INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted from September 4-5, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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:
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Plan of Correction
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based upon a review of the Staffing Requirements Facility Summary Report (SRFSR) and an interview with the Facility Director (FD), the facility failed to ensure that a counselor assistant was supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7.
The findings include:
The SRFSR was reviewed on September 6, 2012. The SRFSR listed three full-time counselors and one full-time counselor assistant for the program. However, the SRFSR did not list any clinical supervisors for the program.
Licensing Staff spoke with the FD on September 6, 2012, at approximately 2:15 PM. At that time, the FD confirmed that at the time of inspection, the program neither employed a full-time clinical supervisor, nor did it utilize a full-time counselor to supervise the counselor assistant. In addition, the FD reported that they (the FD) provide the supervision for the program's counselor assistant.
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Plan of Correction
The Counselor Assistant will be supervised by the Counselor III weekly, that meets the criteria of having a minimal of two years supervisory experience and has completed the approved trainings. Once a Clinical Supervisor is hired they will supervise the Counselor Assistant with the qualifications.
Program Director will develope a system to assure/check that supervision is being provided to the counselor assistant as indicated by licensure and policy and proceedure. |
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 upon the physical plant inspection, 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:
The physical plant inspection was conducted on September 5, 2012.
The secondary exit from the basement of the Nelson building is located at the rear of the building and opens to a concrete stairwell. The drain at the bottom of the stairwell is directly in front of the exit door and was clogged at the time of inspection, which led to a puddle of standing water between the exit and the stairs. The standing water presented a safety hazard as the area is shaded and someone could slip on the wet surface. In addition, the standing water was a sanitation / health issue as it could facilitate the growth of insects and / or mold.
The findings were confirmed during the inspection by the Maintenance Supervisor.
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Plan of Correction
The maintenance person lifted the drain lid and the standing water went doen the drain. A drain cover with larger holes will be puchased so water is able to go into drain more easily. Maintenance will monitor the building exit area to assure that leaves or anything else is not covering the drain to assure safety and that the area remains clear. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based upon the physical plant inspection, the facility failed to keep milk at or below 40 degrees Fahrenheit (F), and the facility failed to provide documentation that verified that they kept cold food at or below 40 degrees F and frozen food at or below 0 degrees F.
The findings include:
Upon arriving at the facility on September 5, 2012, at approximately 8:07 AM, the Licensing Specialist observed a milk delivery truck parked and idling in the facility's parking lot.
The Facility Director, the Kitchen Supervisor, and the Maintenance Supervisor accompanied the Licensing Specialist during the inspection of the facility's kitchen and food storage areas. The inspection was conducted on September 5, 2012, from approximately 8:45 to 9:15 AM.
Upon exiting the main kitchen at approximately 9:08 AM, the Kitchen Supervisor requested that 2 individuals help store the milk delivery in the refrigerator. At approximately 9:10 AM, the Licensing Specialist, while accompanied by the Kitchen Supervisor, observed 10 crates of milk stacked outside the produce and dairy refrigerator Upon close inspection, it was noted that condensation had collected on the outside surfaces of the milk cartons and the milk cartons were not cold to the touch. The Kitchen Supervisor confirmed that the facility had received the milk delivery at some point within the previous hour. At the request of the Licensing Specialist, the Kitchen Supervisor took the temperature of the milk, using a laser thermometer. The temperature registered 68 degrees F. To ensure the reading was accurate, a new battery was installed in the laser thermometer. The second reading also registered 68 degrees F.
The findings were confirmed by the Kitchen Supervisor. The facility corrected the deficiency at the time of the inspection by returning the milk to the vendor.
Temperature logs for the Meat Freezer (#3) and Bread Freezer (#2), for the time frame of May 30, 2012 to June 18, 2012, a 20 day period, were reviewed on September 5, 2012. Temperatures were taken at 10 AM, 2 PM, 6 PM, 10 PM, 2 AM, 4 AM and 6 AM on each day.
Temperatures ranged from 1 to 9 degrees F for the Meat Freezer (#3) as follows:
19 of 20 daily readings taken at 10 AM
17 of 20 daily readings taken at 2 PM
17 of 20 daily readings taken at 6 PM
18 of 20 daily readings taken at 10 PM
19 of 20 daily readings taken at 2 AM
19 of 20 daily readings taken at 4 AM
18 of 20 daily readings taken at 6 AM
Temperatures ranged from 1 to 9 degrees F for the Bread Freezer (#2) as follows:
19 of 20 daily readings taken at 10 AM
20 of 20 daily readings taken at 2 PM
17 of 20 daily readings taken at 6 PM
19 of 20 daily readings taken at 10 PM
19 of 20 daily readings taken at 2 AM
19 of 20 daily readings taken at 4 AM
18 of 20 daily readings taken at 6 AM
In addition:
The facility maintained a combination refrigerator / freezer for the clients in the facility's kitchenette. However, the facility did not maintain temperature logs to demonstrate that cold food was stored at or below 40 degrees F and frozen food at or below 0 degrees F.
