INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 26, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia - New Destiny was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
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.
|
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:
1) The plumbing access door, next to the bathroom between Room 5 and Room 7b, allowed free access to hot-water pipes, jagged flooring and a large hole through to the ceiling of the 2nd floor.
2) In Room #1, there was an area of cracked plaster on the inside door jamb, as well as an area of damaged plaster in the hallway just outside of Room #1 that the facility had covered with cardboard.
3) There was an area of cracked plaster on the inside wall near the door jamb of Room #8.
4) Room #7a had a closet door that had been kicked and was missing the middle panel; this damage left dried paint chips hanging from the wood.
5) The 3rd floor stairwell landing had a section of handrail that was missing and the supporting ledger board was broken, which left splintered wood.
6) There is an old blacktop walkway leading from the building in the outside children's playground area that had unstable wood landscape ties and broken/chipped blacktop, which created a tripping hazard.
The findings were reviewed with facility staff during the licensing inspection process.
|
Plan of Correction
Building exterior and grounds shall be clean, safe, sanitary, a 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.
The plumbing access door next to the bathroom between rooms 5 and 7b was made safe through the installation of a lock and hasp on May 27, 2016, by New Destiny Staff. There is no access to the area except by key.
All areas requiring repair: areas with cracked plaster (Rooms 1 and 8) around the door jamb; and the third floor hall; the closet door, room 7a; the damaged handrail on 3rd floor; the area of blacktop in the children's play area, will be reviewed by a construction contractor, a bid submitted, and work completed within 120 days of this POC. Date of completion: 10/16/2016. Responsible: The Program Director and Facilities Manager will ensure work is completed to ensure safety and well-being.
|
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.
|
Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent to release information form in client records, #1, 5, 6, 7, 8, 10, and 13. Additionally, client records, #11, 12, and 13 were missing the specific information to be released and/or the specific name of the person/organization to whom the disclosure was made to.
#1 was admitted on 03/03/2016 and was still an active client at the time of the inspection. There was documentation that a facsimile was sent to the a government agency on 04/17/2016; however, there was no proper consent to release information form completed by the client prior to disclosure
#5 was admitted on 09/16/2015 and was discharge on 11/27/2015. There was documentation that a facsimile was sent to a government agency on 09/17/2015; however, the consent to release information form completed by the client had expired prior to disclosure.
#6 was admitted on 09/16/2015 and was discharged on 11/27/2015. There was documentation of telephone contact to an outside agency (dated 3/15/2016) and two separate treatment providers (dated 3/20/2015 and 3/23/2015); however, there was no proper consent to release information form completed by the client prior to all disclosures.
#7 was admitted on 12/04/2015 and was discharged on 04/18/2016. There was documentation that telephone contact was made to a government agency on 04/06/2016; however, there was no consent to release information form completed by the client prior to disclosure.
#8 was admitted on 12/17/2015 and was discharged on 04/28/2016. There was documentation that a facsimile was sent to a government agency on 12/22/2015; however, the consent to release information form completed by the client had expired prior to disclosure.
#10 was admitted on 02/09/2016 and was still a client at the time of the inspection. There was documentation that a telephone contact was made to a government agency on 04/28/2016; however, there was no consent to release information form completed by the client prior to disclosure.
