INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9-10, 2018 at Gaudenzia Fountain Springs 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 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:
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
The facility failed to document direct observation of staff #5, a counselor assistant during the month of July 2017 prior to obtaining an Associates degree in August 2017.
Staff # 5 was originally hired on April 22, 2013 and promoted to the position of a counselor assistant on July 7, 2017. The facility would have been required to provide direct observation until the employee received their Associate's Degree and continue close supervision for a period of 9 months thereafter.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will meet with the Clinical Supervisor and review regulation 704.9(c) by August 31, 2018 and will obtain written notification that the regulation is understood. The Program Director will ensure future compliance through discussions at weekly Administrative Meetings. |
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, it was observed that the facility failed to ensure the safety and well-being of clients, staff, and visitors as evidenced by the following:
The front exterior stairs were in disrepair.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Plant Manager has already employed a contractor to make the necessary repairs to the exterior stairs at the entrance of the building. The Program Director and Facility Plant Manager will oversee the completion of this work in order to ensure the safety and well-being of clients, staff and visitors. Expected date of completion for the above work is 10/1/18. |
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, the facility failed to maintain bathrooms in a functional manner at all times.
The bathroom floors and showers on the first floor and third floor were in need of repair and there were several toilets that were not available for use because of plumbing concerns.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Plant Manager has already employed a contractor to make all necessary repairs to showers and flooring. In addition, all toilets will be checked by the Facility Plant Manager for functionality and repairs will be made if necessary. The Program Director and Facility Plant Manager will oversee the completion of this work to ensure that each bathroom is functional, clean and sanitary. Expected date of completion for the above work is 10/1/18. |
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 on a physical plant inspection, it was observed that the facility failed to ensure that stairways, hallways and exits were unobstructed.
The front exterior stairs were roped off so the stairs could not be used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Plant Manager has already employed a contractor to make the necessary repairs to the exterior stairs at the entrance of the building. The Program Director and Facility Plant Manager will oversee the completion of this work to ensure that the area is unobstructed for the safety and well-being of clients, staff and visitors. The expected date of completion for the above work is 10/1/18. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential 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, it was observed that the facility failed to maintain a well-secured handrail for the front exterior stairs.
The siderail of the front exterior stairs was coming unhinged from the stairs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Plant Manager has already employed the services of a contractor to make the necessary repairs to the handrail on the exterior stairs at the entrance of the building. The Program Director and the Facility Plant Manager will oversee the completion of this work to ensure the safety and well-being of clients, staff and visitors. Expected date of completion for the above work is 10/1/18. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
The facility failed to document a medication administration 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 record's #1, 2, 3, and 6.
Client #1 was admitted on February 9, 2018 and was discharged on March 18, 2018.
Client #2 was admitted on January 19, 2018 and was discharged on February 5, 2018.
Client #3 was admitted on January 18, 2018 and was still an active client at the time of the inspection.
Client #6 was admitted on May 17, 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
The Program Director will hold a mandatory staff meeting on August 30, 2018 to discuss regulation 703.32(c)(1) and will obtain written notification that the regulation is understood. The Facility Nurse will provide an in-service regarding this regulation to all staff at this meeting.The Facility Nurse will ensure compliance with this regulation by conducting weekly audits of the client MARs and report findings to the Program Director at the weekly Administrative Meeting. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
The facility failed to document an inspection of the drug storage areas at least quarterly. The last inspection of the drug storage areas was conducted in March 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director met with the Facility Nurse on August 9, 2018 and reviewed regulation 709.32(c)(3) and obtained written notification of her understanding of the regulation. The Facility Nurse will continue to do her monthly inspections of the medication room and present her results to the Program Director at weekly Administrative Meeting. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
The facility failed document a client orientation to the project and a disclosure for the criteria for admission, treatment, completion, and discharge in client record's # 4, 5, 6, and 7.
Client #4 was admitted on April 9, 2018 and was still an active client at the time of the inspection.
Client #5 was admitted on April 13, 2018 and was still an active client at the time of the inspection.
Client #6 was admitted on May 17, 2018 and was still an active client at the time of the inspection.
Client #7 was admitted on may 25, 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
The Program Director will hold a clinical meeting with the Clinical Supervisor, Intake Counselor, and all counselors to review regulation 709.51(b)(1) by August 31, 2018 and will obtain written notification that the regulation is understood. The Clinical Supervisor will ensure compliance of this regulation through monthly CQI audits. In addition, the Orientation Checklist/Signoff Sheet was uploaded into the electronic health record of Client #4, Client #5, Client #6, and Client #7. All are still current clients of Fountain Springs. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to document type and frequency of treatment in the comprehensive treatment plan for client # 4, 5, 6, and 7.