The facility also maintains a "Reach-In Refrigerator" in the main kitchen. However, the facility did not maintain temperature logs to demonstrate that cold food was stored at or below 40
degrees F.
The findings were confirmed by the Facility Director and the Kitchen Supervisor.
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Plan of Correction
The food service person will have the milk delevered after 9am when she is present to check the temperature for the appropiate temperature, if the milk is not at standard it will be returned to vendor.
The freezer was serviced and repaired 7/17-7/23-7/24, it was also servived and rpaired on 10/13/12, all service receipts will be forwared. New thermometer were placed in each unit. Food will be pulled twice daily to assure the temperature is accurate, (persons not in and out of freezer all day).
West Chester and Kindred are maintaining a log for the refrigerator and freezer: temperatures are taken each shift (3). The Director monitors Kindred House, the food service person will monitor West Chester's log. |
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 upon the physical plant inspection, the facility failed to ensure that it remained rodent free at all times.
The findings include:
The physical plant inspection was conducted on September 5, 2012, from approximately 11:00 AM to 12:00 PM.
While inspecting the exterior of the building, the Licensing Specialist observed dirt and small stones spread out in front of a hole in the ground. The hole was located just off the corner of bedroom # 4, right next to the foundation of the facility.
The FD confirmed that the hole had been used by a groundhog.
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Plan of Correction
The Pest Control was contracted and the situation of the ground hog hole was addressed by setting a trap. The area as well as the total perameter around the building will be monitored daily by maintenance and the program director. Pest control will be contated if any occurances arise. |
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 the physical plant inspection, the facility failed to ensure that fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
The physical plant inspection was conducted on September 5, 2012, from approximately 11:00 AM to 12:00 PM.
A fire extinguisher located in a basement classroom within the Nelson building had an expired tag. The inspection tag indicated that the fire extinguisher was last inspected in October 2009.
The findings were confirmed by the facility's Maintenance Supervisor.
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Plan of Correction
October 10, 2012 was the annual inspection on all fire extinguishers.
The fire extinguisher in question was replaced immediately on 9/5/12 before the licensure person left the room. A log was created that will track each fire extinquisher's location, number and the date it was put into service, and the date it is due to be inspected. The program director makes weekly program inspections and will monitor the fire extinguishers and log at those time and log the monitoring. |
705.11 (2) (ii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(ii) Maintain security screens or safety locks for all operable windows.
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Observations
Based upon the physical plant inspection, the facility failed to maintain security screens or safety locks for all operable windows.
The findings include:
The physical plant inspection was conducted on September 5, 2012, from approximately 11:00 AM to 12:00 PM.
The facility had eight client bedrooms that contained windows for natural lighting. The facility utilized security screens instead of safety locks to secure the windows. However, security screens were either damaged or missing in four of eight bedrooms, specifically room #'s 4, 5, 6, and 7.
Room # 4 contained two side-by-side windows. The security screen for the right side window was missing at the time of inspection.
Room # 5 contained two side-by-side windows. The left side of the security screen for the left side window was damaged and could not be secured to the window frame at the time of inspection.
Room # 6 contained two side-by-side windows. The right side of the security screen for the left side window was damaged and could not be secured to the window frame at the time of inspection.
Room # 7 contained two side-by-side windows. The left side of the security screen for the left side window was damaged and could not be secured to the window frame at the time of inspection.
The FD confirmed the findings during the physical plant inspection.
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Plan of Correction
All damaged security screens will be replaced. The facility staff and program director will make daily maintenance runs to assure the screens stay undamaged and secure. |
709.28(c)(2) 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. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based upon the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of specific information contained in the client record.
The findings include:
Nine records requiring documentation of informed and voluntary consent forms were reviewed from September 5 - 6, 2012. Consent forms contained in five of nine records, specifically #'s 1, 2, 3, 4, and 5, failed to identify the specific information to be disclosed.
Client # 1 was admitted on June 22, 2012, and was still an active client on the date of inspection. The record contained documentation of a consent form for the client's funding source that was signed and dated by the client on June 22, 2012. The consent form listed "Admission, Continued Stay, and Discharge" as the information to be disclosed to the funding source.
Client # 2 was admitted on May 25, 2012, and was still an active client on the date of inspection. The record contained documentation of a consent form for the client's funding source that was signed and dated by the client on May 25, 2012. The consent form listed "Admission, Continued Stay, and Discharge" as the information to be disclosed to the funding source.
Client # 3 was admitted on August 10, 2012, and was still an active client on the date of inspection. The record contained documentation of a consent form for the client's funding source that was signed and dated by the client on August 10, 2012. The consent form listed "Admission, Continued Stay, and Discharge" as the information to be disclosed to the funding source.
Client # 4 was admitted on July 5, 2012, and was still an active client on the date of inspection. The record contained documentation of a consent form for the client's funding source that was signed and dated by the client on July 5, 2012. The consent form listed "Admission, Continued Stay, and Discharge" as the information to be disclosed to the funding source.
