INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection to the initial on-site licensure inspection conducted on May 10 - 11, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
The follow-up inspection was conducted on November 15, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site follow-up 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 and a plan of correction is due February 24, 2011.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
This deficiency can not be re-evaluated until the next licensing inspection.
Please resubmit the original plan of correction date for the date of completion.
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Plan of Correction
According to policy and procedure manual the facility will implment a check and balance system to ensure that training plans are being developed for each employee training period. Supervisors will meet with employees on a quarterly basis to ensure staff are completing doucmentation needed for the next calendar year. Training plan have been completed on all employess as of 3/1/2011 |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facility's October work schedule, an interview with the administrative assistant and copies of staff Cardio Pulmonary Resuscitation (CPR) certification and First Aid cards provided by the facility for the staff working during the month of October, the facility failed to ensure that CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills was onsite during the project's hours of operation.
The findings include:
On November 15, 2010, copies of staff CPR and First Aid cards and the October 2010 work schedule as provided by the facility were reviewed.
Employee number one's first aid certification expires September 14, 2011; however, the CPR certification expired September 14, 2010. There was no documentation that any other employees working the 12 AM - 8 AM shift on the identified dates below had first aid training or CPR certification.
Based on the work schedule and the CPR and First Aid cards provided by the facility, the facility failed to provide CPR coverage on the 12 AM - 8 AM shift on the following dates:.
October 1, 2, 6, 7, 8, 12, 13, 14, 17, 18, 19, 20, 23, 24, 25, 26, and 29, 2010.
The administrative assistant confirmed that employee number one's CPR certification had expired on September 14, 2010 and that the facility did not have a staff person trained in these skills on site during the 12:00 AM - 8:00 AM shift on October 1, 2, 6, 7, 8, 12, 13, 14, 17, 18, 19, 20, 23, 24, 25, 26, and 29, 2010.
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Plan of Correction
The facility will ensure that CPR and first aid is provided to sufficient number of staff so one person is trained by having staff attend the training. This has been corrected and staff was receertified on 1/18/2011 |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
This deficiency can not be re-evaluated until the next licensing inspection.
Please resubmit the original plan of correction date for the date of completion.
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Plan of Correction
The facility/clinical supervisor will ensure that the counselor assistant will have the minimun training haours that is expected of her. A training planned has been completed with the courses needed for her to be in compliance and she will be attending these trainings courses to met reqired training number. |
705.1 (2) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
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Observations
Based on observation shortly after arriving at the facility and an interview with the administrative assistant, the facility failed to provide a certificate of occupancy from the Department of Labor and Industry for the Kindred House building and the Nelson Building.
The findings include:
On November 15, 2010 at approximately 12:05 PM, it was observed that the facility lacked a posted certificate of occupancy from the Department of Labor and Industry for the Kindred House building and the Nelson Building.
The administrative assistant was able to produce a Certificate of Occupancy for the Kindred House building from the local municipality; however, it predated the 2004 opt-in date for local municipalities conducting their own inspections. The opt-in date for the township where the facility is located was 7/6/2004. In addition, the administrative assistant was not able to provide anything for the Nelson Building at the time of the inspection.
When asked about the Certificates of Occupancy for each building, the administrative assistant stated that she had no additional documentation other than the one Certificate of Occupancy provided by the local municipality.
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Plan of Correction
Certificate of Occupancy has been located for the Nelson Center and has been hung on the wall as soon as you enter the front door.
****When checking the Nelson facility daily the staff on duty for that day will be responsible to check and make sure the COO is in posted on the wall.
A duplicate copy of the Certicate of Occupancy for Kindred House has been ordered. The money order and form was mailed out on 3/15/2011.
A copy of the form and money order receipt is available to be faxed over to office and will be on file at Kindred House by 4/01/2011 if not sooner which will be visible during next monitoring visit.
**** At Kindred house the Administrative Assistant will place COO in a frame and place it on the wall in her office. She will be responsible to assure it stays on the wall.
**** At Kindred house the Administrative Assistant will place COO in a frame and place it on the wall in her office. She will be responsible to assure it stays on the wall.
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based upon observation, a physical plant inspection, and interviews with the administrative assistant and the facility director, the facility failed to maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
The findings include:
Shortly after arriving at the facility, the Licensing Specialists were taken to the Nelson Building and the following observations were noted:
1.It was observed at 12:02 PM that the stucco wall of the exterior exit stairs of the Nelson Building was cracked. There were several cracks with one starting at teh bottom stair and running a distance of six stairs before turning and running to the top of the wall. Some of the stuco was pulling away from the wall
2.It was observed at 12:02 PM that the foundation wall of the Nelson Building had holes in it which could allow insects and rodents to gain access to hte inside of the building..
