INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 2, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of 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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705.2 (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 on May 2, 2024, the facility failed to keep the yard free of hazards, as a garden box on the path to the children ' s play area had several exposed rusty nails.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon discovery of the garden box hazard, the Program Director immediately asked staff to remove the garden box and it was discarded in the facility dumpster the same afternoon.
Ongoing compliance will be monitored via a monthly safety inspection reviewed by the Recovery Support Professional Supervisor.
Completed 5/2/2024 |
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 a physical plant inspection on May 2, 2024, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as there was an uncovered dumpster in the front of the building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Recovery Support Professional Supervisor will ensure that garbage is stored in covered containers that prevent the penetration of insects and rodents.
The dumpster lids were promptly closed by staff.
All staff and clients were reminded of the regulations requiring lids to be kept closed on refuse containers.
Recovery Support Professionals will monitor daily ongoing compliance via facility rounds each shift and monthly self-inspection logs.
Completed 5/3/24 |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on May 2, 2024, the facility failed to provide an operable soap dispenser in one first-floor and one second-floor communal bathroom.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that all bathrooms include an operable soap dispenser.
A work order was submitted to the Maintenace Department for the reinstallation of two soap dispensers identified as missing in the bathrooms.
In the interim while awaiting installation of wall mounted soap dispensers, pump bottles of hand soap have been placed on each bathroom sink counter.
The Recovery Support Professional Supervisor will conduct ongoing monitoring of conformance via monthly physical plant inspection logs.
Targeted 6/30/24 |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable record reviewed.
Client # 2 was admitted on February 27, 2024 and was discharged Against Staff Advice (ASA) on April 5, 2024. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Program Director and Clinical Supervisor will ensure that the Emergency Contact is notified within 12 hours of a client discharge against staff advice and documented in the record.
The protocols for actions to be taken in the event of a discharge against staff advice were reviewed with Counselors and support staff.
Monitoring of ongoing conformance will be conducted by the Clinical Supervisor and the Continuous Quality Improvement Dept via monthly client record audits
Completed 5/22/24 |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that annual written individual staff performance evaluations, were reviewed and signed by the employee per the facility's policy and procedure manual in four of four applicable personnel records reviewed. The facility's policy and procedure manual states that the annual job performance evaluations are due at the beginning of each calendar year. Project staff indicated evaluations specifically are to be completed and signed by February 1 each year.
Employee # 1 was hired as the Project Director on September 9, 2019 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, it was not signed by the employee until February 28, 2024.
Employee # 3 has been in the position of Clinical Supervisor since February 25, 2020. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, it was not signed by the employee until February 12, 2024.
Employee # 4 has been in the position of counselor since June 13, 2022. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, however, it was not signed by the employee until February 15, 2024.
Employee # 5 has been in the position of counselor since November 16, 2009. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, however, it was not signed by the employee until February 15, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Deputy and Program Directors will meet with facility managers to ensure that all personnel records will include a written annual staff performance evaluation, reviewed, and signed by the employee in accordance with agency policy by February 1 each year, including but not limited to the Project Director and facility staff.
Facility supervisors will begin evaluations with direct supervisees in early January and submit completed documentation by February 1 each year.
Training will be provided as needed.
The Deputy and Program Directors and Human Resources will monitor weekly the facility evaluation progression in January to assure conformance.
Completed 6/3/2024 |
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
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in six records reviewed.
Client # 1 was admitted on July 31, 2023 and was discharged on December 13, 2023. The record contained documentation of a disclosure of information to a government agency on September 18, 2023, however, the record did not contain a client signed consent to release information form to the agency.
Client # 2 was admitted on February 27, 2024 and was discharged on April 5, 2024. The record contained documentation of a disclosure of information to a government agency on March 1, 2024, however, the record did not contain a client signed consent to release information form to the agency.
Client # 3 was admitted on August 29, 2023 and was discharged on February 22, 2024. The record contained documentation of a disclosure of information to a government agency on September 12, 2023, however, the record did not contain a client signed consent to release information form to the agency.
Client # 4 was admitted on June 23, 2023 and was discharged on October 19, 2023. The record contained documentation of a disclosure of information to a government agency on September 12, 2023, however, the record did not contain a client signed consent to release information form to the agency.
