INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7, 2017 through June 8, 2017 by staff from the Division of Drug and Alcohol Program Licensure. 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:
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Plan of Correction
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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
The physical plant inspection was conducted on June 7, 2017. The facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
At the time of the inspection, it was observed in the second floor bathroom that the cover of the lower portion of the heating unit was missing, exposing debris such as hairs, grass and touch-n-foam insulation. Additionally, without the cover, there were exposed, sharp edges, some of which were rusted.
It was observed in the stabilization unit bathroom that baseboards were missing, exposing crumbling gypsum, torn paper on the drywall and some areas with mold.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Plant Manager will complete a physical walk through of the bathroom areas and ensure all necessary baseboards are replaced. In addition, the heating unit in the second floor bathroom will have a bottom panel added to it so as to cover the exposed edges and touch-n-foam insulation. The Program Director and Facility Plant Manager will oversee the completion of work to ensure the safety and well being of clients, children, staff and visitors. Expected date of completion for the above work is August 11,2017. Also, the Program Director will hold a mandatory staff meeting by July 30, 2017 to discuss conducting regular walk throughs of the bathroom areas in order to ensure sanitary and safe conditions. The Program Director will obtain written notification that this is understood. |
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.
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Observations
Seven client records were reviewed on June 7, 2017 and June 8, 2017. The facility failed to obtain an informed and voluntary consent in two of seven client records reviewed.
Client #5 was admitted into treatment on October 24, 2016 and was discharged on February 19, 2017. The client record contained documentation indicating that the facility released patient identifying information to a pharmacy on February 13, 2017, a hospital on February 13, 2017 and a physician on November 9, 2016. The facility failed to obtain informed and voluntary consents prior to the disclosures.
Client #7 was admitted into treatment on September 20, 2016 and was discharged on March 7, 2017. The client record contained documentation indicating that the facility released patient identifying information to a physician's office on November 9, 2016 and failed to obtain an informed and voluntary consent prior to the disclosure.
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 meeting for all staff by July 30, 2017 to review regulation 709.28. confidentiality.(c) and will obtain written notification that the regulation is understood. The Clinical Supervisor will ensure compliance through monthly CQI audits. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Seven client records were reviewed on June 7, 2017 and June 8, 2017. The facility failed to document written acknowledgement by clients that they have been notified of all their rights as the following rights were not listed on the Client Rights Forms:
* Clients have the right to appeal a decision limiting access to their records to the director.
* Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"Gaudenzia will ensure that all clients are fully informed of their rights as per DDAP regulations. Relevant sections of existing Gaudenzia, Inc. policy will be added to the client orientation materials which will be reviewed with the client at the beginning of treatment who will sign to indicate that they have received and understand all orientation materials. The Program Director will ensure that this is completed by July 30, 2017. The regular CQI audits at each program will be utilized on a monthly basis to monitor completion of orientation sign off." |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Seven client records were reviewed on June 7, 2017 and June 8, 2017 for intake and admission documentation. The facility failed to document a psychosocial evaluation in two of the seven records reviewed. Specifically, in client records #4 and #5.
Client #4 was admitted into treatment on August 29, 2016 and was discharged on December 15, 2016. The client record contained no documentation of a psychosocial evaluation.
Client #5 was admitted into treatment on October 24, 2016 and was discharged on February 19, 2017. The client record contained no documentation of a psychosocial evaluation.
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 and all counselors to review regulation 709.51 (b)(6) Psychosocial Evaluation by July 30, 2017 and will obtain written notification that the regulation is understood. The Clinical 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.
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Observations
Seven client records were reviewed on June 7, 2017 and June 8, 2017 for treatment and rehabilitation services.
Client #3 was admitted into treatment on March 17, 2017 and was still an active client at the time of the inspection. A treatment plan update was due on May 3, 2017, but was not completed until May 7, 2017.
Client #4 was admitted into treatment on August 29, 2016 and was discharged on December 15, 2016. A treatment plan update was due on October 22, 2016, but was not completed until October 27, 2016. Additionally, a treatment plan update was due on November 27, 2016 but was not completed.
Client #6 was admitted into treatment on October 13, 2016 and was discharged on March 5, 2017. A treatment plan update was due on November 28, 2016 but was not completed until February 24, 2017.
Client #7 was admitted into treatment on September 20, 2016 and was discharged on March 7, 2017. A treatment plan update was due on November 10, 2016 but was not completed until November 18, 2016.
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 and all counselors to review regulation 709.52(b) TX Plan Update and will obtain written notification that the regulation is understood. Also, an electronic calendar will be implemented and utilized by all clinical staff to better track when client treatment plan updates are due. The Clinical Supervisor will ensure compliance with this regulation through weekly clinical meetings and monthly CQI chart audits. |
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
Seven client records were reviewed on June 7, 2017 and June 8, 2017 for treatment and rehabilitation services. The facility failed to provide counseling services as stated on the treatment plan in five of seven client records.
Client #1 was admitted into treatment on January 30, 2017 and was still an active client at the time of the inspection. The client's treatment plan indicated that individual sessions were to occur once per week. The progress notes and record of service forms contained in the record indicated that the client had no individual sessions during the weeks of March 12, 2017 through March 18, 2017 and May 14, 2017 through May 20, 2017.
Client #2 was admitted into treatment on February 8, 2017 and was still an active client at the time of the inspection. The client's treatment plan indicated that individual sessions were to occur once per week. The progress notes and record of service form contained in the record indicated that the client had no individual sessions during the weeks of May 14, 2017 through May 20, 2017.
Client #3 was admitted into treatment on March 17, 2017 and was still an active client at the time of the inspection. The client's treatment plan indicated that individual sessions were to occur twice per week. The progress notes and record of service forms contained in the record indicated that the client had no individual sessions during the weeks of April 16, 2017 through April 22, 2017 and April 23, 2017 through April 29, 2017.
Client #4 was admitted into treatment on August 29, 2016 and was discharged on December 15, 2016. The client's treatment plan indicated that individual sessions were to occur once per week. The progress notes and record of service forms contained in the record indicated that the client had an individual session on September 16, 2016 and then did not have another individual session until November 16, 2016. Additionally, the individual session that occurred on November 16, 2016 was the last session documented in the record.
Client #6 was admitted into treatment on October 13, 2016 and was discharged on March 5, 2017. The client's treatment plan indicated that individual sessions were to occur twice per week. The progress notes and record of service forms contained in the record indicated that the client had no individual sessions during the weeks of October 30, 2016 through December 3, 2016, December 11, 2016 through December 31, 2016, January 1, 2017 through January 28 2017 and February 5, 2017 through February 11, 2017.
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 and all counselors to discuss regulation 709.52(c) Provision of Counseling Services by July 30, 2017 and will obtain written notification that the regulation is understood. Additionally, all counselors will submit a weekly schedule to the Clinical Supervisor outlining when their respective clients will be seen that week. The Clinical Supervisor will ensure compliance of this regulation through weekly clinical meetings and monthly CQI chart audits. |