INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on 5/21/2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the facilities staff schedule work hours and the CPR certification cards, the facility failed to provide a sufficient number of staff persons trained in CPR during the project's hours of operation.
The findings include:
The CPR certification cards were reviewed on 5/5/2015 as part of the presubmission review process. The facility is an inpatient facility that operates 24 hours a day and 7 days per week. There was only one staff member that had documented current CPR certification on varied shifts. The facility failed to have sufficient coverage.
On 4/6/2015 - 4/10/2015, 4/13/2015 - 4/17/2015 and 4/21/2015 - 4/30/2014 during the 12:00 AM - 8:00 AM shift there was only one staff member present in the facility. The staff member present in the facility during the 12:00 AM - 8:00 AM shift did not have a current certification in CPR.
On 4/19/2015 during the 8:00 AM - 4:00 PM shift there was only one staff member present in the facility. The staff member present in the facility during the 8:00 AM - 4:00 PM shift did not have a current certification in CPR.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 5/22/15 all staff attended training and is certified in CPR/First aid. A grid was established to track the dates that every employee receives their CPR and the date it expires. The grid will be reviewed in the weekly administrative meeting to assure that CPR training is scheduled before the present CPR expires,so that no CPR lapses.
The Administrative Assistant will maintain the grid to track the expiration dates, and schedule all CPR training. Training will be scheduled 3 months before present CPR of each employee expires. Program Director will monitor this process to assure the tracking and scheduling are completed in a timely manner. The monitoring will occur in weekly Administrative meeting. |
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
|
Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that toilet paper was provided at each toilet at all times.
Findings:
A physical plant inspection was conducted on 5/21/2014 at approximately 1:10 PM. The facility failed to provide toilet paper within the bathroom in the hallway next to the living room area.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will meet with all staff, especially the house manager staff in a staff meeting to reintegrate the procedure for assuring that every bathroom has the proper toiletries.
The house manager will assure that a toiletry run is make every night to sure that all bathrooms are stocked with toilet paper and other needed toiletries. The Staff on Duty will make morning/daily house runs to assure there is toiletries in all bathrooms, which will be documented on the facility run sheets. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
|
Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all exits from the facility were unobstructed.
The findings include:
A physical plant inspection was conducted on 5/21/2015 at approximately 1:10 PM.
A chair was obstructing the front of the emergency exit door that exits from the lower level stairwell into the main lobby.
A high-top baby seat and a chair were obstructing the emergency exit door that exits from the dinning area to the exterior of the facility.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
At the time of inspection both chairs and baby seat were move from the exit pathways. The House Managers will monitor the clientele as they are doing their chores to assure that the exits are not blocked.The Program Director will do a seminar with the clients on fire safety to include the dangers of obstructing emergency exits. The house managers will make hourly safety runs with documentation through-out the facility to assure that all emergency exits are clear. The Program Director will read the safety run sheet daily.
The Program Director and Program Supervisor will make periodic (weekly) safety runs on the facility. |
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:
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent that includes all of the content required by regulation in one of ten client records reviewed.
The findings include:
Ten client records requiring informed and voluntary consent to release information forms were reviewed on 5/21/2015. The facility failed to document all of the required content on the informed and voluntary consent to release information forms in client record # 2.
Client # 2 was admitted on 3/24/2015 and was still an active client at the time of the inspection. Client # 2's informed and voluntary consent to release information to Children and Youth Services dated 3/24/2015 did not specify the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The consent with the deficiency was corrected on 6/01/15 with the proper information.The Program Director will be responsible to review all intake paperwork done that contains initial consents to assure that the consents have the proper/correct documentation.
The Program Supervisor will perform weekly QA (quality assurance) on client files with documentation assuring that consents have the proper documentation. The documentation of QA files will be given to Program Director weekly.
Any/all deficiencies will be addressed with the clinician promptly. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
|
Observations
Based on a review of client records, the facility failed to document the frequency and/or type of treatment services on the individual treatment and rehabilitation plan in four of ten client records reviewed.
The findings include:
Ten client records requiring documentation of the frequency of treatment services on the individual treatment and rehabilitation plans were reviewed on 5/21/2015. The individual treatment and rehabilitation plans contained in client records # 2, 3, 5 and 9 did not include the frequency and/or type of treatment services.
Client # 2 was admitted to treatment on 3/24/2015. The client's individual treatment and rehabilitation plan dated 4/18/2015 did not specify the frequency of individual and group counseling therapy.
Client # 3 was admitted to treatment on 1/8/2015. The client's individual treatment and rehabilitation plans dated 1/23/2015, 2/8/2015, 4/8/2015 and 5/8/2015 did not specify the frequency of individual and group counseling therapy.
Client # 5 was admitted to treatment on 7/2/2014. The client's individual treatment and rehabilitation plans dated 8/2/2014, 9/2/2014 and 10/2/2014 did not specify the type and frequency of counseling therapy.
Client # 9 was admitted to treatment on 10/18/2014. The client's individual treatment and rehabilitation plan dated 1/15/2015 did not specify the type and frequency counseling therapy.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The treatment plan reviewed were corrected on 6/01/2015 to include proper documentation of the type and frequency of services on the treatment plans. The Director will monitor and receive documentation of client files being audited weekly. The Program Supervisor or Program Director has to sign off on all treatment plans. The Program Supervisor and Program Director will assure that entire treatment plan is complete to include the type and frequency of services provided page. All/any deficient treatment plans will be returned to the clinician for corrections before being signed by the supervisor or director, therefore assuring all treatment plans are correct and complete. |