3.It was observed at 12:02 PM that there was an empty trash can at the bottom of the stairs and other debris on the steps of the exterior exit of the Nelson Building.
4.It was observed at 12:05 PM that much of the furniture in the basement lounge area of the Nelson Building was in disarray and not in the upright position.
5.It was observed 12:09 PM that there was a leaking pipe in the " Learning Zone " of the Nelson Building.
6.It was observed at 12:09 PM that there were missing ceiling tiles in the " Learning Zone " of the Nelson Building.
7.It was observed at 12:02 PM that there were two small plastic wastebaskets that had been used to catch water from the leaking pipe in the " Learning Zone " . At 4:48 PM one of the two cans was observed to have water dripping into it from the pipe above it.
At approximately 5:00 PM through 6:15 PM, a physical plant inspection was conducted along with the administrative assistant. The following observations were made during the physical plant inspection:
1.It was observed at 5:01 PM that there was a hole in the ground and a piece of concrete that created tripping hazards, adjacent to the gas meter at the rear of the building.
2.It was observed at 5:01 PM that there was a section of the gutter at the rear corner of the building that was bent down and pulling away from the building.
3.It was observed at 5:01 PM that there was a section of the soffit missing at the rear side of the building that would enable insects and/or rodents to enter the building.
4.It was observed at 5:02 PM that there was a clothes dryer with the back removed located in the children ' s play area. The back had sharp edges and the rear of the clothes dryer had exposed wiring and sharp edges.
5.It was observed at 5:02 that there was a large rodent trap on the clothes dryer that was left in the children ' s play area.
6.It was observed at 5:02 PM that there was an electrical outlet that was no longer attached to the building in the children ' s play area.
7.It was observed at 5:02 PM that there was a cement block left on the ground in the children ' s play area.
8.It was observed at 5:39 PM that there was a register cover pulling away from the wall in the hallway of the Kindred Building near the offices.
The administrative assistant confirmed the findings during the physical plant inspection. In addition, the facility director and administrative assistant stated that the missing and stained ceiling tiles as well as the furnishings not being in place in the Nelson Building were due to a water leak. The facility director stated that the clothes dryer had caught fire and that it been removed and put in the play area by the fire department. The facility director stated that the dryer fire and the water leak occurred on the same day. She was not exactly sure of the date but said that it was either November 6, 2010 or November 9, 2010.
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Plan of Correction
1. Structural issues with findings 1&2 have been entered into Gaudenzia's maintenance system. The Supervisor of the maintenance department is accepting bids to have stucco and foundation repaired and will be completed by 4/01/11.
*** Physical plant manager is responsible for the overall buildings on the West Chester campus.
3. This issue has been resolved by removing the trash can.
4. This issue has been resolved and furniture has been put back into its place.
5-7. Has been communicated to the maintenance staff of Gaudenzia and it has been corrected.
****3,4, 5-7 Staff on duty will be responsible to check the nelson center daily to assure that there are no leaks and the furniture is in it's place. Staff on duty will report any issue to the physical plant manager to be repaired.
1. This issue has been corrected. The hole in the ground has been filled in with dirt.
****Physical plant manager and the house manager will check daily for any issues on the outside of the building they will be reported and then will be repaired.
2-3. These issues have been place into Gaudenzia's maintenance system and has been corrected as of 3/15/11.
*** Physical plant manager is responsible to repair this issue.
4. These issues have been resolved and the dryer has been removed.
***Physical plant manager is responsible to remove broken items. When big items are removed from program he will take the item to dumpster or off of the property.
5-6. This issue has been resolved and the trap and the dryer was removed.
6. This issue has been resolved and the outlet was reattached to the wall.
7. The cement block has been removed.
8. The register cover has been replaced and the issue has been resolved.
***Physical plant manager is responsible for all of the above items. When these items are reported by our house manager or administrative assistant in the maintenance system the physical plant manager is responsible to pull order and complete repair.
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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.
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Observations
Based on a physical plant inspection and an interview with the administrative assistant, the facility failed to 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 findings include:
A physical plant inspection was conducted on November 15, 2010 between the hours of approximately 5:00 PM to 6:00 PM.
1. It was observed at 5:23 PM that the lid of the toilet tank in bedroom # 3's bathroom had a broken corner with a jagged/sharp edge.
