INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2018 of Gaudenzia New Destiny 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 New Destiny 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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705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store food items off the floor. In commissary room 2, there was oatmeal and sugar stored directly on the floor surface.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director had a meeting with staff to discuss the need to always make sure all food is up off of the floor in the commissaries at all times to ensure sanitary measures are being taken. Staff will check each shift to make sure it is in compliance. Program Director will obtain written documentation to ensure they understand the need to always be in compliance. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
The facility failed to document a medication record with the staff and client acknowledging the medication was taken or documentation for the reason why the client did not receive the medication in client records number two, three, five, six, and seven.
Client number two was admitted on January 23, 2017 and was discharged on July 19, 2017.
Client number three was admitted on August 31, 2017 and was discharged on February 6, 2018.
Client number five was admitted on May 21, 2018 and was still an active client at the time of the inspection.
Client number six was admitted on April 4, 2018 and was still an active client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have a training scheduled training with Nilsa Gonzalaz LPN, who is the CR Trainer on 09/10/2018 to make sure all staff to understand the need to document correctly when someone does not take their medication with the reason why. The Program director will audit the Medication Book weekly to ensure compliance. Program Director will obtain written documentation to ensure they understand the need to always be in compliance. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
The facility failed to document a treatment plan be developed with client and including type and frequency in three of seven records reviewed.
Client number five was admitted on May 21, 2018 and was still an active client at the time of the inspection. No comprehensive treatment plan had been developed as of the date of the inspection.
Client number six was admitted on April 4, 2018 and was still an active client at the time of the inspection. A comprehensive Treatment plan developed on May 17, 2018 did not include type and frequency.
Client number seven was admitted on May 2, 2018 and was still an active client at the time of the inspection. A comprehensive Treatment plan developed on June 4, 2018 did not include type and frequency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Clinical Supervisor with counselors to remind them they must have their treatment plans in the charts within five days of admission. The clinical supervisor moving forward will audit charts weekly to ensure they are in compliance. As for the inclusion of the type and frequency this has been added into Avatar, Gaudenzia's electronic charting system, since the inspection. Both counselors have been signed up for a refresher training on Electronic Health Records on 09/18/2018. Program Director will obtain written documentation to ensure they understand the need to always be in compliance. |
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
The facility failed to document in client records that the clients received counseling services according to their individual comprehensive treatment plan in one of seven charts reviewed.
Client #3 was admitted on August 31, 2017 and was discharged on February 6, 2018. A comprehensive treatment plan was developed on October 10, 2017 with an update on December 10, 2017 indicating individual sessions twice a month and group sessions one time per month. There is no documentation of any individual counseling services for the month of January.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Program Director met with counselors for a brief training and reminded them of the importance of making sure they were doing their required individual sessions with clients and making sure they were documented right after the session to ensure to be in compliance. The clinical supervisor will audit charts weekly to make sure they are up to date.Both counselors have been signed up for a refresher training on Electronic Health Records on 09/18/2018. Program Director will obtain written documentation to ensure they understand the need to always be in compliance. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
The facility failed to document in the client treatment plan work being done by the client as part of their treatment in client record # two, five, six, and seven.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director & Clinical Supervisor met with clinical staff electronic charts to let them know they needed to document when the clients completed their treatment work. Gaudenzia is providing on going training to the Avatar the electronic health resords. Program Director gave counselors a demonstartion of how to document the treatment work completed Both counselors will be attending on 09/18/2018 for the refresher course. The Clinical Supervisor will audit charts weekly to ensure they are in compliance.
Both counselors have been signed up for a refresher training on Electronic Health Records on 09/18/2018. Program Director will obtain written documentation to ensure they understand the need to always be in compliance. |