INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 24, 2016 through May 25, 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. Fountain Springs 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:
|
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 physical plant inspection, 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) There is a 5' x 4 1/2' concrete pad in the entryway to the front door of the facility that had a section of broken/cracked concrete, which created a tripping hazard.
2) Upon entering the child daycare room, the left wall had exposed plaster chipping/damage, which created a hazard for the children.
3) There is an old blacktop walkway leading from the building in the outside children's playground area that had unstable wood landscape ties and broken/chipped blacktop, which created a tripping hazard.
4) The window sills in the stabilization unit's "bunk room" had peeling paint which could be easily accessed by children.
5) In the stabilization unit's "single room", there was a broken window frame, which left a wood-splintered surface.
The findings were reviewed with facility staff during the licensing inspection process.
|
Plan of Correction
Building exterior and groups shall be clean, safe, sanitary and in good repair 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.
The window sills in the stabilization units "bunk room" were made safe by removing the peeling paint and repainting the window sills. The FACILITY PLANT MANAGER completed the work on June 22, 2016.
All other areas requiring repair: concrete pad in the entryway to the front door of the facility; childcare room wall with chipping plaster; area of blacktop in the children's play area; and broken window in stabilization units "single room" will be reviewed by a construction contractor, a bid submitted, and work completed within 120 days of this POC. Date of completion 10/20/2016. The PROGRAM SUPERVISOR and FACILITY PLANT MANAGER will oversee completion of work to ensure safety and well-being of clients, children, staff and visitors. |
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.
|
Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form in client records, #4, 7, 13, and 14. Additionally, a consent to release information form in client record # 1 was missing a dated witness signature.
#1 was admitted on 01/26/2016 and was still an active client at the time of the inspection. A consent to release information form to the urinalysis laboratory, dated 2/25/16 by the client, did not have the dated witness signature.
#4 was admitted on 07/15/2015 and was discharged on 10/09/2015. There was documentation that a facsimile was sent to the pharmacy on 09/10/2015; however, there was no proper consent to release information form completed by the client prior to disclosure.
#7 was admitted on 11/05/2015 and was discharged on 01/31/2016. There was documentation that contact was made with the funding source, as well as contact with an attorney on 02/03/2016; however, there were no consent to release information forms completed by the client prior to both disclosures.
#13 was admitted on 02/10/2016 and was still an active client at the time of the inspection. There was documentation that two facsimiles were sent to a government agency on 04/12/2016 and 04/22/2016; however, there was no consent to release information form completed by the client prior to disclosure.
#14 was admitted on 08/24/2015 and was discharged on 10/18/2015. There was documentation that a letter was sent to a government agency on 09/08/2015; however, there was no consent to release information form completed by the client prior to disclosure.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
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. All staff will ensure that an informed and voluntary consent will be obtained from the client prior to the disclosure of information contained in the client chart. The consent shall be in writing and include, but not be limited to: Name of the person, agency or organization to whom disclosure is made, specific information disclosed, purpose of disclosure, dated signature of client, dated signature of witness, date, event or condition upon which the consent will expire.
The PROGRAM SUPERVISOR will review regulation 709.28 CONFIDENTIALITY in and all staff meeting on June 30, 2016 and will obtain written verification that the regulation was reviewed and understood. The PROGRAM SUPERVISOR will ensure compliance through monthly CQI audits and supervision. In regards to client record #1 reviewed during May 24-25, 2016 inspection, client #1 left treatment ASA on 6/4/16 prior to receiving notification of deficiency. New consent with dated witness signature could not be obtained. In regards to client record #13, consents for release of information to the two (2) governmental agencies were obtained and fully completed per regulations. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of seventeen client records, five of the records were required to have termination letters. Client record #4 was admitted on 07/15/2015 and was involuntarily discharged on 10/09/2015. There was no documentation of a termination letter in the client record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.33 Notification of termination (a) Project staff shall notify the client, in writing, of a decision to involuntary terminate the clients treatment at the project. The notice shall include the reason for termination. All counselors will ensure that each client, involuntarily terminated from the project, shall receive a letter of termination indicating the reason for termination and a copy of the termination letter will be placed in the client file. The PROGRAM SUPERVISOR will hold a clinical meeting will all counselors and review regulation 709.33 on June 30, 2016 and will obtain written notification that the regulation is understood. The PROGRAM SUPERVISOR will ensure compliance through monthly CQI discharge case audits. |
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 seventeen client records, client records, #1, 3, 5, 6, 8, and 13 the facility failed to document treatment plan updates within the regulatory timeframe. Additionally, client records, #4, 6, 7, 9, 10, and 13 the facility failed to include documentation of treatment plan updates.
#1 was admitted on 01/26/2016 and was still an active client at the time of the inspection. The record had a treatment plan update dated 05/19/2016, which was due no later than 05/12/2016.
#3 was admitted on 02/17/2016 and was still an active client at the time of the inspection. The record had a treatment plan update dated 05/19/2016, which was due no later than 05/13/2016.
#4 was admitted on 07/15/2015 and was discharged on 10/09/2015. A treatment plan update was due no later than 09/17/2015, but the record did not contain documentation of this update.
#5 was admitted on 10/29/2015 and was discharged on 03/21/2016. The record had a treatment plan update dated 03/07/2016, which was due no later than 03/02/2016.
#6 was admitted on 09/22/2015 and was discharged on 02/22/2016. The record had a treatment plan update dated 11/29/2015, which was due no later than 11/03/2015. Additionally, a treatment plan update was due no later than 02/21/2016, but the record did not contain documentation of an update.
#7 was admitted on 11/05/2015 and was discharged on 01/31/2016. A treatment plan update was due no later than 01/03/2016, but the record did not contain documentation of this update.
#8 was admitted on 06/01/2015 and was discharged on 11/18/2015. The record had a treatment plan update dated 07/25/2015, which was due no later than 07/22/2015.
#9 was admitted on 07/27/2015 and was discharged on 12/28/2015. A treatment plan update was due no later than 12/15/2015, but the record did not contain documentation of this update.
#10 was admitted on 10/28/2015 and was discharged on 04/15/2015. A treatment plan update was due no later than 03/15/2016, but the record did not contain documentation of this update.
#13 was admitted on 02/10/2016 and was still an active client at the time of the inspection. The record had a treatment plan update dated 04/19/2016, which was due no later than 04/14/2016. Additionally, a treatment plan update was due no later than 05/19/2016, but the record did not contain documentation of an update.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
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 rehabilitation plan, review and update shall occur at least every 15 days. Counselors will review and update treatment plans at least every 30 days with every client. The treatment plan update will be maintained in the client file and will be signed and dated by the individual counselor.
A clinical paperwork tracking form will be developed. Counselors will utilize a clinical paperwork tracking form that will serve as an additional reminder that a treatment plan update is due. The PROGRAM SUPERVISOR will ensure that the tracking form is being utilized by counselors during weekly clinical meetings. The PROGRAM SUPERVISOR will review regulation 709.52 (b) in a clinical meeting on June 30, 2016 and will obtain written verification that the regulation is understood. The PROGRAM SUPERVISOR will also ensure compliance through monthly CQI chart audits. In regards to client #13, the case file was updated and all required monthly treatment plan updates are now completed, fully documented, signed and filed in the chart. |