2. It was observed at 5:20 PM that the crib in bedroom # 3 was disassembled and parts of it were lying on the floor and the side rails were lying on the adjacent bed.
3. It was observed at 5:30 PM that the window blinds in room # 6 were damaged and missing slats.
4. It was observed at 5:33 PM that one of the windows in room # 7 lacked any window treatment and one of the windows had a blind that was damaged and missing slats.
5. It was observed at 5:27 that three out of four windows in room # 8 had blinds that were damaged and/or missing slats.
6. It was observed at 5:26 PM that there were ceiling tiles in the bathroom of room 8 that were stained.
7. It was observed at 5:26 PM that the drain pipe for the sink in the bathroom of room # 8 had a jagged piece of metal with sharp edges in the sink base cabinet. In addition, part of the paper for the drywall had peeled away leaving unpainted exposed paper under the sink cabinet and above the sink cabinet.
8. It was observed at 5:27 that the walls adjacent to the door in room # 8 were marred.
The administrative assistant confirmed the findings during the physical plant inspection.
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Plan of Correction
1. As of 3/1/11 maintenance dept has ordered the toilet tank cover Target date for completion is 4/1/11.
*** Rooms will be checked by house manager daily and any issue of broken items will be reported to physical plant manager and director to correct issue.
2. The crib has been assembled and placed in a annthoer room to be utilized.
**** House manager will make sure no cribs all left unassembled at any time.
3-5. Blinds have been replaced and residence have broken again. All blinds will continue to be replaced as needed. Room 6-7 and 8 blinds have been replaced.
***House manager is responsible to report blinds that need to be replaced ongoing.House manager will be reported to physical plant manager to purchase blinds as soon as they become broken.
6&8. All issues with room #8 were into entered into Gaudenzia's maintenance system for repairs. Maintance dept has has began work on room 8 and will have all issue completed by the Target date 4/1/11.
**** House manager will be responsible to report repairs to the physical plant manager and the director to assure repairs are done in a timely manner.
7. Bathroom sink has been replaced and this issue has been resovled.
8. Walls have been patched and will be painted and repaied by target date completed by the maintenance dept.
*** The walls have been patched and painted as of 3/21/11.
***House managers will check rooms and report repairs to the physical plant manager and the director to assure repairs are completed as soon as possible. |
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 observation, an interview with the administrative assistant and a phone conversation with the facility director, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
On November 15, 2010, upon arriving at the facility, it was observed at 11:46 AM that the two dumpsters had trash piled so high that the lids of the dumpsters were open and unable to be closed to prevent the penetration of insects and rodents. One of the dumpsters had trash overflowing and there were cardboard boxes, food products and other trash littering the ground around the dumpsters.
The administrative assistant confirmed that the dumpsters were overflowing and that boxes, food products, and other trash was on the ground around the dumpsters. During a phone conversation with the facility director at approximately 12:00 PM, she acknowledged that there was a problem with the trash at times and attributed it to the fact that two other programs on the grounds use the dumpsters as well as her facility. When asked about possibly increasing the number of trash pick ups at the facility, the facility director indicated that this was considered but that the cost of adding another pick up is was a factor. The possibility of providing additional dumpsters was discussed and the facility director indicated that they would look into that option.
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Plan of Correction
Gaudenzia has a contract with a trash removal company from West Chester. They are regulary scheduled to pick up trash every Monday and Thursday. The physical plant staff will be responsible to assure trash is removed in a timely manner preventing the trash from over flowing.
The over flowing trash has been removed for the property.
At the of the visit the West Chester facility had just received new mattresses and dressers which was a unsual amount of trash which caused the over flow.
The two scheduled pick-up will secure trash and the physical plant staff will be responsible to have all bulk items removed the day of delivery of new items thus preventing trash over flow.
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705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
Based upon observation, a physical plant inspection and an interview with the administrative assistant, the facility failed to provide a storage area for clothing for all residents in rooms # 3 & 7.
The findings include:
A physical plant inspection was conducted on November 15, 2010 between the hours of approximately 5:00 PM to 6:00 PM.
1. It was observed at 5:33 PM that there were only nine hangers provided for a closet in room # 7 and the remainder of the residents ' clothing was either stored in garbage bags in the closet or simply piled on top of the garbage bags and/or other clothing.
2. It was observed at 5:25 that due to a lack of storage space for clothing in room #3, the remainder of the residents ' clothing was in and on top of suitcases. In addition, having suitcases stored in resident rooms is in violation of the facility ' s bed bug policy.