Client # 5 was admitted on February 12, 2024 and was active at the time of the inspection. The record contained documentation of a disclosure of information to a government agency on March 1, 2024, however, the record did not contain a client signed consent to release information form to the agency.
Client # 6 was admitted on February 26, 2024 and was active at the time of the inspection. The record contained documentation of a disclosure of information to a government agency on March 1, 2024, however, the record did not contain a client signed consent to release information form to the agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director, Clinical Supervisor, and Administrative Coordinator will ensure that an informed and voluntary consent from the client for the disclosure of information is obtained prior to a release of information including to governmental agencies.
The regulations were reviewed with admission and clinical staff and training provided as needed.
Ongoing conformance will be monitored monthly by program managers and the Continuous Quality Improvement Dept via record audits.
Completed 5/22/24 |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the reason for the facility's decision to involuntarily terminate the client's treatment at the project in one applicable record reviewed.
Client # 1 was admitted on July 31, 2023 and was involuntarily discharged on December 13, 2023. The record did not contain documentation that the client was notified, in writing, of the facility's reason to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Clinical Supervisor will ensure that the record includes documentation of a client's receipt of written notice of reason for the facility's decision to involuntarily terminate the client's treatment at the project.
The related regulation and program policy was reviewed with clinical staff.
The Clinical Supervisor and Continuous Quality Improvement Manager will conduct monthly client record audits to monitor ongoing conformance.
Completed 5/22/2024
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on the review of the unusual incident tracking system, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the physical or sexual assault by staff or a client.
There was documentation of a client assault on April 24, 2024; however, there was no documentation that a written unusual incident report was ever filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will assure that the facility files a written unusual incident report with the Department within three business days following an unusual incident involving the physical or sexual assault by staff or a client.
The incident reporting policies and procedures were reviewed with staff including required notification of the Department.
The Clinical Supervisor will submit the identified outstanding incident report to the Dept by 6/22/24
Ongoing compliance will be monitored monthly by the Administrative Coordinator in conjunction with Continuous Quality Improvement activities and safety meeting.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the unusual incident tracking system, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel.
There was documentation of the presence of ambulance and police personnel onsite on April 24, 2024 and ambulance personnel on March 6, 2024; however, there was no documentation that written unusual incident reports were ever filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will assure that the facility files a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel.
The incident reporting policies and procedures were reviewed with staff including required notification of the Department.
The Clinical Supervisor will submit the identified outstanding incident reports to the Dept by 6/22/24.
Ongoing compliance will be monitored monthly by the Administrative Coordinator in conjunction with Continuous Quality Improvement activities and safety meeting.
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709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a client ' s personal history within five days of admission, per facility policy, in three of seven applicable records reviewed.
Client # 1 was admitted on July 31, 2023 and was discharged on December 13, 2023. The personal history was not completed until August 24, 2023.
Client # 3 was admitted on August 29, 2023 and was discharged on February 22, 2024. The personal history was not completed until September 13, 2023.
Client # 5 was admitted on February 12, 2024 and was active at the time of the inspection. The personal history was not completed until March 2, 2024
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Program Director will assure that a client's personal history is documented within 5 days of admission per organization policy.
The clinical workflow and policy on history collection was reviewed with counselors. Training will be provided as needed.
Ongoing conformance will be monitored via monthly record audits conducted by program managers and the Continuous Quality Improvement Department
Completed 5/22/2024 |
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
Based on a review of seven client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within five days of admission, per facility policy, in four records reviewed.
Client # 1 was admitted on July 31, 2023 and was discharged on December 13, 2023. The psychosocial evaluation was not completed until August 24, 2023.
Client # 3 was admitted on August 29, 2023 and was discharged on February 22, 2024. The psychosocial evaluation was not completed until September 13, 2023.
Client # 4 was admitted on June 23, 2023 and was discharged on October 19, 2023. The psychosocial evaluation was not completed until August 22, 2023.
Client # 5 was admitted on February 12, 2024 and was active at the time of the inspection. The psychosocial evaluation was not completed until February 23, 2024.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Clinical Supervisor will assure the documentation of a psychosocial evaluation within 5 days of admission per facility policy.
The clinical workflow and related policy was reviewed with counselors and training provided as needed.
The Continuous Quality Improvement Dept and program managers will monitor ongoing compliance via monthly record audits.
Completed 5/22/24 |