Client # 5 was admitted on July 3, 2012, and was still an active client on the date of inspection. The record contained documentation of a consent form for the client's funding source that was signed and dated by the client on July 3, 2012. The consent form listed "Admission, Continued Stay, and Discharge" as the information to be disclosed to the funding source.
The findings were confirmed with the Facility Director during the record review.
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Plan of Correction
The consent forms in the records were corrected with the proper/specific information within the 5 domanines of confidenttality. All staff (clinical) will recieve an in-house training on the correct information that needs to be on consent forms. All staff has recieved or is scheduled to attend confidentiality training. Director will monitor proper documentation of consent forms weekly. |
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
Based upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan.
The findings include:
The facility's P&P Manual was reviewed on September 6, 2012.
The policy titled, "Counseling Services" includes the following language:
"Counseling services shall be provided for each client according to the frequency and nature identified on the client's individualized treatment and rehabilitation plan."
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"Individual counseling shall occur at least one (1) hour weekly, generally divided into two 30 minute sessions, and shall be documented in the client record in an Individual Counseling Progress Note. (Residential DOH, PA)"
Nine client records requiring documentation of counseling services were reviewed from September 5 - 6, 2012. Three of nine records, specifically records #'s 1, 2, and 4, did not contain documentation that verified that counseling services were provided according to the individual treatment plan.
Client # 1 was admitted on June 22, 2012, and was still an active client on the date of inspection. The record contained an Initial Treatment Plan that was signed and dated on June 25, 2012. The Treatment Plan specified that Individual counseling sessions be conducted one time per week. However, the record did not contain documentation of an Individual session for the week of:
August 19 - 25, 2012
In addition, the Initial Treatment Plan contained in record # 1 specified that Static Group sessions be conducted one time per week. However, the record did not contain documentation of Static Group sessions for the weeks of:
July 1 - 7, 2012; July 8 - 14, 2012; July 15 - 21, 2012; July 22 - 28, 2012
July 29 - August 4, 2012; August 12 - 18, 2012; August 19 - 25, 2012
Client # 2 was admitted on May 25, 2012, and was still an active client on the date of inspection. The record contained an Initial Treatment Plan that was signed and dated on May 28, 2012. The Treatment Plan specified that Individual counseling sessions be conducted one time per week. However, the record did not contain documentation of Individual sessions for the weeks of:
June 10 - 16, 2012; June 24 - 30, 2012
July 1 - 7, 2012; July 15 - 21, 2012; July 22 - 28, 2012
August 19 - 25, 2012; August 26 - Sept. 1, 2012
In addition, the Initial Treatment Plan contained in record # 2 specified that Static Group sessions be conducted one time per week. However, the record did not contain documentation of Static Group sessions for the weeks of:
May 28 - June 2, 2012
June 3 - 9, 2012; June 10 - 16, 2012; June 17 - 23, 2012; June 24 - 30, 2012
July 1 - 7, 2012; July 8 - 14, 2012; July 15 - 21, 2012; July 22 - 28, 2012
July 29 - August 4, 2012;
August 12 - 18, 2012; August 19 - 25, 2012
Client # 4 was admitted on July 5, 2012, and was still an active client on the date of inspection. The record contained an Initial Treatment Plan that was signed and dated on July 9, 2012. The Treatment Plan specified that Individual counseling sessions be conducted one time per week. However, the record did not contain documentation of Individual sessions for the weeks of:
July 8 - 14, 2012
August 19 - 25, 2012; August 26 - Sept. 1, 2012
In addition, the Initial Treatment Plan contained in record # 4 specified that Static Group sessions be conducted one time per week. However, the record did not contain documentation of Static Group sessions for the weeks of:
August 19 - 25, 2012; August 26 - Sept. 1, 2012
The findings were reviewed with the Facility Director during the record review and during the exit interview.
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Plan of Correction
The program director met with the clinical staff to discuss the importance of providing treatment as indicated on treatment plans. Director reviewed with clinical the proper documentation of sessions and missed sessions.
The director will review clinical files weekly to assure that treatment plans are being followed through as indicated on treatment plan. |
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 upon a review of client records, the facility failed to maintain a complete client record, to include a 'record of services' provided.
The findings include:
Nine client records were reviewed from September 5 - 6, 2012, for completion of the 'record of services' provided. Two of nine records, specifically #'s 4 and 5, did not contain a complete 'record of services' provided to the client.
Client # 4 was admitted on July 5, 2012, and was still an active client at the time of inspection. The record contained a 'record of services' that was incomplete as it did not include entries for static group sessions that were documented by progress note on the following dates:
July 5, 11, 18, and 25, 2012
August 1 and 15, 2012
Client # 5 was admitted on July 3, 2012, and was still an active client at the time of inspection. The record contained a 'record of services' that was incomplete as it did not include entries for static group sessions that were documented by progress note on the following dates:
July 5, 11, 18, and 25, 2012
August 1 and 15, 2012
The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
The recored of services indicated in the citiation were all updated and completed. The program director will have bi-weekly clinical meetings that will review each clinical file to assure the record of service is complete with documentations being file and recored on the record of servide. |