INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15 through 17, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc., Harrisburg Concept 90 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 and a plan of correction is due on October 2, 2007.
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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
Based upon documentation reviewed on August 15, 2007 at 9:30 AM and an interview with employee #2, it was determined that the facility failed to document that counselor assistant #6 received supervision in the form of direct observation from the hire date of 4-27-07 through August 16, 2007, the ending date of the visit, and that employee #7 received close supervision beyond 4-28-07.
The findings were:
The facility lacked documentation in the form of supervisory notes for employee #6 at the time of the survey, documentation for employee #7 in the form of supervisory notes did not go beyond 4-28-07, and the interview with employee #2 revealed that no other documentation was available.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based upon review of staffing schedules for the period of July 15, 2007 through August 8, 2007 and staff First Aid and CPR certifications on August 15, 2007, it was determined that the facility failed to ensure that at least one person trained in these skills was on site during the project's hours of operation.
The findings were:
Documentation reviewed indicated that there was a lapse in First Aid and CPR coverage on 7/15/07 from 6:00 PM- 11:00 PM, on 7/22/07, 7/29/07 and 8/5/07 from 10:30 AM - 3:00 PM, on 7/20/07 from 9:00 PM -11:00 PM and on 7/21/07, 7/28/07 and 8/4/07 from 4:00 PM -11:00 PM.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
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Observations
Based upon observation on August 16 during the facility tour between 1:30 PM and 2:30 PM it was noted that the facility failed to ensure that a minimum of one operable, automatic smoke detector was provided on each floor, including the basement and attic.
The Findings were:
The basement lacked an automatic smoke detector.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (b) (2) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(2) On floors with resident bedrooms, maintain a smoke detector which shall be located within 15 feet of each bedroom door. On floors with no resident bedrooms, the smoke detection device shall be located in a common area or hallway. All detection devices shall be interconnected.
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Observations
Based upon observation on August 16 during the facility tour between 1:30 PM and 2:30 PM it was noted that the facility failed to maintain a smoke detector located within 15 feet of each bedroom door.
The Findings were:
The distance between the bedroom doors of rooms 211 & 213 to the nearest smoke detector exceeded 15 feet.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (b) (5) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(5) Maintain automatic smoke detectors and fire alarms of a type approved by the Department of Labor and Industry or by the Underwriters Laboratories.
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Observations
Based upon an interview with employee #2 on August 16, 2007, the facility failed to verify that the automatic smoke detectors were tested and operational in accordance with the Department of Labor and Industry or Underwriters Laboratories standards.
The Findings were:
The facility lacked documentation to verify that the smoke detectors located in their building had been tested and verified to be operational. These are not included on the fire alarm inspection report for Harrisburg State Hospital (HSH) as they are not tied into the hospital's fire alarm system, only the manual pull stations are included on the HSH reports.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
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Observations
Based upon review of the 2005-2006 annual report during the corporate visit conducted August 8, 9, 10, 13 and 14, 2007, the facility failed to identify activities and accomplishments of the preceding year for the program.
The Findings were:
The annual report did not include a statement for each individual program.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based upon review of the goals and objectives for the 2007-2008 fiscal year, the facility failed to identify available resources and time frames for achievement.
The Findings were:
The majority of the goals and objectives do not include available resources and time frames for achievement.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Facility policy states that employees in probationary status are to be evaluated within 90 days. Based upon personnel records reviewed on August 14, 2007 it was determined that the facility failed to complete probationary performance evaluations for two of two staff records reviewed within the 90 day period.
The Findings were:
The personnel record for employee #6 lacked an evaluation and employee record #7 contained an evaluation that was conducted 52 days late per facility policy.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based upon client records reviewed August 15 through 17, 2007 the facility failed to ensure that all consents to release information were informed and voluntary.
The findings were:
Six of six records reviewed contained consents to release information that failed to identify what was being released and to whom information was being released.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28 (c)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based upon client records reviewed August 15 through 17, 2007 the facility failed to inform the client as to whom information was being released to:
The Findings were:
Six of six records reviewed contained a form titled "Medical Release" which was a general consent to release information. The form failed to indicate who the information will be released to.
Three of six records reviewed, # 2, 3 & 4, contained consent to release information forms addressed to Court/Probation parole and/or other referring agencies.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 client records reviewed August 15 through 17, 2007 the facility failed to inform the client as to what information was being released:
The Findings were:
Six of six records reviewed contained consent to release information forms to a check cashing agency that did not indicate what information would be released.
Three of six records reviewed, #2, 3 & 4, contained consent to release information forms addressed to Court/Probation parole and/or other referring agencies that did not indicate what information would be released.
One of six records, #4, reviewed contained a consent to release information form addressed to the parole officer that did not identify the specific information to be released, it simply listed the information as " treatment information " .
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 upon client records reviewed it was determined that the facility failed to provide complete psychosocial evaluations.
The Findings were:
Four of six records reviewed, #1, 2, 4 & 6, lacked a composite picture of the client.
Four of six records reviewed, #1, 2, 5 & 6, failed to identify the client's coping mechanisms.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based upon review of the individual treatment plans in the client records it was determined that the facility failed to identify individualized long term goals for clients in their treatment plan.
The Findings were:
Six of six records reviewed failed to identify individualized long term goals.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based upon review of the individual treatment plans it was determined that the facility failed to list support services for clients.
The Findings were:
Four of six records reviewed, #1, 2, 3 & 6, failed to list support services.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Based upon review of client records it was determined that treatment plan updates either lacked required signatures or that the treatment plan updates were missing.