The administrative assistant confirmed that there were clothes in piles in the closets and that there was clothing in bags and luggage in the rooms.
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Plan of Correction
Hangers have been purchased as of 3/15/2011 and have been given to the residents that needed additional hangers.
House manager superviser will be responsible to ensure that all residents have ample amount of hangers upon admission.
Hangers wil be purchased and be on hand at all times. Hampers/laundry bags will be provided to clients to ensure that no plastic trash bags are used for dirty clothes. All plastice bags will be removed. As part of work therapy client's will maintain their closet space to ensure clothes are not inappropriately stored. No suitcases will be stored in rooms. The suitcases in room #3 have been removed according to policy. The purchasing department of Gaudenzia will be notified and they will order the needed hampers/laundry bags.
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705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based upon observation, a physical plant inspection and an interview with the administrative assistant, the facility failed to provide a securely attached ladder for the bunk bed in room #6.
The findings include:
A physical plant inspection was conducted on November 15, 2010 between the hours of approximately 5:00 PM to 6:00 PM.
1. It was observed at 5:21 PM that the ladder for the bunk bed was not securely attached to the bed but was being used to prop the bedroom door open,
The administrative assistant confirmed the findings.
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Plan of Correction
1.Each room has an assigned floor plan that is posted in each room on the left side of the wall when entering the room.
2. During the time of the site visit the furniture in room 6 had inadvertlently been rearranged in that room thus taking away from the square footage requirnments of the room.
3. The furniture has now been rearranged to meet the square footage requirnments as of 3/17/2011 according to the floor plan.
4. Bunk bed ladder need to be repaired and this issue will be entered into the maintenance system for repair physical plant manager is the processes of repairing these ladders of 3/17/2011 but new ladders have been ordered by the purchasing department of Gaudenzia.
****** Bunk bed ladders have arrived as of 3/21/11 and have been attached to the beds.
5. House managers will make sure that the furniture in each room will be arranged according to the assigned floor plan for each room. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection and an interview with the administrative assistant, the facility failed to provide privacy for the toilet in the daycare/nursery area and to provide slip-resistant surfaces in all bathtubs and showers.
The findings include:
A physical plant inspection was conducted on November 15, 2010 between the hours of approximately 5:00 PM to 6:00 PM.
1. It was observed at 5:10 PM that the bathroom for the day care/nursery is located in the basement laundry area without any separation from where the washer and dryer area where there would be soiled linen. This laundry area is heavily used as the laundry on the first floor was without a functional dryer at the time of the inspection. One dryer had been removed due to a fire and the one dryer that was still located in the first floor laundry was not providing heat even after allowing it to run for 6 minutes.
2. It was observed at 5:34 PM that the shower of room # 7 was without a slip-resistant surface.
The administrative assistant confirmed the findings.
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Plan of Correction
1. An accordian door will be purchased and put up between the laundry room and the bathroom in the daycare area. This objective will be entered into the maintenance system to be completed. Dryer on the 1st floor is working properly and the dryer on the lower level is still in need of repair and will be entered into the maint. sys.
2. All showers will be supplied with slip resistant tub mats. |
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on observation and an interview with the administrative assistant, the facility failed to provide toilet paper at each toilet at all times.
The findings include:
On November 15, 2010, a physical plant inspection was conducted between approximately 5:00 PM and 6:15 PM.
At approximately 5:27 PM, the bathroom of room # 8 was observed to be without toilet paper.
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Plan of Correction
There is always a minimum of two cases of toilet paper on the property at all times. Part of work therapy for clients (laundry/supplies) is to keep the bathrooms supplied with toilet paper. It is each client's responsibility to make sure that their bathroom has toilet paper in it; not staff. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection and an interview with the administrative assistant, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
A physical plant inspection was conducted on November 15, 2010, between the hours of approximately 5:00 PM to 6:00 PM.
1.It was observed at 5:10 PM that the toilet seat in the day care/nursery was severely stained and was not clean or sanitary as it was delaminating and had fecal stains on it. In addition, the walls were marred, a section of cove base was missing.
2.It was observed at 5:10 PM that the bathroom for the day care/nursery is located in the basement laundry area without any separation from where the washer and dryer area where there would be soiled linen. This laundry area is heavily used as the laundry on the first floor was without a functional dryer at the time of the inspection. One dryer had been removed due to a fire and the one dryer that was still located in the first floor laundry was not providing heat even after allowing it to run for 6 minutes.
3. It was observed at 5:15 PM that the toilet seat in the bathroom of room # 1 was not sanitary or clean as it had fecal stains on it.
4.It was observed at 5:23 PM that the lid of the toilet tank in bedroom # 3's bathroom had a broken corner with a jagged/sharp edge.
The administrative assistant confirmed the findings during the physical plant inspection.
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Plan of Correction
1. The toilet seat has been replaced and bathoom in nursery has also been painted as today's date. 3/15/2011
2. Maintanance department has looked at these rooms and will be hanging a room divider to separate into two areas to be completed by 4/1/2011.
3. The residents responsible for this area has cleaned the toliet seat. Clients will be supervised by house managers to assure the cleaning is being done correctly on a daily basis.
3. The maintanace department is aware of cover and is in the process of repacing the cover with the correct size. To be completed by 4/1/2011 |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation and a conversation with the administrative assistant, the facility failed to ensure that there were no heaters located within the facility that were not permanently mounted or installed.
The findings include:
On November 15, 2010, a physical plant inspection was conduced between the hours of approximately 5:00 PM and 6:15 PM.
At 6:11 PM a "Maxi Heat" portable space heater was observed in the counselor's office located adjacent to the living room/group room.
The administrative assistant confirmed that the counselor's office had a portable space heater.
This is a repeat deficiency from the May 11, 2010 inspection.
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Plan of Correction
Heater was removed from the office and the staff member has been warned about the heater and it's hazaards. The next infraction will result in a corrective action. |
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.
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Observations
Based on observation, a physical plant inspection and a conversation with the administrative assistant, the facility failed to ensure that the facility was free of rodent and insect infestation.
The findings include:
Shortly after arriving at the facility on November 15, 2010 at approximately 11:53 AM, the licensing team was escorted to an office in the basement of the Nelson building.
There was a pile of mouse droppings observed on a desk in the office. The administrative assistant attempted to clean up the mouse droppings. Following a short discussion, the assistant administrator acknowledged that due to the mouse droppings it might be better if the licensing team worked out of another room.
The licensing team was then taken to the "Learning Zone" and upon entering that room, it was observed that there were dead bugs in the florescent light fixtures.
It was observed at 5:34 PM that there were bugs in the florescent light fixture in resident room #7 in Kindred House.
It was observed at 6:00 PM that there were bugs in the florescent light fixture in the clinical supervisor's office in the Kindred House building.
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Plan of Correction
The maintenance department has been notificed of the mice dropping and this issue and has started preventive measures to address the rodent issue.
Bugs in the light fixture were removed in both room #7 and the clinical supervisor office and fixture were cleaned by the maintance department.
House manager supervisor will check light fixtures weekly to assure that there are no bugs in the light fixtures, if found will have them removed immediately and fixtures cleaned.
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based upon observation, a physical plant inspection and an interview with the administrative assistant, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
The findings include:
Shortly after arriving at the facility the Licensing Specialists were taken to the Nelson Building the following observations were noted:
1.It was observed at 12:05 PM that there were boxes, a shop vacuum and a cord in the back hall of the basement and much of the furniture in the basement lounge area of the Nelson Building was in disarray obstructing the exit.
At approximately 5:00 PM through 6:15 PM, a physical plant inspection was conducted along with the administrative assistant. The following observations were made during the physical plant inspection:
1.It was observed at 5:02 PM that there was a clothes dryer, cement block and child ' s picnic table obstructing exit access from one of the building exits and to the gate out of the play area.
2.It was observed at 5:03 that there was a large picnic bench obstructing exit access to the gate out of the play area.
The administrative assistant confirmed the findings.
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Plan of Correction
1. These issues have been corrected all items removed and furniture put back into it's place therfore not obstucting the exit.
The residents and house managers will not put items in front of any exit. Exits will be checked when these area's are cleaned nightly by the staff who is supervising the clean up.
2. The bench has been moved from the exit and there is access to the gate in the play area. Child care staff will be responsible to check area and make sure that exit by gate is never obstructed on a daily basis. |
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 upon observation, a physical plant inspection and an interview with the administrative assistant, the facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
Shortly after arriving at the facility the Licensing Specialists were taken to the Nelson Building the following observations were noted:
1.It was observed at 12:05 PM that there was a fire extinguisher in the "Learning Zone" that had an expired inspection tag on it. The last inspection was conducted in October 2009.
The administrative assistant confirmed the findings.
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Plan of Correction
All fire extinguishers will be inspected and tags updated by Boardman Fire Exitinguiser Co. Call will be placed to company and will be completed by 4/1/2011.