Client # 4 was admitted on April 9, 2018 and was still an active client at the time of inspection. A comprehensive treatment plan was not developed with the client and there was no documentation of type and frequency of treatment.
Client #5 was admitted on April 13, 2018 and was still an active client at the time of inspection. There was no documentation of type and frequency of treatment in the client record.
Client #6 was admitted on May 17, 2018 and was still an active client at the time of inspection. There was no documentation of type and frequency of treatment in the client record.
Client #7 was admitted on May 25, 2018 and was still an active client at the time of inspection. There was no documentation of type and frequency of treatment in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Documentation type and frequency of treatment in the client treatment plan has been corrected in the Gaudenzia Electronic Health Record and is being utilized by all clinical staff. The Clinical Supervisor will ensure compliance with this regulation by conducting monthly CQI audits of client records. |
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
The facility failed to document a treatment plan update at least every 30 days in client record's # 3, 5, and 7.
Client # 3 was admitted on January 9, 2018 and discharged on June 15, 2018. An updated treatment plan was dun on March 27, 2018.
Client # 5 was admitted on April 13, 2018 and was still an active client at the time of the inspection. An updated treatment plan was due on June 14, 2018.
Client #7 was admitted on May 25, 2018 and was still an active client at the time of the inspection. An updated treatment plan was due on June 30, 2018.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. the facility was previously cited for noncompliance with this regulation during the June 8, 2017 and May 25, 2015 licensure inspections.
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Plan of Correction
The Program Director will hold a clinical meeting with the Clinical Supervisor and all counselors and review regulation 709.52(b) by August 31, 2018 and will obtain written notification that the regulation is understood. A supervisory note will also be placed in each counselor personnel file documenting awareness of the regulation. The Clinical Supervisor will ensure compliance of this regulation through monthly CQI chart audits. In addition the Clinical Supervisor will develop a spreadsheet tracking when a client treatment plan review is due and review this spreadsheet with counselor at each weekly clinical meeting. The Program Director will ensure compliance of this regulation by reviewing the treatment plan spreadsheet with the Clinical Supervisor at the weekly Administrative Meeting. |
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 6 charts reviewed.
Client #1 was admitted on February 9, 2018 and was discharged on March 18, 2018. The comprehensive treatment plan, dated 03/2/18, indicated 3 group sessions per week and 1 individual session per week. The chart's record of service and progress notes indicated that the client only received group sessions on 2/12, 2/16, 2/23, 3/5, and 3/12. The chart's record of service and progress notes indicated that the client did not receive an individual session for the weeks of 2/25 and 3/3.
Client #3 was admitted on January 9, 2018 and was discharged on June 15, 2018. The comprehensive treatment plan, dated 2/1/18, indicated 3 group sessions per week and 1 individual session per week. The chart's record of service and progress notes indicated that the client only received 6 group sessions in January, 7 group sessions in February, 8 group sessions in March, 7 group sessions in April, 6 group sessions in May, and 1 group session in June. The chart's record of service and progress notes indicated that the client did not receive an individual session for the weeks of 1/21-27, 2/25-3/3, 4/8-14, 4/22-28, 4/26-5/5, 5/20-26.
Client #4 was admitted on April 4, 2018 and was an active client at the time of the inspection. Treatment plan being followed was unable to be determined because type and frequency was not documented.
Client #5 was admitted on April 13, 2018 and was an active client at the time of the inspection. Treatment plan being followed was unable to be determined because type and frequency was not documented.
Client #6 was admitted on May 17, 2018 and was an active client at the time of the inspection. Treatment plan being followed was unable to be determined because type and frequency was not documented.
Client #7 was admitted on May 25, 2018 and was an active client at the time of the inspection. Treatment plan being followed was unable to be determined because type and frequency was not documented.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. the facility was previously cited for noncompliance with this regulation during the June 8, 2017 licensure inspection.
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Plan of Correction
The Program Director will hold a meeting with the Clinical Supervisor and all counselors to review regulation 709.52 by August 31, 2018 and will obtain written notification that the regulation is understood. The counselors will document via a clinical note in the client record why the client was not able to attend a group or individual session for a specific reason. The Clinical Supervisor will ensure compliance with this regulation by conducting monthly CQI chart audits and discussing client services with the counseling staff at the weekly Clinical Meeting. |