INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 19, 2016 through May 20, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia, Inc. 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential 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 clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on 05/20/2016 at approximately 12:45 pm, it was observed that the facility failed to ensure the safety and well-being of clients, staff, and visitors as evidenced by the following:
1) The wall in the northwest corner of the large group room had a water leak, which resulted in significant plaster damage.
2) All eight windows in the facility's main hallway had plaster damage due to water intrusion.
3) The window nearest to the administrative office had paint peeling/chipping on the window sill.
The findings were reviewed with facility staff during the licensing inspection process
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Plan of Correction
On June 16, 2016 the Division Director will submit a letter to Integrated Insurance Management 1 S. Second Street 2nd floor Pottsville, Pa. 17901 requesting repairs be completed to the wall in the northwest corner of the large group room, 8 windows in the facilities main hallway as well as the window nearest the administrative office. The repairs will include fixing any water, plaster or paint peeling damage. A completion date will be requested by July 31, 2016. The onsite Clinical Supervisor will report weekly to the Division Director for repair update. Once repairs have been completed, compliance will be documented monthly on the Safety Report. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential 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 a physical plant inspection conducted on 05/20/2016 at approximately 12:45 pm, it was observed that the large group room door had a 5" x 20" window with no window treatments, thus allowing unobstructed visual access
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 6-14-16 Division Director covered group room door window with paper to obstruct the visual access to the room. Staff on site will monitor daily to ensure privacy and confidentiality of all group members. Compliancy will be reported monthly during the management team meeting. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection conducted on 05/20/2016 at approximately 12:45 pm, it was observed that the handrail for the rear emergency exit steps that lead from the loading dock to the parking lot was not well-secured.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On June 16, 2016 the Division Director will submit a letter to Integrated Insurance Management 1 S. Second Street 2nd floor Pottsville, Pa. 17901 requesting repairs be completed to the hand rail on the rear emergency steps that lead from the loading dock to the parking lot. The repairs will include securing the handrailing to ensure that no movement occurs when utilized. A completion date will be requested by July 31, 2016. The onsite Clinical Supervisor will report weekly to the Division Director for repair update. Once repairs have been completed, compliance will be documented monthly on the Safety Report. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of eighteen client records, client record #'s 5, 6, 7, 14, 15, 16, and 18 did not have documentation of treatment plan updates within the regulatory timeframe.
#5 was admitted on 05/19/2015 and was discharged on 05/19/2016. The record had three treatment plan updates, dated 09/03/2015 (due no later than 08/30/15), 01/07/2016 (due no later than 01/03/16), and 03/30/2016 (due no later than 03/07/16), that were completed after the 60-day regulatory timeframe.
#6 was admitted on 09/28/2015 and was discharged on 02/12/2016. A treatment plan update was due no later than 12/19/2015, but was not completed until 12/28/2015.
#7 was admitted on 08/10/2015 and was discharged on 04/12/2016. The comprehensive treatment plan was completed on 08/10/2015, but the record did not have documentation of any treatment plan updates.
#14 was admitted on 12/22/2015 and was still an active client at the time of the inspection. A treatment plan update was due no later than 05/15/2016, but the record did not have documentation of an update.
#15 was admitted on 01/22/2016 and was discharged on 04/19/2016. A treatment plan update was due no later than 03/22/2016, but the record did not have documentation of an update.
#16 was admitted on 07/14/2016 and was discharged on 12/11/2015. A treatment plan update was due no later than 10/14/2015, but the record did not have documentation of an update.
#18 was admitted on 01/19/2016 and was discharged on 05/18/2016. A treatment plan update was due no later than 04/21/2016, but the record did not have documentation of an update.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training will be held on June 17, 2016 to address clinical staff on treatment management procedures specific to the treatment plan update process. All staff will be directed to update treatment plans every 60 days or sooner. The Clinical Supervisor and Division Director will review treatment plans for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions.