#13 was admitted on 10/08/2015 and was discharged on 01/25/2016. There was documentation that a facsimile was sent to a government agency on 10/12/2015; however, the consent to release information form completed by the client had expired prior to disclosure.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Informed and voluntary consents will be maintained in order for information to be released. Prior to releasing any information clinical staff will ensure there are consents that are signed and maintained. Following the onsite visit of 5/26/2016 all open charts were reviewed in order to ensure the proper consents were completed and to make sure none were expired. On 6/01/2016 a training was conducted by the Program Director and Clinical Supervisor to discuss consents for phone calls and faxes and the importance of timeliness and completeness. Further, the importance of establishing dates of expiration were discussed and the importance of ensuring the consents covered the appropriate time frame. A tool was developed and will be put into place by July 1 following additional clinical training to list all consents signed for each client. The tool will consist of a master list which is a living document to add or delete consents as needed. The counselors will review all their own charts at least once a month. The Clinical Supervisor will review randomly selected files monthly to ensure compliance. The Clinical Supervisor is responsible for ensuring compliance and will report on progress monthly to Program Director. The first files will be reviewed before June 30th, 2016 in conjunction with Quality Assurance review.Completion date: July 1 |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of client records, the facility failed to document physical examinations in client records, #1, 2, 10, 11, and 13 as of the date of the inspection.
#1 was admitted on 03/03/2016 and was still an active client at the time of the inspection.
#2 was admitted on 04/14/2016 and was still an active client at the time of the inspection.
#10 was admitted on 02/09/2016 and was still an active client at the time of the inspection.
#11 was admitted on 10/05/2015 and was still an active client at the time of the inspection.
#13 was admitted on 10/08/2015 and was discharged on 01/25/2016.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Physical examinations must be documented in the client records. A licensed physician has been obtained who will examine and document a physical examination for each client admitted to the facility. Each client will have a physical exam completed within seven (7) days of admission and entered into the client case record. The Case Manager will ensure the physicals are scheduled in a timely manner and the Clinical Supervisor and Program director will ensure that all case records are compliant and contain the physical exam. In files for those still in treatment at the time of the survey and in one file that had completed, it was possible using consents signed during treatment to obtain copies of nursing assessments or physicals completed within six months of admission to the facility. One file also contained emergency room report containing vitals and system examination with recommendations. Efforts to obtain the final physical via DOCNET are continuing and expected to be obtained by July 1.The Program Director has examined the files without physicals to ensure that the medical information is in place. Date of completion: July 1, 2016.
|
709.53(a) LICENSURE Complete Client Record
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:
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include Follow-up, case consults, aftercare plan and discharge summaries, in client records, #5, 7, 8, 9, 12, and 13.
#5 was admitted on 09/16/2015 and was discharged on 11/27/2015. The client record did not contain follow-up information as of the date of the inspection.
#7 was admitted on 12/04/2015 and was discharged on 4/18/2016. The client record did not contain follow-up information as of the date of the inspection.
#8 was admitted on 12/17/2015 and was discharged on 4/28/2016. The client record did not contain follow-up information as of the date of the inspection.
#9 was admitted on 2/1/2016 and was discharged on 3/21/2016. The client record did not contain follow-up information as of the date of the inspection.
#12 was admitted on 10/28/2015 and was discharged on 3/24/2016. The client record did not contain follow-up information, case consultation notes, and an aftercare plan as of the date of the inspection.
#13 was admitted on 10/8/2015 and was discharged on 1/26/2016. The client record did not contain follow-up information and case consultation notes as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
There will be a complete client record that includes client's involvement with the program. On 5/26/2016 the Program Director and Clinical Supervisor spoke to Intake Specialist regarding the need to ensure documentation of all contacts whether by mail, phone, or face to face within 7 days of discharge. This was also covered in Clinical Training on 6/1/2016 and at the staff meeting 6/16/2016 where all staff was informed of the need to make sure all contacts are documented. On 6/16/16 addition training was conducted with clinical staff by the Clinical Supervisor on the effective use of the Case Consult and the importance of documenting consultations in a timely and effective manner. The importance of the aftercare plans being reviewed by Clinical Supervisor prior to discharge was also discussed. It is a requirement that the client receive the Aftercare Plan prior to discharge and the counselor will ensure the document and its attending documents are filed in accordance with facility procedure. The Clinical Supervisor will review charts periodically and at discharge to ensure compliance. Results of the review will be provided on a monthly basis to the Program Supervisor. Completed 6/16/2016
|