The Findings were:
Two of two records reviewed requiring the physicians signature on treatment plan updates, #1 & 2, contained treatment plans that were not signed by the physician.
One of five records reviewed, #2, contained a treatment plan that was not signed by the client and the clinical supervisor.
Three of six records reviewed, #1, 2 & 6, were missing treatment plan updates. Record #1 lacked a treatment plan update for August 2, 2007, record #2 lacked an update for July 13, 2007 and record #6 lacked updates for April and May of 2007.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 the review of treatment plans it was determined that the record of services and progress notes in the client records on August 15 through 17, 2007, and staff interview with employee #2 indicating that clients are to receive a minimum of three group sessions per week, the facility failed to document the provision of services in accordance with the client's treatment plan in four of six client records reviewed.
The Findings were:
Client record #1 showed the client as still being admitted on 8-15-07, however, as of that date, the last entry in the record of service and the last progress note was dated 6-27-07.
Client #1's record of service and progress notes were incomplete for the month of March and June 2007. In addition there was no documented group sessions between May 7 and 18, 2007.
Client record #2 had no entry in the record of service for individual sessions in August, however there were progress notes for 8/6/07 & 8/11/07.
Client records #2 & 3 lacked a record of service and progress notes for group sessions.
Client record # 5 contained no record of service for February, March or April and no individual progress notes in the file beyond January. The client was admitted in January and discharged in April of 2007.
Client record #6 was missing a record of service for April and May, 2007.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based upon the review of client records, specifically the treatment plans, the record of services and progress notes on August 15 through 17, 2007, and staff interview with employee #2 indicating that clients are to receive a minimum of three group sessions per week, it was determined that the facility failed to document the provision of services on a regular and scheduled basis in four of six client records reviewed.
The Findings were:
Client record #1 showed the client as still being admitted on 8-15-07, however as of that date the last entry in the record of service and the last progress note was dated 6-27-07.
Client record #1 contained records of service and progress notes which were incomplete for the month of March and June 2007. In addition there were no documented group sessions between May 7 and 18, 2007.
Client record #2 had no entry in the record of service for individual sessions in August, however there were progress notes for 8/6/07 & 8/11/07.
Client records #2 & 3 lacked a record of service and progress notes for group sessions.
Client record # 5 contained no record of service for February, March or April and no individual progress notes in the file beyond January. The client was admitted in January and discharged in April of 2007.
Client record #6 was missing a record of service for April and May, 2007.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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:
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Observations
Based upon client records reviewed on August 15 through 17, 2007 the facility failed to maintain complete complete client records.
The findings were:
Six of six records reviewed had missing and incomplete records of services and progress notes.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Based on four out of six medication administration records (MAR) reviewed, from client records #1, 2, 4 & 6, on August 15 through 17, 2007, it was determined that the facility failed to ensure that clients received medications in accordance with doctor's orders and failed to document when clients were not present to take medications or refused to take medications.
The findings are:
The MAR for client #1 indicated that there were medications during the months of April, May, July and August that were not administered as ordered.
The MAR for client #2 indicated that there were medications during the month of May that were not administered as ordered. In addition, Amoxicillin which was to be administered three times per day, was documented as being given to the client four times on May 22 & 23, 2007. There was no indication of the error in the facility's log book.
The MAR for client #4 indicated that there were medications during the month of March that were not administered as ordered.
The MAR for client #6 indicated that there were medications during the month of May that were not administered as ordered.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 the review of the record of services and progress notes in the client records on August 15 through 17, 2007, and staff interview with employee #2 indicating that clients are to receive a minimum of three group sessions per week, the facility failed to maintain an accurate record of services in the client's file.
The Findings were:
Four of six client records reviewed lacked an accurate record of services.
Client record #1, showed the client as still being admitted, however as of 8-15-07 the last entry in the record of service and the last progress note was dated 6-27-07. The facility lacked documentation in the record of services for the months of March and June 2007.
Client record #6 was missing a record of service for April and May, 2007.
Client record #2, had no entry in the record of service for individual sessions in August, however there were progress notes for 8/6/07 & 8/11/07.
Client records #2 & 3, lacked a record of service for group sessions.
Client record # 5, had no record of service for February, March or April.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based upon the review of the record of services and progress notes in the client records on August 15 through 17, 2007, and staff interview with employee #2 indicating that clients are to receive a minimum of three group sessions per week, the facility failed to maintain documented progress notes in the client's file.
The Findings were:
One of six client records reviewed, #1, showed the client as still being admitted, however as of 8-15-07 the last progress note was dated 6-27-07. The facility lacked group progress notes, for the month of March and June 2007.
Three of six client records reviewed, were missing progress notes for group sessions, refer to client records #1, 2 & 3.
One of six client records reviewed, #5, had no individual progress notes on file beyond January 2006, yet the client was not discharged until 4/8/07.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based upon a review of client records it was determined that the facility failed to complete aftercare planning as per facility policy. Facility policy states that aftercare plans are begun upon the date of the client's admission to treatment and are to be finalized 8 days prior to the scheduled discharge date.
The Findings were:
One of three client records reviewed, #4, lacked an aftercare plan in the client's file.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based upon client records reviewed it was determined that the facility failed to provide a complete discharge summary in two of three records reviewed.
The Findings were:
Client record #4 was missing the discharge summary.
Client record #6 lacked a prognosis on the discharge summary.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |