
Client #1 was admitted on February 4, 2019 and was still active at the time of the inspection. The client's record showed a funding source, but no consent was in the record for the funding source. In an interview with the facility director, acknowledgement was made that a consent to the funding source should have been in the record as billing would have begun on the day of admission.
Client #2 was admitted on February 13, 2019 and was still active at the time of the inspection. The client's record showed a funding source, but no consent was in the record for the funding source. In an interview with the facility director, acknowledgement was made that a consent to the funding source should have been in the record as billing would have begun on the day of admission.
Client #4 was admitted on October 9, 2018 and was discharged on January 23, 2019. The client's record showed a funding source, but no consent was in the record for the funding source. In an interview with the facility director, acknowledgement was made that a consent to the funding source should have been in the record as billing would have begun on the day of admission.
Client #5 was admitted on September 8, 2018 and discharged on January 26, 2019. The client's discharge summary indicated contact was made with another treatment provider regarding the client's aftercare but no consent to release information was documented for the other treatment provider.
Client #7 was admitted on May 29, 2019 and discharged on June 13, 2019. The client's record showed a funding source with a consent to release information form dated two days after admission on May 31, 2019. In an interview with the facility director, acknowledgement was made that a consent to the funding source should have been signed and dated the day of admission as that is when billing would have begun.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 20, 2018 inspection.
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Plan of Correction
On June 24,2019 the staff was trained to document informed and voluntary consent to release information on client's day of admission which includes funding sources. This training will be conducted for new employees and quarterly as a refresher. As of August 8, 2019, a review of the current client records will be conducted to ensure all required informed and voluntary consents are documented.
The program management will monitor consents to release information for clients on their date of admission to ensure that are client's charts.
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709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of seven client records on June 19-20, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in client records #3, 5, and 6.
Client #3 was admitted on April 10, 2019 and was still active at the time of the inspection. A consent to release information form was signed and dated on April 10, 2019 to a funding source that allowed for the release of medications and aftercare plans.
Client #5 was admitted on September 8, 2018 and discharged on January 26, 2019. A consent to release information form was signed and dated on September 8, 2018 to a funding source that allowed for the release of medication and aftercare plans.
Client #6 was admitted on February 11, 2019 and discharged on April 25, 2019. A consent to release information form was signed and dated on February 12, 2019 to a funding source that allowed for the release of medication and aftercare plans. In addition, a consent to release information form was signed and dated on April 2, 2019 to a government agency that allowed for release of medication and aftercare plans.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 21, 2019, the Program Director met with the clinical staff for a training regarding specific information that can be disclosed in Consent Forms.
As of June 28, 2019, all current client files were reviewed to ensure informed and voluntary consents were within the regulation.
The Program Director will review forms weekly to ensure that release of information forms are in writing and include, but not be limited to specific information.
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709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of seven client records on June 19-20, 2019, the facility failed to document a completed consent to treatment in two client records.
Client #4 was admitted on October 9, 2018 and discharged on January 23, 2019. The consent to treat form was not signed and dated by the client.
Client #7 was admitted on March 29, 2019 and was still active at the time of the inspection. The consent to treat form was not signed and dated by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 21, 2018, the Program Director met with the clinical staff for a refresher training regarding the Consent to Treatment documentation. As of June 26, all current client records were reviewed to ensure a consent to treat was obtained.
The program management will ensure that consent forms are properly completed through weekly regular chart audits.
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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 seven client records on June 19-20, 2019, the facility failed to document treatment plan updates within the regulatory timeframe in four client records reviewed.
Client #2 was admitted on February 13, 2019 and was still active at the time of the inspection. A treatment plan update was completed on March 13, 2019 and the next update was due no later than April 13, 2019; however, the next update was completed on May 17, 2019.
Client #3 was admitted on April 10, 2019 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 11, 2019 and an update was due no later than May 11, 2019; however, the next update was completed on May 31, 2019.
Client #4 was admitted on October 9, 2018 and discharged on January 23, 2019. A comprehensive treatment plan was completed on October 10, 2018 and an update was due no later than November 10, 2018; however, the update was completed on December 17, 2018.
Client #5 was admitted on September 8, 2018 and discharged on January 26, 2019. A comprehensive treatment plan was completed on November 2, 2018 and an update was due no later than December 2, 2018; however, no updates were documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 24, 2019, the Program Director met with the clinical staff for a refresher training on updated treatment plan due dates.
The Program Director and Clinical Supervisor will monitor client files weekly to ensure treatment plans are updated every 30 days.
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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
Based on a review of seven client records on June 19-20, 2019, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plans in six records reviewed.
Client #1 was admitted on February 4, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated February 4, 2019, indicated weekly individual sessions. The record of service and progress notes indicated the client did not receive individual sessions between February 14 - 26, March 3 - 19, March 21 - April 1, April 3 - 15, May 10 - 19 and May 21 - June 16, 2019.
Client #2 was admitted on February 13, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated February 14, 2019, indicated weekly individual sessions. The record of service and progress notes indicated the client did not receive individual sessions between February 28 - March 12, March 14 - April 7, April 9 - May 16, May 20 - June 13, 2019.
Client #3 was admitted on April 10, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated April 11, 2019, indicated weekly individual sessions. The record of service and progress notes indicated the client did not receive individual sessions between April 23 - May 15, 2019.
Client #4 was admitted on October 9, 2018 and was discharged on January 23, 2019. The comprehensive treatment plan, dated October 10, 2018, indicated weekly individual sessions. The record of service and progress notes indicated the client's first individual session was on December 17, 2018.
Client #5 was admitted on September 8, 2018 and discharged on January 26, 2019. The comprehensive treatment plan, dated November 2, 2018 and the orientation packet indicated weekly individual sessions. The record of service and progress notes indicated the client did not receive individual sessions between October 10-18, October 23 - December 18, and December 20, 2018 - January 24, 2019.
Client #6 was admitted on February 11, 2019 and discharged on April 25, 2019. The comprehensive treatment, dated February 12, 2019, indicated weekly individual sessions. The record of service and progress notes indicated the client did not receive individual sessions between February 13 - 17, March 1 - 12, and March 23 - June 5, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 24, 2019, the Program Director met with the clinical staff for a refresher training on providing and documenting weekly individual sessions.
The Program Director and Clinical Supervisor will monitor client files weekly to ensure individual treatment plans are conducted and documented weekly.
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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
Based on a review of seven client records on June 19-20, 2019, the facility failed to provide a complete client record, which is to include case consults and documentation of work therapy in client records #1, 4, 5, 6 and 7.
Client #1 was admitted on February 4, 2019 and was still active at the time of the inspection. The client record did not contain documentation of work therapy.
Client #4 was admitted on October 9, 2018 and discharged on January 23, 2019. The client record did not contain any case consults and documentation of work therapy.
Client #5 was admitted on September 8, 2018 and discharged on January 26, 2019. The client record did not contain any case consults and documentation of work therapy.
Client #6 was admitted on February 11, 2019 and discharged April 25, 2019. The client record did not contain any case consults and documentation of work therapy.
Client #7 was admitted on May 29, 2019 and discharged on June 13, 2019. The client record did not contain any case consults and documentation of work therapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 24, 2019, the Program Director met with the clinical staff for a refresher training on client records which included case consults and documentation of work therapy in client records.
The Program Director and Clinical Supervisor will monitor client files weekly to ensure case consults and documentation of work therapy is in client records.
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