House manager supervisor will be responsible to check tags monthly in both facilities to assure they are are inspected and updated on time.
They will put in request to have Boarman company come out and update and service exitinguisher informtion as needed but at least one time a year. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of the fire drill records, the facility failed to document unannounced fire drills at least once a month.
The findings include:
The facilities fire drill log was reviewed on November 15, 2010.
The fire drill log lacked documentation of an unannounced fire drill during the month of October 2010.
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Plan of Correction
Staff will attend a refresher fire drill in-service training. Fire drill refersher was held on 3/3/2011 for all staff including housemangers. Staff attendance can be verified by reviewinf the staff meeting notes on 3/3/2011.
We are in the process of hiring a Housemanager Supervisor who would overseer that the fire drills are done monthly and on each shift 8-4 4-12 and 12-8. The hiring packet has been submitted and is waiting approval.
Until the housemanager supervisor is hired the director will assign a house manager on each shift a day and time that the fire drills must completed, ensuring that a drills are done three times a month and on each shift.
Director will then check to assure that the drill was complted and documented correctly on designated day and time the Director specified, this
will ensure that the fire drills are being performed per regulations.
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705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Based upon observation, a physical plant inspection and an interview with the administrative assistant, the facility failed to secure all hazardous and poisonous substances and materials with safety latches or locks.
The findings include:
A physical plant inspection was conducted on November 15, 2010 between the hours of approximately 5:00 PM to 6:00 PM.
1. It was observed at 5:15 PM that there were hair care products (shampoos, conditioner and mousse), hand lotions, baby oil, baby powder, deodorants and a tube of adult toothpaste on a table in the bathroom of room #1. These were not secured out of reach of children. In addition, there were two tooth brushes and three children ' s cups and lids on the same table.
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Plan of Correction
House manager will assist the client with moving their personal care and baby care products items from the bathroom tables and assist them in placing those items into their top dresser drawer or they may place items on the top shelf of their closets.
House managers will perform a daily check on the bathroom and bedrooms to assure that no items including tooth is left within the reach of children. If items are found in bathroom they will get the resident to remove item(s) and place in their top drawer or top of closet.
Childrens cups and lids will be washed by the childs mother and placed in the kitchen or on top of their dresser. No cups or lids will be left in the bathrooms.
When house managers check the bathroom/bedroom daily they will check and have the mother(s)remove cups and put in their new prespective place.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client medical records, an interview with the administrative assistant, and a review of the policy and procedures manual, the facility failed to document a physical examination by a qualified physician within seven days of admission in accordance with policies and procedures.
The findings include:
The facility's policy states:
A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend. Documentation of the results of the physical examination shall include but not be limited to: evidence of injury, neurological findings, investigation of the organ systems for potential infectious disease, pulmonary, liver and cardiac abnormalities, dermatological sequelae of addiction, vital signs, examination of general appearance, head, ears, eyes, nose, throat, chest, abdomen, extremities, skin assessment, concurrent problems and the physician's overall impression of the client.
On November 15, 2010, five client medical records were reviewed.
The facility failed to document physical examinations per policy in five of five client records reviewed, # 1, 2, 3, 5, and 6.
Client # 1 was admitted to the program on 7/12/10.
A certified nursing assistant completed the vital signs on 7/13/10.
The physician signed the last page of the physical on 7/19/10; however, the exam did not include the patient's general appearance nor the physician's impressions/diagnosis.
Client # 2 was admitted to the program on 8/10/10.
A certified nursing assistant completed the vital signs, but did not document the completion date.
The physician signed the last page of the physical on 8/16/10; however, the exam did not include the patient's general appearance nor the physician's impressions/diagnosis.
Client # 3 was admitted to the program on 9/1/10.
A registered nurse completed the vital signs on 9/2/10.
The physician signed the last page of the physical on 9/6/10; however, the exam did not include the patient's general appearance nor the physician's impressions/diagnosis.
Client # 5 was admitted to the program on 7/28/10.
A certified nursing assistant completed the vital signs on 8/2/10.
The physician signed the last page of the physical on 8/2/10; however, the exam did not include the patient's general appearance nor the physician's impressions/diagnosis.
Client # 6 was admitted to the program on 7/29/10.
A physician signed the physical and a certified registered nurse practitioner completed the physical on 8/31/10.
The administrative assistant confirmed that the physician was not checking the clients vital signs on the day of the physical, but was using vital signs recorded by certified nursing assistants and other medical staff that were documented one or more days prior to the physician seeing the client.