The treatment plan update for chart # 14 was completed on 5-26-16. The remainder of the charts audited have all been disharged. |
709.93(a) LICENSURE Client records
709.93. 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 client records, the facility failed to provide a complete client record, which is to include record of services, progress notes, case consultation notes, discharge summaries, aftercare plans, and follow up information, in client record #'s 2, 7, 10, 15, 16, and 18.
#2 was admitted on 03/28/2016 and was still an active client at the time of the inspection. The client record did not contain a record of services for the month of May, based on documented group progress notes dated 05/03/16, 05/04/16, 05/10/16, and 05/17/16, as of the date of the inspection.
#7 was admitted on 08/10/2015 and was discharged on 04/12/16. The client record did not contain case consultation notes as of the date of the inspection.
#10 was admitted on 12/22/2015 and was discharged on 03/15/2016. The client record did not contain case consultation notes, a discharge summary, an aftercare plan, and follow-up information as of the date of the inspection.
#15 was admitted on 01/22/2016 and was discharged on 04/19/2016. The client record did not contain case consultation notes as of the date of the inspection.
#16 was admitted on 07/14/2015 and was discharged on 12/11/2015. The client record did not contain case consultation notes as of the date of the inspection. Additionally, the record of service for August 2015 was incomplete as there were documented group notes dated 08/04/15, 08/07/15, and 08/11/15 and the record of service for September 2015 was incomplete as there were group progress notes dated 09/09/15, 09/16/15, 09/18/15, and 09/21/15, and 09/25/15. In addition, there were entries in the record of services with no corresponding progress notes:
July 2015 - group-07/14;
September 2015 - individual-09/16;
October 2015 - group-10/09, 10/13, 10/14, 10/16, 10/20, 10/21 and individual-10/9; November 2016 - group-11/03, 11/04, 11/10 and individual-11/10, 11/19.
#18 was admitted on 01/19/2016 and was discharged on 05/18/2016. The client record did not contain case consultation notes as of the date of the inspection. Additionally, the record of service for April 2016 had individual session entries on 04/05/16 and 04/11/16, but did not have corresponding progress notes as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training will be held on June 17, 2016 to address clinical staff on complete client records to include record of service, progress notes, case consultation notes, discharge summaries, aftercare plans and follow up information. All staff will be reminded that a record service must represent each month, a progress note must be done for each individual, group or family session, a case consult must be done on every client at 90 days or sooner (level of care change) or at discharge if prior to 90 days. All charts must have a discharge summary within 7 days of discharge. Staff will be directed to develop the aftercare plan throughout the treatment process and complete prior to discharge. Part of the in service will be to include follow up timelines. 7 day follow ups will be for all referrals and 30 day follow ups for every other type of discharge. The Clinical Supervisor and Division Director will review for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions.
A May 2016 record of service for chart # 2 was completed and added to the record on 5-24-16. The remainder of the charts reviewed were clients who have been discharged.
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, client record #'s 8 and 17 were identified as medical assistance clients and the facility failed to obtain a physician signature on the client's comprehensive treatment plans and/or treatment plan updates.
#8 was admitted on 05/15/2015 and was discharged on 01/29/2016. As of the date of the inspection, there was no physician signature on the 10/08/15 treatment plan update and the 12/03/15 treatment plan update.
#17 was admitted on 11/10/2015 and was discharged on 01/08/2016. As of the date of the inspection, there was no physician signature on the initial treatment plan, dated 10/06/15, and the comprehensive treatment plan, dated 11/10/15.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training will be held on June 17, 2016 to address clinical staff on treatment management procedures specific to the treatment plan process in obtaining physician signatures for all medical assistance clients. Staff will be reminded that treatment plans require a physician signature. Physician is available at least 1 X monthly. The Clinical Supervisor and Division Director will review treatment plans for compliancy during the CQI process monthly. Clinical staff will review monthly in regular supervisory sessions. |