This is a repeat deficiency from the May 11, 2010, May 20, 2009, and June 20, 2008 inspections.
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Plan of Correction
1. The CNA has been notified that she is not to sign for any vital signs. The Director of Medical for Gaudenzia needs to provide appearance, oppressions, and diagnosis. The Division Director for the program will be notified so that this issue can be addressed with the medical director. |
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 the review of client records, an interview with the administrative assistant, and a review of the policies and procedures, the facility failed to document treatment and rehabilitation plan updates in accordance with regulation and the facility's policies and procedures.
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.
On November 15, 2010, five client records were reviewed for treatment and rehabilitation plan updates.
The facility failed to document a treatment and rehabilitation plan update per policy in three of five client records reviewed, records # 1, 2 and 6.
Client # 1 was admitted to the program on 7/12/10.
The comprehensive individual treatment plan was documented on 7/19/10.
The treatment plan updates were documented on 8/16/10, 9/16/10 and 10/16/10; however, the treatment plan updates conducted on 8/16/10, 9/16/10 and 10/16/10 failed to provide a report on the client's progress with the goals identified on the treatment plan.
Client # 2 was admitted to the program on 8/10/10.
The comprehensive individual treatment plan was documented on 8/10/10.
Treatment plan updates were documented on 9/10/10 and 10/10/10, but there was no documentation of a treatment plan update conducted on 11/10/10 in the client record.
In addition, the individual treatment plan updates conducted on 9/10/10 and 10/10/10 failed to provide a report on the client's progress with the goals identified on the treatment plan.
Client # 6 was admitted to the program on 7/29/10 and discharged on 9/22/10.
The comprehensive individual treatment plan was completed on 7/14/10.
Treatment plan updates were documented on 8/14/10 and 9/14/10; however, the individual treatment plan updates conducted on 8/14/10 and 9/14/10 failed to provide a report on the clients progress with the goals identified on the treatment plan.
The administrative assistant confirmed that there was no report on progress on the treatment plan updates.
This is a repeat deficiency from the 5/11/10 inspection.
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Plan of Correction
Clinical supervisor will conduct weekly supervision of counselor charts. Clinical Supervisor will provide training in treatment plan goal connection and continuation. Clinical Supervisor will ensure that the treatment plans will be submitted on time. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, an interview with the administrative assistant and clinical supervisor, and a review of the policy and procedures manual , the facility failed to document a complete record of service.
The findings include:
The facilities policy states:
3.Record of Services: All services rendered to a client shall be documented on the Record of Services form, which is maintained in the client record. The form should initially be completed with the intake paperwork. The Counselor or staff person scheduled to provide a service shall record the date a service is scheduled to be provided, the specific service and the initials of the staff responsible for the service. Documentation of this should be made promptly after the appointment is scheduled. The client's attendance status and the duration of the service shall be noted as soon as the disposition is known. A ROS is completed daily.
The findings include:
On November 15, 2010, five client records were reviewed for a record of services provided. Two out of five records reviewed lacked a record of services provided in accordance with the facility policies and procedures.
Client #1 was admitted on 7/12/10 and was an active client at the time of the inspection on 11/15/10. There was no documentation in the record of services provided for the group sessions on 8/18/10 and 9/20/10. There was no documentation in the record of services provided for the 11/3/10 individual session.
Client # 5 was admitted on 7/28/10 and discharged on 10/11/10. There was no record of services in client record # 5.
The administrative assistant and the clinical supervisor confirmed that the record of service in client record # 1 was incomplete and the record of services provided was missing from client record #5.
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Plan of Correction
To ensure that record of services are complete in the charts counselors will take the last hour of each work day to ensure that all services provided by the organization and outside services are documented on the record of services form. Clinical Supervisor will check record of services weekly. Clinical Supervisor will hold an in-service training on the importance of keeping accurate records. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, an interview with the administrative assistant, and a review of the policy and procedures manual, the facility failed to document follow-up information within seven days post discharge as per facility policies and procedures.
The findings include:
The facility's policy states:
20. Follow Up: Within seven (7) days of the date of a referral appointment made for a client
leaving treatment, the referral shall be contacted by the Counselor to determine if the client kept the initial appointment and if the referral was appropriate. In the case of a client ending treatment without a referral appointment (ASA, Therapeutic Discharge, Completion who refuses further treatment), the client shall be contacted directly by the counselor or supervisor' s designee to determine the client ' s well-being and to maintain the opportunity for re-admission should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder.
On November 15, 2010, two client records were reviewed for documentation of follow-up information.
The facility failed to document follow-up information within 7 days from the date of discharge, as per facility policy, in one of two records reviewed, client record # 6.
Client # 6 was admitted to the program on 7/29/10 and discharged on 9/22/10, follow-up with the client was not documented at the time of review on 11/15/10.
The administrative assistant confirmed that the follow ups were not documented.
This is a repeat deficiency from the 5/11/10 and 8/28/07 inspections.
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Plan of Correction
*********The intake/after care counselor met with client # 6 and completed the follow up. The intake/after counselor counselor has provided documented of these findings.
The Program Director will ensure that the follow up is completed on all discharged clients within of 7 days post discharge on all residents by assigning the responsibility to the intake/aftercare counselor.
The follow up information is kept in a binder in the Admistrative Office. The status of the follow call will be reviewed in our weekly staff meeting to assure the follow-up was completed.
Administrative Assistant will be the back up person to make the follow up call in the absence of the intake/aftercare counselor and she will also be responsible to update follow book every time a resident calls into the facility. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of daily census sheets, population sheets and fire drill records, as well as a discussion with the facility director, clinical supervisor and the administrative assistant on November 15, 2010, the facility failed to notify the Department within 90 days of the occurrence of a change in the authorized maximum capacity.
The findings included:
The facility is licensed to provide residential treatment to 16 women and their children.
On November 15, 2010 the administrative assistant was asked to provide a copy of the daily census from May 2010 through November 15, 2010 (the date of the unannounced follow up inspection). The administrative assistant stated that she could provide the information for September 2010 and October 2010, but she could not provide the daily census reports for the remaining time requested, as it was on her computer and her computer was in the shop to be repaired.
A review of the daily census reports for the months of September, 2010 and October, 2010 showed the facility to be at or below the licensed capacity of 16 clients each day of the month. However, the " RESIDENTIAL STATISTICAL REPORT " completed following the end of the month showed the average daily census to be 16.03 for September and 16.5 for October.
The administrative assistant was asked to provide a copy of the fire drill records from May 2010 through October, 2010. The administrative assistant provided a copy of the fire drill records from May 2010 through September 24, 2010.
A review of the fire drill records revealed that out of 11 fire drills, the facility exceeded the licensed capacity 7 times as follows:
On May 6, 2010 at 7:40 AM, 17 clients were documented on the fire drill record on the first page and on the second page via printed name and signature.
On May 29, 2010 at 8:26 (AM & PM both circled), 17 clients were documented on the fire drill record on the first page and on the second page via printed name and signature.
On June 16, 2010 at 7:20 AM ,17 clients were documented on the fire drill record on the first page and on the second page via printed name and signature.
On July 29, 2010 at 8:00 AM, 17 clients were documented on the fire drill record on the first page and on the second page via printed names and 16 signed the fire drill record. One client did not sign, nor was the client's whereabouts during the fire drill noted.
On July 29, 2010 at 11:00 AM, 17 clients were documented on the fire drill record on the first page. There were only 15 printed names on the second page and none of the clients signed their names, nor had the whereabouts of the clients been documented.
On August 10, 2010 at 3:35 PM, 16 clients were on the fire drill record; however, there were 17 printed names on page two with 16 signatures and one client being identified as being in the hospital.
On August 26, 2010 at 8:00 AM, 17 clients were documented on the fire drill record on page 1; however, there were 18 printed names and 17 signatures on the second page with one client not signing and the whereabouts not being documented.
In addition, the facility provided copies of the facility's " Population Sheet " for May 1, 2010 and November 8, 2010, and without any specified dates, for the months of July through October of 2010. The May 1, 2010 population sheet indicated that there were 17 clients, the population sheets for the months of July through October inclusive listed 17 clients. The November 8, 2010 population sheet was the only population sheet provided where the facility had not exceeded the licensed capacity of 16.
The facility director, clinical supervisor, and the administrative assistant confirmed that the facility exceeded the licensed capacity on the above mentioned dates and failed to notify the department of a change in the licensed capacity.
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Plan of Correction
Intake worker will be supervised by Director and will not be permitted to admit any residents over the limited capacity of 16.
Intake worker will report in staff meetings/case consults potential intakes and counselor will report potential clients discharges and there date of discharge preventing client overlapping. This system will assure that there is never more than 16 clients admitted to the program, and that our daily census do not exceed the stated capacity.
Current program director and divisional director will not allow residents to be admitted into the program in excess of the maximum of 16 by adhering to the above system.
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